Patient Safety Structural Measures

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Karie Untiedt

Director of Quality and Patient Safety

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573-893-3700| ext. 1369

Key 2026 Patient Safety Structural Measure Updates

Required Facilities:
- Hospitals participating in Hospital Inpatient Quality Reporting (IQR)
- Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR)
Attestation: 2025 data submitted through NHSN in spring 2026
- Patient Safety Structural Measure Attestation Form
Transparency: CMS will publicly report PSSM scores on Care Compare in October 2026
Financial Implications: Failure to report data will lead to reduced Medicare payments in future fiscal years

The impact of not meeting the requirement

Hospitals that fail to report will face reductions in the annual payment update, beginning in 2027.
The scoring of the domains does not directly impact reimbursement. However, the public posting of the hospital’s scores on Care Compare can negatively affect the patient’s perception.

Why is this important?

Compliance ensures a comprehensive and integrated approach to patient safety.
Addressing and improving safety systems can enhance patient outcomes.
Public reporting on Care Compare allows patients to make informed decisions about their care.

Overview of each domain, key components and strategies for attesting “YES”

Senior leadership and the governing board must be accountable for patient safety outcomes and ensure that patient safety is the highest priority for the hospital. The most senior governing board must oversee all safety activities and hold the organizational leadership accountable for outcomes.
Key Components:
- Leadership actively promotes a culture of safety
- Leadership regularly reviews and acts on patient safety data
- Leadership provides resources and support for patient safety initiatives
Suggested strategies for attesting YES:
- Integrate safety goals in accountability
- Establish a process for board review of safety metrics
Hospitals must leverage strategic planning and organizational policies to demonstrate a commitment to safety as a core value. Hospitals should acknowledge the ultimate goal of zero preventable harm, even while recognizing that this goal may not be currently attainable and requires a continual process of improvement and commitment.
Key Components:
- Hospital has a formal patient safety plan
- Hospital’s strategic plan includes patient safety goals
- Hospital implements patient safety curriculum and competencies
Suggested strategies for attesting YES:
- Strategic plan publicly shares commitment to patient safety
- Policies and protocols cultivate “just culture”
Hospitals must integrate a suite of evidence-based practices and protocols that are fundamental to cultivating a hospital culture that prioritizes safety and establishes a learning system both within and across hospitals.
Key Components:
- Hospital-wide culture of safety survey
- Hospital fosters a nonpunitive environment for reporting errors
- Patient safety data used to drive continuous improvement
Suggested strategies for attesting YES:
- High reliability practices such as safety huddles, leader rounding, team communications
- Use of the HIDI Care Optics Patient Safety Dashboard
Accountability for outcomes, as well as transparency around safety events and performance, represent the cornerstones of a culture of safety. There must exist a culture that promotes event reporting without fear or hesitation and safety data collection and analysis with the free flow of information.
Key Components:
- Hospitals use evidence-based practices to prevent harm
- Confidential safety reporting system to report, analyze and learn from errors
- Patient safety metrics collected and shared publicly
Suggested strategies for attesting YES:
- Feedback loop for reporting
- Ensure there is transparent reporting of safety data to staff and leadership
Effective engagement of patients, families and caregivers is essential to safer, better care. Hospitals must embed patients, families, and caregivers as co-producers of safety and health through meaningful involvement in safety activities, quality improvement and oversight.
Key Components:
- Hospitals actively involve patients and families in care decisions
- Engagement of patient/family in bedside rounding, shift report, discharge planning
- Patient and caregiver provide input on safety events
Suggested strategies for attesting YES:
- Establish a Patient and Family Advisory Council (PFAC)
- Patients have full access to their medical records