Navigating the New CMS Attestation Requirements: Your Questions Answered

As a follow up to our webinar, our panel of experts answers your questions about how to successfully prepare for the new CMS Attestation Requirements. 

Q1: One of the panelists mentioned having a quality committee meeting prior to the “big board” meeting.  In the attestation guide it states the main hospital board is where everything must occur, not in sub-boards or regional boards.  Are you stating something different?

A1: All Board responsibility ultimately lies with the “master” or “full” Board. However, it is common and considered best practice to form a Quality Subcommittee. This subcommittee, made up of members who understand and are interested in Quality of Care, evaluates Quality information and makes recommendations to the full Board. The existence of a Quality Subcommittee does not remove the full Board’s responsibility for decisions, including attestations. The reference to the Quality Committee aligns with common practice and does not deviate from the attestation guide expectations. 

 

Q2: Would you recommend a non–profit health center be a part of a Patient Safety Organization (PSO)?

A2: The answer to whether a non-profit health center should join a PSO (Patient Safety Organization) depends on the specific nature of the center. Here are the key points: 

• Reasons to Join a PSO: PSOs offer a protected environment for gathering, reporting, and evaluating quality information, which was not historically covered by peer review protections. This became more significant in areas like Florida, where peer review protections were removed. Since PSOs are federally mandated, they override state-level removal of protections. Initially, this protection was the main motivation for joining PSOs. However, many organizations have found additional benefits, such as forums for deep discussions about quality findings and the ability to compare experiences with other group members. This has led to a better understanding of quality issues and the development of more comprehensive quality projects. 

• Obligations and Considerations: Organizations that must gather and report quality data, such as hospitals, may find it beneficial to join a PSO. The local legal environment and understanding of protections are important factors. It is recommended that all entities consider PSO involvement seriously, but the decision should be made on a case-by-case basis. Seeking outside support from experts in this area can help ensure all potential benefits and risks are considered 

• Broadly speaking, for-profit and not-for-profit hospitals can participate fully in a PSO; here is a link to the AHRQ web site which briefly answers this question as well.

 

Q3: If applicable hospitals / cancer centers do not answer yes (do not attest that they are currently doing one of the listed requirements), currently there is no penalty – monetary or withholding of reimbursement.  However, because the responses will be posted publicly via Hospital Care Compare, there could be a negative monetary impact through reputational issues if the public sees noncompliance with the measure(s).  Can you confirm this is the case?

A3: Currently, hospitals are required to attest, and CMS has announced that these results will be publicly reported starting in 2025. The questioner correctly notes the potential fiscal impact due to public reputation effects. Monetary penalties will begin in 2027, although the extent and manner of these penalties have not yet been announced. Many believe the government may be waiting to see the impact of public reporting before committing to specific monetary costs. At present, there is no direct monetary penalty for the attestations. 

Regarding the requirement for the board to attest to the Patient Safety Structural Measurements (PSSMs), this is part of the CMS program. PSSMs are sourced through CMS’s FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS). One part of this is the Hospital Inpatient Quality Reporting (IQR) Program, which added seven new quality measures, including the PSSM.  

The National Healthcare Safety Network (NHSN) is the CDC-mediated infection reporting system, proposed as the reporting vehicle for hospitals to submit their PSSM attestations. In the end, they are essentially the same thing with many governmental acronyms. CMS has an attestation guide that provides insight and instructions regarding attestation compliance, which can be downloaded from the CMS website. 

 

Q4: Where can I find the requirement that the board is the entity that must attest to the PSSMs? Is that separate from the attestation that will be completed through NHSN?

A4: The answer to this question lies within the complex CMS program. Patient Safety Structural Measurements (PSSM) are part of CMS’s FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS). The Hospital Inpatient Quality Reporting (IQR) Program, which added seven new quality measures, includes the PSSM. The National Healthcare Safety Network (NHSN) is the CDC-mediated infection reporting system proposed as the vehicle for hospitals to submit their PSSM attestations. Essentially, they are the same thing with many governmental acronyms.  

CMS provides an attestation guide with instructions for compliance, available on their website.

 

Q5: What successful methods have you experienced/utilized to help promote MSP participation in Performance Improvement (PI) Projects and non-medical staff committee meetings?

A5: If PI projects or non-medical staff committees involve MSPs and their scope of work, it is appropriate to include them. For example, in many organizations, Quality Departments support peer review work, but MSPs handle data compilation, performance assessments by Medical Leaders, and results reporting. Therefore, PI projects can play a role in communication and division of responsibilities in peer review processes. Similarly, since Quality meetings often involve physician performance as part of the care team, it makes sense for MSPs to be involved in these committees. Identifying MSP contributions and gaining their participation in these areas is important.

 

Q6: Will there be a financial penalty to the practitioners or just hospitals? 

A6: Hospitals are solely responsible for PSSM attestations and any resulting financial penalties. No individual responsibility is identified.

 

Q7: How is the training sent to the physicians /AHPs?

A7: Training physicians and AHPs requires effective educational methods, which vary by organization. Some prefer written documentation, others visual digital training, and some in-person teaching. First, clearly define the outcomes, and then determine the most effective approach to achieve them.

 

Q8: What are the panelists thoughts about not knowing when a serious safety event occurs — and therefore not being able to report to the board within 3 days — will this be a way for hospitals *sustainably* to be compliant and/or to avoid reimbursement penalty?

A8: Organizations must promptly respond to serious safety events, as ignorance is not an excuse. A well-run healthcare organization should address such incidents within three days. Failure to do so indicates significant safety issues that need correction. Establish proactive safety processes to meet the three-day reporting requirement.

 

Q9: Do the attestation requirements apply to ambulatory healthcare facilities and dialysis centers?

A9: Currently, the attestation requirements apply only to inpatient hospitals, not to ambulatory or dialysis centers. Hospital systems that include both inpatient and outpatient facilities should ensure a comprehensive quality and patient safety program. This not only prepares them for future CMS PSSM demands but also promotes excellent patient care.

Q10: Does the administration really know or understand the medical staff is responsible for patient safety?

A10: Hospital administrations hold various views on patient safety responsibilities. These views range from considering patient safety as a collective obligation of all staff, including medical personnel, to seeing it as the sole responsibility of the patient safety department reporting to the Board. The perspective that includes the Medical Staff as an integral part of patient safety efforts is considered more inclusive.

 

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