CMS Patient Safety Structural Measure: Best Practices to Enhance Safety: March 13
Location:
2025 MAPS PSO Annual Culture of Safety Workshop
Webinar - 9 a.m. to 3:30 p.m.
Registration:
MAPS Member: Complimentary Registration
There is no fee for MAPS members to attend. This program is a benefit of MAPS membership. To confirm your organization’s MAPS membership status, please contact us.
Non-MAPS Member Registration Fees
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Hospital: $395 – full-day event access
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Health System: $1,095 – full-day event access
Non-MAPS Member Registration Examples
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Hospital Registration: A hospital registering for this program can connect an unlimited number of internal units or departments at that specific location only. Example: Hospital A registers for the program and shares connection information with multiple internal units or departments. Note: Hospital A cannot share the webinar with any other hospital, even if they are part of the same health system.
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Health System Registration: A health system registering for this program can connect an unlimited number of units or departments within their corporate office(s) and any affiliated hospitals within their health system. Example: Health System B registers for the program and shares connection information with all their affiliated hospitals and within their corporate office(s). Note: Health System B cannot share webinar information outside of their system.
Important Notice: Individuals connecting to the webinar from an organization that did not register will be billed the full registration fee.
Register OnlineWith patient safety critical to quality care, IHA’s Midwest Alliance for Patient Safety (MAPS) Patient Safety Organization (PSO) is offering a robust workshop centered on the new Patient Safety Structural Measure (PSSM) from the Centers for Medicare & Medicaid Services (CMS) effective this year. The program—offered to MAPS members and IHA members not part of MAPS—will guide organizations in meeting PSSM requirements. We’ll cover approaches to planning and implementation, how to assess current systems and gaps that may hinder compliance, and results of IHA’s PSSM assessment tool. By attending, your organization will gain expert insight to aid in meeting each CMS compliance standard across five domains. Join us for an impactful day of virtual learning and collaboration!
Agenda
8:45-9:00 am
Online Check-in
9:00-9:15 am
Welcome
Carrie Pinasco, Senior Director, MAPS PSO
9:15-10:15 am
MAPS Top 10 Patient Safety Focus White Paper as a Tool to Strategize for the PSSM
Kim Werkmeister, MS, RN, CPHQ, CPPS, Improvement Senior Vice President, Improvement and Implementation, Convergence Health
This session will walk you through the 2025 MAPS Top 10 Patient Safety Focus White Paper, focused entirely on the PSSM. We’ll explore MAPS PSO resources that address key domain issues and opportunities to engage leadership in understanding the PSSM.
10:15-11:15 am
Engaging Leadership in Eliminating Preventable Harm
Col. (Ret.) John Murray, PhD, RN, USAF, Executive Leader Coach, VHA High Reliability Organization Support Team, Cognosante
Learn the value in adopting a Just Culture that includes accountability, leadership rounding and an “open door policy.” You’ll also hear how high-reliability practices like safety huddles, monthly leadership rounding, data infrastructure to measure safety, defined improvement methods, communication and collaboration training, and human factors principles can help to improve patient safety. Polling will be used to promote collaboration on how to engage leadership.
11:15 am-12:15 pm
Building a Collaborative Just Culture Program in Your Organization
K. Scott Griffith, Author, Founder and Managing partner of SG Collaborative Solutions, LLC
Dale Oda, MD, Chief Medical Advisor, SG Collaborative Solutions, LLC
Just culture and high reliability are bedrock principles and the foundation of patient safety efforts. Yet new scientific, evidenced-based standards have emerged to take just culture and high reliability to the next level in your organization. This session will present these new operational standards—Collaborative Just Culture® and Collaborative High Reliability®—designed to align every part of your organization to drive stakeholder engagement and high reliability.
12:15-12:45 pm
Lunch Break
12:45-1:45 pm
The Vital Role of Including Patients and Families in Patient Safety
Lindsey Galli, Vice President of Programs, PFCCpartners
Libby Hoy, Founder and Chief Executive Officer, PFCCpartners
Patient and Family Advisory Councils (PFACs) ensure transparent communication between patients, family members, caregivers and the community. The collaboration promotes safety-related activities, including representation at board meetings, consultation on safety goal setting and metrics, and participation in safety improvement initiatives. This session will offer new insights into PFACs, whose conversations and documents are part of an organization’s Patient Safety Work Product when properly included in the Patient Safety Evaluation System.
1:45-3:15 pm
Building a Collaborative Approach to the PSSM – Gap Survey Discussion
Jenny Winkler, IHA Senior Director, Quality, Safety and Health Policy
Christina Boyd, IHA Director, Quality, Patient Safety and Health Policy
This session will discuss questions and operational standards presented in the MAPS/IHA PSSM Evaluation Report, which was designed to uncover organizational gaps so you can effectively plan for and meet CMS’ patient safety requirements. You’ll also learn about results from IHA’s PSSM assessment, AIM statements, Project Charters and other planning tools to help design your organization’s strategic plan.
3:15-3:30 pm
Open Discussion, Q&A and Wrap-Up
Crystal Lathen, Consultant, MAPS PSO
As the workshop wraps up, we encourage you to provide feedback, ask questions and share your thoughts on the programs, tools, action items and next steps highlighted during the workshop.
Objectives
At the conclusion of this program, participants will be able to:
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Evaluate gaps in your organization’s current patient safety and quality programs and devise strategies to meet many of the CMS Patient Safety Structural Measures.
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Estimate the internal resources and timeline needed to achieve fulfillment of the CMS Domains and Attestations.
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Identify best practices and tools to satisfy the requirements of each PSSM.
Who Should Attend
This program is designed for hospital leaders and staff responsible for PSSM compliance, including those in:
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Administration (CEOs, COOs, CMOs, CNOs)
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Quality improvement
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Risk management
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Compliance, accreditation and regulation
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Physicians, nurses and other clinical staff
Speakers
Christina Boyd, MPH, CPHQ
IHA Director, Quality, Safety and Health Policy
Boyd has over 15 years of experience in hospital associations, working to advance quality and health outcomes in Illinois hospitals. In her current role, Boyd is responsible for leading and coordinating quality and patient safety initiatives to support the implementation of improvement processes and improve member performance. She is the lead for various federal, state and local quality improvement projects, as well as the topic lead for patient and family engagement and EMS operations and policy development.
Lindsey Galli
Vice President of Programs, PFCCpartners
In her role, Galli supports organizations, patients, and family caregivers to partner and collaborate authentically, promoting improvement in their organizations. She began her career in the Safety Department of a large integrated healthcare system, where she partnered with PFCCpartners to integrate Patient Family Advisors into improvement teams across the system. In 2016, Galli was hospitalized for nine days, diagnosed with multiple blood clots in the lungs (pulmonary emboli) and a blood clot in the leg (deep vein thrombosis). This experience grew the passion she already had to create solutions for patients and family caregivers to engage in their care from the bedside to the boardroom. She uses this experience and passion to develop and implement programs supporting partnerships in healthcare. Galli brings the patient perspective to all efforts at PFCCpartners, including the development of patient family engagement strategies across the U.S.
K. Scott Griffith
Author, “The Leaders Guide to Managing Risk: A Proven Method to Build Resilience and Reliability” and Founder and Managing Partner, SG Collaborative Solutions, LLC
Griffith created the world’s first Collaborative High Reliability® and Collaborative Just Culture® improvement programs, independently audited and certified by the Norwegian company DNV, which sets standards in quality management, risk assessment and sustainability. He is the principal architect of the Sequence of Reliability® model of socio-technical improvement, bringing the science of reliability to diverse industries and organizations. Griffith pioneered the development of multiple predictive risk management strategies, including socio-technical probabilistic risk assessment (STPRA) and Reliability Management Systems (RMS). He has worked extensively with management, labor and government officials and is widely recognized for his ability to help organizations achieve consensus results in support of common goals.
Libby Hoy
Founder and Chief Executive Officer, PFCCpartners
From an early age, Hoy became a caregiver to her mother who was battling breast cancer. Shortly after her mother’s death, Hoy became a parent to three sons who live with mitochondrial dysfunction. In 2016, she was diagnosed with stage IV salivary gland cancer. These experiences over the course of decades have shaped her passion for creating a person-centered health system.
In 2010, Hoy founded PFCCpartners to create a community of patients, families and healthcare stakeholders committed to the shared learning of patient and family-centered care practice. PFCCpartners also supports the PFAnetwork, which includes more than 1,000 patient family advisors in active partnership with health systems, measure developers, and policy and quality improvement teams and researchers across the U.S. to improve the healthcare quality, safety, experience and design.
Hoy serves on many national and statewide groups, including the Healthcare Payment LAN Executive Forum and Patient Perspectives Council, National Quality Forum Multi-Stakeholder Council, Patient-Centered Outcomes Research Institute Ambassador and California Healthcare Compare Board of Directors.
Crystal Lathen, BS
Consultant, Midwest Alliance for Patient Safety, an IHA Company
For four years, Lathen has led MAPS’ ambulatory focus groups and the MAPS PSO Ambulatory Action Committee. She is actively involved in the onboarding of new members. Lathen works closely with MAPS members to outline the benefits of the PSO program and facilitate member training and educational events. She actively listens to members’ needs and challenges to develop targeted collaborative communications. She has expanded her efforts in data collection, submission training and the creation of data dashboards for MAPS members. Lathen has worked in healthcare since 2007. She was previously a patient advocate, lead patient service representative and surgical scheduler at two ambulatory facilities.
Col. (Ret.) John Murray, PhD, RN, USAF
Executive Leader Coach, VHA High Reliability Organization Support Team, Cognosante
Col. Murray served on active duty in the U.S. Air Force for 28 years, retiring with the rank of Colonel. For the past four years, he has worked as an Executive Leader Coach to support the Veterans Health Administration’s enterprise-wide journey to high reliability supporting three VISN 1 facilities — Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Mass., Providence VA Medical Center in Providence, R.I. and the VA Connecticut Healthcare System in West Haven, Conn.—along with one VISN 10 facility, Chillicothe VA Medical Center in Chillicothe, Ohio. Col. Murray has more than 35 years of healthcare, process improvement and high-reliability organization experience in both military and civilian healthcare systems. He has published over 90 peer-reviewed articles, seven book chapters and one book. Thirteen of the peer-reviewed publications are on topics related to high reliability in healthcare.
Dale Oda, MD
Chief Medical Advisor, SG Collaborative Solutions, LLC
Dr. Oda joined SG Collaborative Solutions as a principal collaborator, bringing 25 years of experience at The Emergency Group, Inc., a multi-physician partnership that staffed the emergency department (ED) at Queen’s Medical Center in Honolulu, the lead trauma center and busiest ED in Hawaii. He previously served as Vice-President of the Emergency Group and Chief of the ED. Dr. Oda also was chairman of the ED physician peer review committee and reviewed morbidity/mortality cases throughout the hospital. He became the company’s Managing Director in 2007. Under his direction the Emergency Group expanded from seven physicians to over 30 physicians and staff.
Carrie Pinasco, BS, CDM, BCQS
Senior Director, Midwest Alliance for Patient Safety, an IHA Company
Pinasco’s healthcare career includes 15 years of extensive experience supporting clinical benchmarking projects, patient safety data collection and PSO program development. After working in patient safety at UHC (now Vizient, Inc.), Pinasco joined MAPS to provide marketing, strategic planning, data management and educational support to the PSO program. She spearheads the coordination of all member engagement including: onboarding, data collection, training, member collaboration, advisory council activities and virtual events. In addition, Pinasco oversees MAPS’ collaborative efforts with other PSOs, marketing and new business development.
Kim Werkmeister, MS, RN, CPHQ, CPPS
Improvement Senior Vice President, Improvement and Implementation, Convergence Health
A nurse leader with over 25 years of experience, Werkmeister is a national expert in the reliable implementation of patient safety and process improvement strategies. She has worked as an improvement leader and clinical educator for Cynosure Health and the Hospital Quality Institute and various Hospital Improvement Innovation Networks. Her areas of expertise include the reduction of venous thromboembolism, adverse drug events, readmissions, hospital-associated infection prevention, sepsis mortality reduction, failure to rescue, patient and family engagement, and maternal/child safety. Werkmeister has developed numerous patient safety and quality improvement toolkits, certification courses, and virtual educational program. She is chair of the Patient and Family Advisory Council at Mission Hospital in California. Previously, Werkmeister directed quality and patient safety at two California hospitals.
Jenny Winkler, MPH, CIC, CPPS
IHA Senior Director, Safety, Quality and Health Policy
With over 14 years of experience in healthcare, Winkler has extensive knowledge and expertise in the areas of infection prevention, patient safety, quality improvement and project management. Through IHA’s Institute in Innovations in Care and Quality, she works with hospitals to support and enhance their patient safety and quality work.