Annette Macias-Hoag

Chief Nurse Executive & Patient Care Officer Rochester Regional Health, USA

Abstract Title:Promoting Safety and Accountability: A Nursing Case Review Through a Just Culture Lens

Biography:

Dr. Annette Macias-Hoag has served as a nurse leader for over 20 years. She received her Bachelor's degree in Nursing from the University of Wisconsin and a Doctorate in Nursing Practice from the Texas Tech Health Science Center School of Nursing. Dr. Macias-Hoag leads Nursing as the EVP, CNE & Patient Care Officer at Rochester Regional Health she is responsible for Nursing Practice & Operations while leading the Rochester General College of Health Careers and the Isabella Graham Hart School of Practical Nursing.

Research Interest:

The Centers for Medicare & Medicaid Services (CMS) issued a final ruling for U.S. hospitals to include a new quality measure to assess how well hospitals have implemented strategies and practices to strengthen systems for safety. CMS adopted the Patient Safety Structural; Measure (PSSM) for the Hospital Inpatient Quality Reporting (IQR) Program beginning with the calendar year 2025 reporting period (FY 2027 payment determination). The PSSM, which includes five domains, is an attestation-based measure that assesses whether hospitals demonstrate having a structure and culture that prioritizes patient safety. One of the domains must address how the hospital’s strategic plan emphasizes patient safety as a core value, aiming for “zero preventable harm” and addressing safety. An organization assessment demonstrated a tool was necessary to achieve the goal. This session outlines how Nursing led the adoption of the Just Culture framework within the organization to embed safety and accountability into clinical and operational practices. The training and tools for the Just Culture framework emphasize balancing individual accountability with system-based learning, creating an environment where staff feel supported in reporting errors while striving for excellence in care delivery. This case review session will provide attendees with insights into the implementation journey, practical tools, and strategies to replicate success in their organizations. It will also discuss lessons learned and the potential broader impact of integrating safety culture into strategic planning and reporting.