An Overview of the Patient Safety Structural Measure (PSSM)

The CMS Hospital Patient Safety Structural Measure (PSSM) is a newly required measure under the Inpatient Quality Reporting (IQR) program. The purpose of this structural measure is to ensure organizations are approaching patient safety in a hospital system in a comprehensive and integrated approach, ensuring that safety is a core value and integrated into all aspects of their operations at all levels of the hospital.

Safety is a high priority for CMS. Before COVID, the U.S. had made incremental progress in areas like reducing CLABSI and CAUTI rates. During COVID, there was a significant decline in hospital safety. This indicates that the underlying safety systems are not robust enough to withstand times of stress. Nationally, this trend is starting to improve. Recent progress has brought down these rates, but there is still more work to be done. Thus, was born this structural measure. A structural measure allows CMS to look at underlying processes and structures within an organization so it can ensure those structures exist.

Right now, only short-term acute-care eligible hospitals are required to submit this measure. However, CMS indicated that they intend to roll this measure out in all settings of care. It is not mandatory for CAHs.

The reporting year for this measure is January 1 – December 31, 2025. Hospitals must complete their attestation on this measure in spring of 2026. The PSSM is reported through the National Healthcare Safety Network (NHSN) (not through the CMS HQR system). 

You must report this measure to ensure full IQR compliance, but your score on this measure won’t impact reimbursement; however, results will be publicly posted on Care Compare, which will influence patient choice and trust.

Because this measure requires your executive team’s involvement, I created a PSSM Fact Sheet for you to share with your leadership. This PDF tells them what it is, why it’s important, what happens if you don’t do it, and the basics of each domain. I hope this helps you navigate this conversation with your leadership. And thank you to the wonderful clients who gave me this suggestion. 🤗

Key Components of the PSSM

The PSSM is structured into five key domains, each worth one point. Hospitals must attest to all statements within a domain to earn that point. The measure is worth five points, and your score will be displayed on Care Compare in a range from 0 to 5. The patient safety structural measure closely aligns with the Safer Together National Action Plan, tying each domain to one aspect of the action plan.

Domain 1. Leadership Commitment to Eliminating Preventable Harm

• Overview: Leadership plays a crucial role in setting the tone for patient safety. The senior governing board must prioritize safety, hold leadership accountable, and allocate adequate resources for patient safety initiatives. CMS defines the governing board as the highest board for your specific hospital. So not a sub-committee on safety in your hospital. And it’s also not your health system’s governing board. It’s your local hospital.
• Key Components:
  • Prioritizing patient safety in strategic planning.
  • Holding leadership accountable for safety outcomes.
  • Allocating resources for safety programs and training.
• Criteria for Attestation: Hospitals must demonstrate that leadership actively supports and promotes patient safety as a core value.
• Domain Attestation Statements:
  • Senior governing board prioritizes safety as a core value, holds hospital leadership accountable for patient safety, and includes patient safety metrics to inform annual leadership performance reviews and compensation.
  • Leaders place patient safety as a core institutional value. One or more C-suite leaders oversee a system-wide assessment on safety and the execution of patient safety initiatives and operations, with specific improvement plans and metrics. These plans and metrics are widely shared across the hospital and governing board.
  • Governing board, in collaboration with leadership, ensures adequate resources to support patient safety (such as equipment, training, systems, personnel and technology)
  • Reporting on patient safety and workforce safety events and initiatives (such as safety outcomes, improvement work, risk assessments, event cause analysis, infection outbreak, culture of safety, or other patient safety topics) accounts for at least 20% of the regular board agenda and discussion time for senior governing board meetings.
  • C-suite executives and individuals on the governing board are notified within 3 business days of any confirmed serious safety events resulting in significant morbidity, mortality or other harm.

Domain 2. Strategic Planning & Organization Policy

• Overview: A well-defined strategic plan is essential for achieving patient safety goals. This domain requires hospitals to have a strategic plan that outlines specific safety goals and metrics, including the goal of 'zero preventable harm.'
• Key Components:
  • Developing a strategic plan with clear safety goals and metrics.
  • Integrating patient safety into performance reviews and compensation.
• Criteria for Attestation: Hospitals must have a documented strategic plan that is regularly reviewed and updated.
• Domain Attestation Statements:
  • Has a strategic plan that publicly shares its commitment to patient safety as a core value and outlines specific safety goals and associated metrics, including the goal of "zero preventable harm."

• • Safety goals include the use of metrics to identify and address disparities in safety outcomes based on the patient characteristics determined by the hospital to be most important to health care outcomes for specific populations served.
  • Implemented written policies and protocols to cultivate a just culture that balances no-blame and appropriate accountability and reflects the distinction between human error, at-risk behavior, and reckless behavior.
  • Requires implementation of patient safety curriculum and competencies for all clinical and non-clinical hospital staff, including C-suite executives and individuals on the governing board, regular assessments of these competencies for all roles, and action plans for advancing safety skills and behaviors.
  • Has an action plan for workforce safety with improvement activities, metrics, and trends that address issues such as slips/trips/falls prevention, safe patient handling, exposures, sharps injuries, violence prevention, fire/electrical safety and psychological safety.

Domain 3. Culture of Safety & Learning Health System

• Overview: A culture of safety is fostered through regular hospital-wide surveys, the implementation of a just culture, and using data for continuous improvement. This is a very important part of the measure. To create a culture of safety, this must be a push at every level of the organization (from top-level leadership, down to housekeeping services). CMS wants you to view safety as an all-hands-on-deck approach and must be informed by data and experience to improve. Additionally, CMS specifically wants you to use external benchmarks to measure this, not just your internal benchmarks.
• Key Components:
  • Conducting annual or bi-annual hospital-wide surveys on safety culture.
  • Implementing a just culture that encourages reporting and learning from errors.
  • Using data to drive continuous improvement in safety practices.
• Criteria for Attestation: Hospitals must demonstrate a commitment to a culture of safety through regular surveys and data-driven actions.
• Domain Attestation Statements:
  • Conducts a hospital-wide culture of safety survey using a validated instrument annually, or every two years with pulse surveys on target units during non-survey years. Results are shared with the governing board and hospital staff and used to inform unit-based interventions to reduce harm.
  • Has a dedicated team that conducts event analysis of serious safety events using an evidence-based approach, such as the National Patient Safety Foundation's Root Cause Analysis and Action.
  • Has a patient safety metrics dashboard and uses external benchmarks (such as CMS Star Ratings or other national databases) to monitor performance and inform improvement activities on safety events (such as: medication errors, surgical/procedural harm, falls, pressure injuries, diagnostic errors, and healthcare-associated infections).
  • Implements a minimum of 4 of the following high-reliability practices:
    • Tiered and escalating (e.g., unit, department, facility, system) safety huddles at least 5 days a week, with one day being a weekend, that include key clinical and non-clinical (e.g., lab, housekeeping, security) units and leaders, with a method in place for follow-up on issues identified.
    • Hospital leaders participate in monthly rounding for safety on all units, with the C-suite executives rounding at least quarterly, with a method in place for follow-up on issues identified.
    • A data infrastructure to measure safety, based on patient safety evidence (e.g., systematic reviews, national guidelines) and data from the EMR that enables identification and tracking of serious safety events and precursor events. These data are shared with C-suite executives at least monthly, and the governing board at every regularly scheduled meeting
    • Technologies, including a CPOE system and BCMA system, that promote safety and standardization of care using evidence-based programs.
    • The use of a defined improvement method (or hybrid of proven methods), such as Lean, Six Sigma, PDSA, and/or high reliability framework.
    • Team communication and collaboration training of all staff.
    • The use of human factors engineering principles in selection and design of devices, equipment and processes.
  • Participates in large-scale learning network(s) for patient safety improvement (such as national or state safety improvement collaboratives), shares data on safety events with these network(s), and has implemented at least one best practice from the network or collaborative.

Domain 4. Accountability & Transparency

• Overview: High-reliability practices are essential for maintaining a safe environment for both patients and staff. These practices include daily safety huddles and monthly rounding for safety. During the measure vetting process, patients and patient advocates were very supportive of this domain. They supported the opportunity to join these discussions, learn about the process and have hospitals openly address these issues.
• Key Components:
  • Implementing daily safety huddles to discuss and address safety concerns.
  • Conducting monthly rounding for safety to identify and mitigate risks.
• Criteria for Attestation: Hospitals must have established and documented high-reliability practices that are consistently followed.
• Domain Attestation Statements:
  • Has a confidential safety reporting system that allows staff to report patient safety events, near misses, precursor events, unsafe conditions, and other concerns, and prompts a feedback loop to those who report.
  • Voluntarily works with a Patient Safety Organization listed by AHRQ to carry out patient safety activities, such as, but not limited to, the collection and analysis of patient safety work product, dissemination of information such as best practices, encouraging a culture of safety, or activities related to the operation of a patient safety evaluation system.
  • Patient safety metrics are tracked and reported on to all clinical and non-clinical staff and made public in hospital units (e.g., displayed on units so that staff, patients, families, and visitors can see).
  • Has a defined, evidence-based communications and resolutions program reliably implemented after harm events, such as AHRQ's Communication and Optimal Resolution (CANDOR) toolkit, that contains the following elements:
    • 1. Harm event identification
    • 2. Open and ongoing communication with patients and families about the harm event
    • 3. Event investigation, prevention, and learning
    • 4. Care-for-the-caregiver
    • 5. Financial and non-financial reconciliation
    • 6. Patient-family engagement and on-going support
• Uses standard measures to track the performance of our communication and resolution program and reports these measures to the governing board at least quarterly.

Domain 5. Patient and Family Engagement

• Overview: Engaging patients and families is crucial to improving patient safety. This domain focuses on involving patients and families in safety initiatives and providing them with access to medical records. In this domain, CMS also wants you to have varied patient representation to address discrepancies in health outcomes. However, CMS understands that different regions may have unique patient demographics. As a result, your “diversity” in your PFAC should reflect your specific hospital population.
• Key Components:
  • Establishing a Patient and Family Advisory Council (PFAC).
  • Providing patients and families with comprehensive access to medical records.
• Criteria for Attestation: Hospitals must demonstrate active engagement with patients and families in safety initiatives.
• Domain Attestation Statements:
  • Has a Patient and Family Advisory Council (PFAC) that ensures patient, family, caregiver, and community input to safety-related activities, including representation at board meetings, consultation on safety goal setting and metrics, and participation in safety improvement initiatives.
    • The American Hospital Association (AMA) gathered a group of patient and family engagement leaders to create a blueprint for developing high-performing PFACs:
      • https://www.aha.org/system/files/media/file/2022/01/alliance-pfac-blueprint-2022.pdf
      • https://www.aha.org/patient-and-family-advisory-councils-podcasts-and-blueprint
    • Agency for Healthcare Research and Quality's (AHRQ's) also provides a "Working With Patient and Families as Advisors Implementation Handbook": https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf
  • PFAC includes patients and caregivers of patients who are diverse and representative of the patient population.
  • Patients have comprehensive access to and are encouraged to view their own medical records and clinician notes via patient portals and other options, and the hospital provides support to help patients interpret information that is culturally and linguistically appropriate as well as submit comments for potential correction to their record.
  • Incorporates patient and caregiver input about patient safety events or issues (such as patient submission of safety events, safety signals from patient complaints or other patient experience data, or patient reports of discrimination).
  • Supports the presence of family and other designated persons (as defined by the patient) as essential members of a safe care team and encourages engagement in activities such as bedside rounding and shift reporting, discharge planning, and visitation 24 hours a day, as feasible.

Best Practices for Implementing the PSSM

To effectively implement the PSSM, hospitals can focus on the following best practices:

• Leadership Commitment:
  • Prioritize patient safety as a core value.
  • Set specific safety goals and metrics.
  • Integrate patient safety into performance reviews and compensation.
• Strategic Planning:
  • Develop a strategic plan with clear safety goals and metrics.
  • Regularly review and update the plan.
• Culture of Safety:
  • Conduct regular culture of safety surveys.
  • Use survey results to inform unit-based interventions.
  • Foster a just culture that encourages reporting and learning from errors.
• High Reliability Practices:
  • Implement daily safety huddles.
  • Conduct monthly rounding for safety.
• Patient and Family Engagement:
  • Establish a PFAC.
  • Provide comprehensive access to medical records.

Other Resources

CMS put together an attestation guide that provides a variety of resources, examples, and definitions to help support your understanding. We have included the official specification, information about all web-based attestation requirements, and examples for items such as training and curriculum or safety metrics that hospitals may want to incorporate into their culture of learning and continuous improvement. The guide also defines terms like governing board and offers additional examples.

Measure Specification: https://qualitynet.cms.gov/files/66ac085486c07e0c5ec5e930?filename=PSSM_Specs_073124.pdf

Attestation Guide: https://qualitynet.cms.gov/files/66ac08646a3d89e3e32733c4?filename=PSSM_AttestationGuide_073124.pdf