“First, Do No Harm” – Turning the Ideal into Reality

We all recognize the Hippocratic Oath, but how well do we understand the systems in our hospitals that ensure patient safety every day?

The Patient Safety Structural Measure (PSSM) is a new attestation-based measure designed to help hospitals evaluate whether they have the culture, systems, and processes in place to truly prioritize patient safety.

Beginning in spring 2026, hospitals will attest to their practices across five key domains:

Leadership Commitment to Eliminating Preventable Harm
Strategic Planning & Organizational Policy
Culture of Safety & Learning Health System
Accountability & Transparency
Patient & Family Engagement

📄 For full measure details, check out the CMS PSSM Specifications and attestation guide.

What We Learned from Hospitals About PSSM

At Convergence Health, we’ve worked closely with hospital leaders, clinicians, policymakers, and patient advocates to drive meaningful patient safety improvements.

To understand how hospitals are responding to the PSSM, we connected with hospital leaders in early 2025 across urban, rural, and critical access settings.

We asked:

  • What about this measure worries you?

  • What questions do you have?

  • Where are you excelling?

Key Takeaways from Over 250 Healthcare Professionals

Our overview webinar and solutioning sessions revealed important themes about the PSSM’s impact:

1. PSSM Provides a Framework for Safer Care

The PSSM is based on decades of research into systems-based safety improvements.

Dr. Michelle Schreiber, a long-time patient safety advocate at CMS, emphasized how this simple attestation measure provides a structured roadmap for hospitals looking to enhance patient safety practices.

Takeaway: If your hospital is looking for a clear starting point for safety improvements, PSSM aligns with evidence-based best practices and can help shape a safer healthcare environment.

2. Even Critical Access Hospitals See Value in PSSM

While Critical Access Hospitals (CAHs) are not currently required to submit the PSSM, many expressed enthusiasm for implementing the recommended safety practices.

Helpful Resource:
The Institute for Healthcare Improvement’s Self-Assessment Tool for the National Action Plan to Advance Patient Safety provides guidance for hospitals of all sizes.

Takeaway: Whether required or not, all hospitals can benefit from integrating PSSM principles into their patient safety strategy.

3. Leadership Education Is Essential

Many hospitals emphasized the need to educate board members on quality and patient safety to ensure strong executive buy-in.

Helpful Resources:

  • Board Training Toolkits

  • Podcasts on Hospital Safety Leadership

  • Videos & Guides on Implementing PSSM Best Practices

Takeaway: A culture of safety starts at the top. Educating hospital leadership and governance boards on patient safety is crucial for successful PSSM implementation.

4. Patient and Family Engagement is a Key Pillar

One of the five core domains of PSSM focuses exclusively on Patient & Family Engagement.

At Convergence Health, we are proud to collaborate with PFCCpartners, a leader in:

  • Implementing Patient & Family Advisory Councils (PFACs)

  • Translating Lived Experience into System Improvements

  • Developing Innovative Strategies for Patient Engagement

Helpful Resource:
Our Solutioning Summary includes free tools and guides on Domain 5 (Patient & Family Engagement).

Takeaway: Patient engagement is not just a compliance requirement—it’s a proven strategy for improving patient safety and outcomes.

5. Collaboration is the Key to Long-Term Success

Even hospitals that may score a 5 on the PSSM measure recognize that patient safety is never “done.”

Join a Community of Experts!

Takeaway: A collaborative network of hospital leaders and safety experts can inspire new ideas and sustain momentum for continuous improvement.

Get Involved: Next Steps for Hospitals

Stay Informed – Bookmark our PSSM Resource Hub for the latest tools and case studies.
Engage Your Leadership – Use free toolkits to educate boards and executive teams on PSSM.
Leverage Patient & Family Input – Explore PFCCpartners' approaches to patient engagement.
Join the Conversation – Sign up for our QI Connection Listserv to connect with other hospital leaders.

💬How is your hospital preparing for PSSM? Share your thoughts and join the discussion in the comments!

📩 Need support? Contact Natalie Graves at ngraves@convergencehealth.org for personalized guidance.

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How to Get Hospital Staff Buy-In for SDOH Screening: Building Engagement Beyond Education