PATIENT SAFETY STRUCTURAL MEASURE (PSSM)
Everything you need to get started.
BACKGROUND
In Spring 2026 hospitals will begin reporting the Patient Safety Structural Measure (PSSM) as part of the CMS Inpatient Quality Reporting (IQR) Program and the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting Program. At this time, Critical Access Hospitals (CAHs) are not required to submit the measure, although they may do so voluntarily.
The PSSM is an attestation-based measure to assess whether hospitals demonstrate having the structure and culture that prioritizes patient safety (PSSM_Specs). The purpose is to “drive action and improvement in patient safety across key domains” (PSSM_AttestationGuide_073124) by encouraging implementation of best practices for using a total systems framework that views patient safety events as a result of system failure, rather than individual error.
To report the PSSM, hospitals will attest to practices across five domains:
Leadership Commitment to Eliminating Preventable Harm
Strategic Planning & Organizational Policy
Culture of Safety & Learning Health System
Accountability & Transparency
Patient & Family Engagement
If a hospital responds “yes” to all practices listed within a domain, they will receive a point for that domain. The highest score a hospital can receive is 5.
HOW CONVERGENCE CAN HELP
Our team is helping hospitals prepare to submit the PSSM and to strengthen the policies, practices, and culture that contribute to patient safety.
If you’re just getting started:
Watch our overview webinar hosted with Dr. Michelle Schreiber from CMS:
Sign up for our National Healthcare Listserv to join a community of thousands of professionals in health care quality and safety across the country who are wrestling with the same challenges and are eager to swap solutions.
Watch our blog for updates and to learn about new ways to partner with our team.
Send us a note. We look forward to working with you!
Learn from your peers in our Solutioning Session Summary. In early 2025 Convergence hosted solutioning sessions with hospitals across the country to explore anticipated challenges related to the PSSM. This document summarizes FAQs and publicly available resources.
HELPFUL LINKS:
At-A-Glance: PSSM Domains and Attestation Statements
A simple listing of the PSSM domains and attestation statements.
CMS Measure Specifications:
From CMS, background of the measure and attestation statements for all domains.
CMS Attestation Guide:
Drafted by CMS, this document includes clarifying information and examples to support hospital responses included in the measure.
AHRQ National Action Alliance for Patient and Workforce Safety:
Includes a page with resources and tools on patient and healthcare workforce safety, research that informed development of the PSSM, data, affinity groups, funding opportunities and more.
Institute for Healthcare Improvement National Action Plan to Advance Patient Safety:
Actionable and effective recommendations to advance the goal of creating the safest health care for patients and those who care for them.
Institute for Healthcare Improvement National Action Plan Self Assessment Tool:
Designed to help health care organizations evaluate their safety readiness, identify opportunities for improvement, and track progress over time.
FREQUENTLY ASKED QUESTIONS
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No. At this time CAHs are not required to submit the PSSM. CAHs may submit the measure voluntarily via the IQR system.
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Yes. Scores will be publicly reported on the CMS Hospital Compare website. Only the total score (0-5) will be posted, not the detail of answers for each domain.
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Hospitals will report in spring 2026 when the IQR system opens, likely in April. Hospitals will report data that describes their performance and practices in 2025.
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Hospitals will only be penalized for non-submission. As long as a hospital submits data, regardless of its score, the hospital will not incur financial penalties.