With the launch of the Patient Safety Structural Measure (PSSM), CMS is reinforcing the importance of hospital infrastructure and culture in preventing harm. This attestation-based measure evaluates whether hospitals have the foundational elements in place to support safe care—not just clinical outcomes.
How to Demonstrate Patient Safety Under the PSSM Program
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Here’s a breakdown of what PSSM is, why it matters, and how to prepare for successful attestation.
PSSM Program Highlights
Domain
What the measure means
Impact of PSSM
Leadership Commitment to Eliminating Preventable Harm
Hospitals must demonstrate executive-level engagement in safety, including self-assessments and resource allocation.
Elevates safety as a strategic priority and embeds it into governance.
Strategic Planning & Organizational Policy
Requires a “zero preventable harm” goal, just culture policies, and workforce safety training.
Aligns organizational goals with safety outcomes and supports staff well-being.
Culture of Safety & Learning Health System
Includes safety culture surveys, event analysis, dashboards, and learning collaboratives.
Promotes continuous improvement and shared learning across departments.
Accountability & Transparency
Involves incident reporting systems, PSO participation, public metrics, and CANDOR programs.
Builds trust and encourages open communication about safety events.
Patient & Family Engagement
Requires PFACs, diverse representation, transparent records access, and family involvement in care.
Strengthens partnerships with patients and families, improving care quality and satisfaction.
What the Measure Means
PSSM is a Yes/No attestation measure that shifts focus from clinical outcomes to the structures and culture that enable safe care. It’s designed to ensure hospitals are actively building environments that prevent harm before it occurs.
CMS describes PSSM as a system-level measure, emphasizing leadership, transparency, and engagement as key drivers of safety.
Impact of the PSSM Program
Public Reporting Begins Fall 2026: Hospitals will be scored from 0–5 based on domain attestations, with results published on CMS Care Compare.
No Financial Penalties for Low Scores: However, non-submission will result in financial disincentives in the following fiscal year.
Reputation and Compliance: Participation signals a hospital’s commitment to safety and may influence public perception and future regulatory expectations.
What to Do Next
Conduct a PSSM Readiness Assessment CereCore can help your organization evaluate current practices across all five domains and identify data collection and reporting gaps. This ensures you’re prepared for attestation and aligned with CMS expectations.
Support Leadership and Culture Initiatives Ensure executive leaders are engaged and safety is embedded into strategic planning. Consider updating governance documents and launching internal education campaigns.
Leverage EHR and Existing Infrastructure Use your EHR to track safety metrics, automate reporting, and support transparency. Many hospitals already have the tools—they just need to optimize workflows.
Engage Patients and Families Revitalize your PFAC, ensure diverse representation, and include patient voices in safety planning. These steps are essential for meeting the engagement domain requirements.
Bottom Line
PSSM is more than a regulatory checkbox—it’s a reflection of your hospital’s values, culture, and commitment to safety. By preparing now, you can ensure full compliance, avoid penalties, and demonstrate leadership in patient safety.
For support with assessments, reporting, and attestation strategy, reach out regarding CereCore’s Regulatory Submissions Program. We’ve helped hospitals achieve 100% on-time regulatory submissions—and we’re ready to help you do the same.
Other Industry Sources
Editor’s note: Refer to official documentation from CMS including 2026 IPPS final rule, the final rule fact sheet, the TEAM fact sheet, and the Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule) as well as these related resources:
