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Summary

The Patient Safety Structural Measure was developed to assess how well hospitals have implemented strategies and practices to build a safety culture and strengthen safety systems. The assessment assigns scores across five domains, and CMS will publish the scores each year. Moreover, it challenges us to go below the surface and work on foundational systems and processes that strengthen our focus on patients as we strive to attain zero harm.

What is PSSM?   

PSSM is an all-or-nothing scoring in five domains:

1.    Leadership commitment to eliminating preventable harm

2.    Strategic planning and organizational policy

3.    Culture of safety and learning health system

4.    Accountability and transparency

5.    Patient and family engagement

How do PSSM scores work?   

For a hospital to affirmatively attest to a domain & receive a point for that domain, each of the five attestation statements comprising the domain must be met. There are five possible points (one per domain). Hospitals will not receive partial points for a domain. Any “NO” on any attestation under a domain results in a score of zero for that entire domain. If a hospital can attest “Yes” at any time during the applicable reporting period (January 1 through December 31), it will satisfy the domain requirement.

These scores are mandatory for acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) & the Prospective-Payment System with an exemption for cancer hospitals. It excludes statutorily exempted children’s, inpatient psychiatric, LTC, & rehabilitation facilities. Critical Access hospitals can voluntarily report. See https://www.federalregister.gov/d/2024-17021/p-3553 for more information on scoring.

Why is PSSM important?

There are several reasons PSSM is important for organizations:

• The five domains represent critical areas of focus, ensuring that the measure will guide hospitals in prioritizing patient safety in their organization’s structure, culture, strategy and overall care delivery.
• By evaluating these foundational components, we can discern whether a hospital demonstrates adequate structure, culture and leadership commitment to prioritizing safety.
• CMS has worked to ensure that the measure is anchored in best practices. This aims to improve patient safety and reduce harm by using a total systems framework (i.e., viewing patient safety events as the result of system failures rather than individual errors). The measure has been structured to assess processes and outcomes specifically. (See https://www.ihi.org/national-action-plan-advance-patient-safety)
• The PSSM scores can impact your organizational reputation, both positively and negatively. Moreover, the details uncovered in your assessment can help guide future strategies and program implementation, ideally fostering greater consensus towards building a safety culture. CMS will publicly display the hospital’s measure performance score, which will range from 0 to 5 points, annually. The CY 2025 performance score will display on the Compare tool on Medicare.gov for the Hospital IQR Program (https://www.medicare.gov/care-compare/) and the Provider Data Catalog for the PCHQR Program beginning in the fall of 2026. (See https://data.cms.gov/provider-data/ for more information.

If a hospital is comprised of more than one acute care hospital facility under one CMS Certification Number (CCN), all facilities sharing the same CCN will need to satisfy domain criteria for a positive (i.e., “Yes”) attestation.