The Centers for Medicare & Medicaid Services (CMS) has launched a new framework of Patient Safety Structural Measures (PSSMs) as part of the FY 2025 Hospital Inpatient Prospective Payment System (IPPS) rule. These measures are designed to assess whether hospitals have the necessary structures and processes to support patient safety effectively. As a Director of Quality or Patient Safety, comprehending these changes is crucial not only for compliance but also for advancing your hospital’s safety culture and patient outcomes. This guide provides an in-depth analysis of the new measures, their domains, reporting requirements, and practical strategies for successful implementation. For additional insights, explore our national patient safety goals guide to reinforce your hospital’s safety framework.
CMS’s shift to structural measures reflects a proactive approach to patient safety, emphasizing the importance of having robust organizational structures that can prevent harm before it occurs. This approach is rooted in the idea that hospitals with strong safety foundations—such as leadership involvement, effective policies, and a supportive culture—are better equipped to achieve positive patient outcomes and reduce adverse events.
The new PSSM is aligned with recommendations from key healthcare safety frameworks, including the Institute for Healthcare Improvement’s (IHI) “Safer Together: The National Action Plan to Advance Patient Safety” and the President’s Council of Advisors on Science and Technology’s (PCAST) 2022 report (Association of Health Care Journalists)(Press Ganey). This measure includes 25 attestation statements that span across five domains and shifts focus from traditional outcome metrics, such as infection rates and patient falls, to evaluating the organizational practices that support positive outcomes. The measure applies to hospitals participating in CMS’s Hospital Inpatient Quality Reporting Program and the PPS-Exempt Cancer Hospital Quality Reporting Program, and hospitals’ overall scores will be publicly reported on the Care Compare website.
This domain examines how the hospital’s senior leadership and governing board integrate patient safety into strategic priorities and daily operations.
Attestation Statements for PSSM Domain 1 |
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| 1. | Our hospital 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. |
| 2. | Our hospital leaders, including C-suite executives, 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. |
| 3. | Our hospital governing board, in collaboration with leadership, ensures adequate resources to support patient safety (such as equipment, training, systems, personnel, and technology). |
| 4. | 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. |
| 5. | 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. |
This domain assesses how hospitals have embedded patient safety into their strategic planning processes and organizational policies.
Attestation Statements for PSSM Domain 2 |
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| 1. | Our hospital 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.” |
| 2. | Our hospital 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. |
| 3. | Our hospital 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. |
| 4. | Our hospital 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. |
| 5. | Our hospital 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. |
This domain measures the hospital’s ability to foster a learning environment that continuously improves patient safety.
Attestation Statements for PSSM Domain 3 |
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| 1. | Our hospital 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. |
| 2. | Our hospital 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 (RCA²). |
| 3. | Our hospital 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). |
| 4. | Our hospital implements a minimum of 4 of the following high reliability practices:
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| 5. | Our hospital participated 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. |
In order to learn from safety data and eliminate preventable harm, a strong, healthy culture of safety that promotes event reporting must exist. Hospitals must demonstrate that they operate with transparency and hold themselves accountable for safety performance.
Attestation Statements for PSSM Domain 4 |
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| 1. | Our hospital 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. |
| 2. | Our hospital reports serious safety events, near misses, and precursor events to a Patient Safety Organization (PSO) listed by AHRQ that participates in voluntary reporting to AHRQ’s Network of Patient Safety Databases. |
| 3. | Patient safety metrics are tracked and reported 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). |
| 4. | Our hospital 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:
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| 5. | Our hospital uses standard measures to track the performance of our communication and resolution program, and reports these measures to the governing board at least quarterly. |
Hospitals should incorporate patients, families, and caregivers as co-producers of safety and health through meaningful involvement in safety activities. This domain focuses on delivering safer, better care by involving patients and families in safety efforts.
Attestation Statements for PSSM Domain 5 |
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| 1. | Our hospital 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. |
| 2. | Our hospital’s PFAC includes patients and caregivers of patients who are diverse and representative of the patient population. |
| 3. | 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. |
| 4. | Our hospital 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). |
| 5. | Our hospital 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. |
The CMS Patient Safety Structural Measure is an annual attestation-based measure that will be reported through the National Healthcare Safety Network (NHSN) platform. Hospitals must begin submitting PSSM data in the 2025 calendar year. The first public reporting of scores will occur in the fall of 2026, with a scale of 0 to 5 points based on compliance with the five domains. All statements within the domain must be affirmed for the hospital to receive a point for that domain. While no penalties are associated with low scores initially, failure to submit data by October 1, 2027, will result in reduced Medicare payments (Association of Health Care Journalists)(Centers for Medicare & Medicaid Services).
For Directors of Quality and Patient Safety, these measures underscore the importance of a robust, proactive approach to safety. The focus on structural and cultural elements means that hospitals must look beyond compliance and actively work to build a sustainable, high-reliability organization. This shift requires:
The new CMS Patient Safety Structural Measure represents a pivotal change in how hospital safety is evaluated and managed. For Directors of Quality and Patient Safety, these measures offer a framework for building stronger, more resilient systems that prioritize patient safety at every level. By proactively engaging with these measures and aligning organizational practices with CMS’s expectations, hospitals can not only improve compliance but also foster a culture of safety and excellence in patient care.
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