Navigating the New CMS Patient Safety Structural Measure (PSSM):
A Roadmap for Quality Leaders
Navigating the New CMS Patient Safety Structural Measure (PSSM): A Roadmap for Quality Leaders
Fellow Hospital Quality Champions - The Centers for Medicare & Medicaid Services (CMS) recently rolled out the Patient Safety Structural Measure (PSSM) - a new set of expectations designed to guide hospitals toward stronger patient safety infrastructures. Think of the PSSM not as a compliance checklist you must perfect overnight, but as a roadmap highlighting where to focus efforts over the next year.
What Is the PSSM - and Why It Matters
The PSSM outlines five key domains of patient safety structure that CMS believes drive better outcomes. While full compliance isn’t expected right now, hospitals should begin assessing and planning to close gaps. The five domains are:
Leadership & Governance: Visible commitment from senior leaders
Safety Culture: Staff engagement and psychological safety
Event Identification & Reporting: Robust processes for capturing near misses and adverse events
Risk Reduction & Safety Solutions: Proactive identification of hazards and system-based fixes
Patient Safety Education & Training: Ongoing staff development in safety best practices
Step 1: Quick Self‑Assessment
Set aside time with your patient safety team and department leaders. Here’s a simple Self-Assessment in Excel that you can download for your team. PSSM Self-Assessment and One-Year Roadmap
Step 2: Develop a One‑Year Roadmap
Based on your gap analysis, draft a phased plan. Keep initiatives manageable - focus on one or two domains each quarter. Here’s a simple roadmap that you can also download for your team. PSSM Self-Assessment and One-Year Roadmap
Step 3: Engage Your Team
Communicate Early & Often: Share PSSM context in leadership meetings, town halls, and newsletters.
Build a Multidisciplinary Task Force: Include representatives from nursing, pharmacy, IT, finance, and frontline staff.
Celebrate Small Wins: Highlight progress in monthly dashboards and huddles.
Practical Tips for Success
Leverage existing structures: integrate PSSM actions into your current quality/safety committees.
Use data you already collect: incident reports, survey results, and safety rounds.
Start small: pilot new processes in one unit before scaling hospital-wide.
Secure executive sponsorship: designate a senior leader as your PSSM champion.
Your Next Steps (Today!)
Schedule a kickoff meeting with key stakeholders this week.
Create a shared editing document for the team to add their thoughts about current compliance with each PSSM attestation statement. Ask leaders to read and add their thoughts prior to the meeting.
Identify one “quick win” action you can launch within 30 days (e.g., schedule leadership rounding).
By taking these first few steps now, you’ll transform the PSSM from a regulatory requirement into a strategic guide for building a safer hospital and will turn this roadmap into real progress - one domain at a time.