In August 2024, the Centers for Medicare & Medicaid Services (CMS) introduced a new Patient Safety Structural Measure (PSSM) as part of its hospital Inpatient Quality Reporting Program (IQR Program). PSSM is an attestation-based requirement for the IQR Program intended to drive action and improve patient safety. Unlike traditional quality measures that focus on outcomes, the PSSM assesses the organizational infrastructure that enables patient safety.
What Hospitals Must Attest To
The measure evaluates whether hospitals have implemented foundational safety practices across five domains, including:
- Leadership commitment to eliminating preventable harm;
- Strategic planning and organizational policy;
- Culture of safety and learning health systems;
- Accountability and transparency in safety reporting; and
- Engagement of patients and families in safety initiatives.
Hospitals affirmatively attesting to all statements in each domain will receive the maximum five points. A hospital’s final score will be between zero and five, based on the number of domains for which all statements were affirmed, and these scores will be publicly reported beginning in 2026.
Reporting Timeline
Attestation reporting occurs annually, with hospitals attesting to whether specific safety practices were in place during the prior calendar year (CY). Hospitals submit their annual PSSM attestation through the National Healthcare Safety Network portal. Hospitals participating in the IQR Program should be aware of the following deadlines:
- For the CY 2025 reporting period, the measurement period is from January 1, 2025, through December 31, 2025.
- The data submission period for the PSSM program will take place between April 1 through May 15, 2026.
- CY 2025 PSSM performance scores will display on the compare tool on Medicare.gov beginning fall 2026.
Consequences of Non-Compliance
While the safety initiatives themselves are technically voluntary, reporting them is mandatory to avoid penalties. Failure to comply with the PSSM reporting requirements may have significant financial and reputational implications, including:
- Reduced Reimbursement: hospitals that do not report PSSM data will face reduced payments in fiscal year 2027.
- Public Reporting and Reputation: failure to report will be reflected on CMS Care Compare, impacting public perception and potentially reducing patient volume.
What Hospitals Should Do Now
CMS’s PSSM represents a significant shift toward evaluating the systems and leadership structures that support safe care, rather than focusing solely on clinical outcomes. Hospitals that proactively review and strengthen their safety governance and documentation will be best positioned to meet CMS requirements and avoid reimbursement risk.
Health care organizations that have questions about how these requirements apply to their operations or that are considering conducting a readiness assessment may benefit from a review of their current patient safety structures and reporting processes in advance of the first reporting deadline.
This blog was drafted by Hillary R. Martel, an attorney in the Spencer Fane Overland Park, Kansas, office. For more information, visit www.spencerfane.com.
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