CMS Patient Safety Structural Measure (PSSM) Toolkit

A comprehensive, operations-focused toolkit that helps hospitals understand, implement, and operationalize the CMS Patient Safety Structural Measure (PSSM) to strengthen governance, leadership engagement, and patient safety culture. 

Who it’s for:

This toolkit is designed for multidisciplinary leaders responsible for patient safety, governance, and compliance, including:

  • Enterprise Risk Managers overseeing governance and regulatory readiness
  • Patient Safety Leaders managing reporting systems and improvement efforts
  • Quality & Performance Improvement Leaders aligning safety structures with outcomes
  • Clinical Leaders & Service Line Directors  who are accountable for operational execution
  • Executive Sponsors & Board Liaisonswho are responsible for leadership accountability and oversight
  • Additional users may include compliance, accreditation, legal/risk counsel, analytics teams, and system-level leaders. 
     

What it can be used for:

Organizations can use this toolkit to:

  • Translate CMS expectations into practical, organization-ready actions
  • Prepare for PSSM attestation and scoring using CMS’s all or nothing methodology
  • Strengthen governance structures, leadership accountability, and safety culture
  • Evaluate and refine patient safety programs, competencies, and system-wide processes
  • Guide strategic planning, safety metrics, workforce safety initiatives, and just culture implementation
  • Support cross-functional alignment between risk, safety, quality, clinical leadership, and boards
  • Build documentation and evidence structures that demonstrate compliance and safety maturity
     

What’s inside:

  1. Purpose & Foundations of the PSSM
  2. Practical Tools & The Five PSSM Domains: Including detailed guidance, attestations, examples, and peer comment clarification for each domain
  3. Risk Considerations
  4. Resource Hub
  5. Role- and Setting-Based Variations: Small and rural hospitals, larger systems, and operational vs ERM perspectives
     

 

Access the Tip Sheet

Strengthen governance structures, leadership accountability, and safety culture.