FREE CHECKLIST

PSSM Infrastructure Readiness Checklist

CMS finalized the Patient Safety Structural Measure (PSSM) as part of the Hospital Inpatient Quality Reporting Program, and hospital scores are now publicly reported on Care Compare (Medicare.gov). Every IQR-participating acute care hospital must attest annually to 25 statements across 5 patient safety domains — and hospitals that fail to report face a reduction in their annual Medicare payment update.

We built this checklist to help quality and patient safety leaders assess their infrastructure before the April 1 – May 15 attestation window and identify gaps while there is still time to act.

What Does the PSSM Readiness Checklist Cover?

• Domain 1 — Leadership Commitment: Verify that senior leadership has formally committed to eliminating preventable harm, with documented accountability and dedicated resources.
• Domain 2 — Strategic Planning and Organizational Policy: Confirm that patient safety goals are embedded in your strategic plan and that RCA2-based policies are in place and current.
• Domain 3 — Culture of Safety Measurement: Assess your SOPS survey cadence — including the pulse survey requirement in off-years — and confirm that action plans are tracked and shared with staff.
• Domain 4 — Event Reporting and Learning Systems: Evaluate whether your event reporting system, PSO membership, or learning loop documentation satisfy CMS requirements.
• Domain 5 — Patient and Family Engagement: Review your processes for receiving and tracking patient safety concerns, grievances, and complaints — and confirm leadership reviews this data quarterly.

Ready to confirm your hospital can attest with confidence before the next submission window? Download the PSSM Infrastructure Readiness Checklist and work through it with your patient safety team. It's free, and it shows you exactly which domains are covered and where the gaps are before they become a public score.