The word "overwhelming" dominated the feedback in the CMS webinar first announcing the Patient Safety Structural Measure (PSSM) requirements. For many healthcare organizations, the timeline feels ambitious, especially given the measure's comprehensive scope across five domains of patient safety. 

Yet beneath that initial apprehension lies a more encouraging reality. As Dr. Michelle Schreiber of CMS emphasized, "This measure is not meant to be burdensome... this synergizes with work that has been going on around patient safety, frankly, for decades." The PSSM isn't asking hospitals to start from scratch — it's providing a framework to strengthen and integrate existing safety practices that many organizations already have in place and help organizations seize an opportunity to transform patient safety practices in ways that create lasting impact. 

The Clock is Ticking 

For acute care hospitals, the PSSM timeline presents both an immediate call to action and a strategic opportunity. At the time of this article’s publication the schedule looked like this: 

2025 

• January 1: Performance period begins 
• Throughout the year: Implementation and documentation for compliance with PSSM requirements 
• Q4: Begin preparing attestation documentation 

2026 

• March/April: First attestation submissions due to CMS 
• October: Results become publicly available on CMS’s Care Compare’s website 

Why Starting Early Matters 

• Rushed implementation may lead to data quality issues and gaps in documentation 
• Staff may not have time to fully understand and embrace new processes 
• Integration with existing systems and workflows becomes more challenging 

Polling in the webinar indicates that 34% of hospitals meet some requirements in each domain, and 17% meet most or all. This suggests while hospitals aren’t starting entirely from a standstill, there is still much work to be done. 

The public reporting impact in 2026 adds another layer of urgency as PSSM scores will be visible to patients, peers, and partners on Care Compare. Look at it as more than just a regulatory requirement — it's an opportunity to demonstrate your commitment to patient safety. While the measure doesn’t impose direct penalties based on scores, there are other financial considerations as reported by Mary Chris Jaklevic, an independent journalist who has covered health care finance, clinical care, and medical research for a variety of professional and consumer publications. “Hospitals will not be penalized for low scores, but Medicare payments will be reduced starting on Oct. 1, 2027, for hospitals that do not submit their data,” she notes. 

Immediate Actions Needed 

The path to PSSM compliance becomes clearer when you understand where to focus first. Early warning signs of reporting challenges often emerge in three critical areas: timeliness, resource constraints, and lack of standardization.  

Start with Leadership Engagement 

The foundation of PSSM compliance begins at the top. As Dr. Schreiber emphasizes, "By the Senior Governing Board we mean your board of governance... We don't mean a board of trustees subcommittee on quality." This distinction is crucial – PSSM requires genuine board-level engagement with patient safety, not just delegation to committees. 

Immediate actions: 

• Schedule a board presentation on PSSM requirements and implications 
• Review current safety metrics and leadership performance reviews to assess how patient safety factors into them 
• Document board-level safety commitments and oversight processes 

Assess Your Current State 

Understanding your starting point is crucial— organizations often discover they're further along than they thought — simply lacking proper documentation or integration of existing practices. Many hospitals already have strong safety practices in place but haven't mapped them to PSSM requirements. The IHI offers a free assessment guide that provides a structured way to identify your strongest domains and areas needing attention. 

Address Common Pain Points Early 

The challenges of PSSM implementation compound over time — what starts as a small reporting delay can cascade into significant compliance issues if not addressed early. By identifying and tackling these pain points early in your PSSM journey, you can develop sustainable solutions rather than rushing to fix problems under pressure. 

Timeliness Challenges: 

• Set clear deadlines for reporting safety events and automate alerts for upcoming deadlines 
• Define escalation paths for delayed responses 

Resource Constraints: 

• Reduce administrative burden 
• Streamline or automate documentation processes 

Standardization Gaps: 

• Review current safety reporting formats 
• Develop standardized safety reporting templates and processes 

Focus on Quick Wins 

The most accessible domain for many organizations is often accountability and transparency because most hospitals already have some form of safety reporting system in place. 

Early victories might include: 

• Expanding and automating safety reporting access 
• Document safety protocols and communication pathways 

Watch for Warning Signs 

Early detection of implementation challenges allows for proactive solutions rather than reactive fixes. These warning signs include: 

• Inconsistent safety event reporting 
• Delays in safety event reviews and responses 
• Limited feedback to staff reporting concerns 

This foundation-setting phase is crucial, but technology can significantly streamline these efforts.  

Technology as a Time-Saver 

As hospitals begin their PSSM journey, it's becoming clear that manual processes alone may not suffice for sustainable compliance.  

Why Manual Processes Fall Short 

The five PSSM domains require continuous documentation, monitoring, and reporting across multiple departments and stakeholders. Manual processes face several inherent challenges: 

• Inconsistent data collection and delayed reporting 
• Difficulty tracking activities and spotting trends 
• Increased administrative burden on staff 

The Power of Automation 

Automated systems can transform these challenges into opportunities for efficiency: 

Proactive Risk Management – Centralized, consistently formatted data reveals patterns that enable early risk identification and intervention, preventing future safety issues. 

Connected Documentation – Integrated systems streamline the documentation process for safety events, creating a single source of truth and improving clarity. 

Streamlined Workflows – Healthcare professionals are already pressed for time with daily responsibilities. Automated systems can: 

• Automate routing, reminders, and documentation generation 
• Populate required fields and create audit trails 

Integration Across All Five Domains 

Technology creates a unified framework that connects all PSSM domains: delivering real-time safety metrics and automated board reporting for leadership, streamlining policy management for strategic planning, standardizing reporting across shifts to build safety culture, ensuring accountability through automated workflows, and enhancing patient engagement through integrated portals.  

Beyond Basic Compliance 

While technology shouldn't be viewed as a silver bullet, the right solutions can transform PSSM compliance from a burden into an opportunity for operational excellence. The key is selecting solutions that: 

• Integrate with and reduce administrative burden of existing workflows 
• Provide meaningful insights that scale across departments and facilities 
• Adapt to evolving requirements 

Your Q1 Critical Path 

With January 2025 marking the start of the PSSM reporting period, your first quarter sets the foundation for success.  

First Quarter Milestones 

January 2025 

• Complete baseline assessment of current practices against PSSM domains and establish PSSM steering committee. 
• Begin documenting board-level safety discussions and commitments. 
• Launch initial staff communication about PSSM requirements. 

February 2025 

• Finalize gap analysis across all five domains 
• Develop action plans for identified gaps 
• Begin standardizing safety event reporting processes 
• Schedule initial patient and family advisory council meetings 

March 2025 

• Implement initial process improvements 
• Begin collecting documentation for eventual attestation 
• Launch staff training on updated safety protocols 
• Establish regular safety metric review cadence 

Your Q1 focus should be on: 

• Building on existing strengths 
• Making incremental improvements 
• Documenting current practices 
• Engaging stakeholders at all levels 

By starting early, engaging leadership, leveraging technology, and focusing on incremental improvements, healthcare organizations can not only meet regulatory requirements but also enhance their overall patient safety culture. The steps taken in these first 90 days will lay a strong foundation for sustainable success and demonstrate a genuine commitment to patient safety.