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CMS presenter outlines Patient Safety Structural Measure, NHSN reporting window for 2025 attestations
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Summary
A CMS presenter summarized the Patient Safety Structural Measure (PSSM), saying hospitals must attest to five domains (five statements each) covering calendar year 2025; NHSN submissions open April 1 and close May 15, 2026. CCN-level scores use the lowest facility score.
A presenter for CMS walked through the Patient Safety Structural Measure, an attestation-based requirement that asks hospitals to confirm systems, leadership actions and patient- and family-engagement practices aimed at improving patient safety. The presenter said the measure is organized into five priority domains, and each domain contains five attestation statements hospitals must respond to.
The presenter said the measure applies to hospitals participating in the Hospital Inpatient Quality Reporting Program and the Prospective Payment System, and that the cancer hospital quality reporting program is exempt. "This measure is required for hospitals participating in the Hospital Inpatient Quality Reporting Program and the Prospective Payment System, exempt cancer hospital quality reporting program," the presenter said.
Hospitals must attest to structures, systems and processes that were in place during calendar year 2025 (Jan. 1–Dec. 31, 2025). The CMS presenter announced the NHSN submission period will run from April 1 to May 15, 2026; facilities must complete attestations in the NHSN application during that window.
On scoring, the presenter said each domain is all-or-nothing: a hospital must answer "yes" to all five statements in a domain to earn that domain's point, and there is no partial credit. "So in summary, for each domain, hospitals must attest yes to all 5 statements to earn a point," the presenter said. A facility can earn up to five points if it fully affirms implementation in all five domains.
The presenter also explained how CMS will aggregate scores for hospitals that share a single CMS Certification Number (CCN). Each facility under a shared CCN is scored separately, and if multiple NHSN org IDs under the same CCN report different scores, CMS will apply the lowest facility score to the CCN. The presenter illustrated: three facilities scoring 5, 3 and 4 would yield a CCN score of 3.
The presentation included a short interactive check to confirm participants' understanding of the scoring example. For guidance and technical help, the presenter directed hospitals to the measure resources and advised contacting the NHSN help desk with questions.
The measure presentation covered the structure and practical requirements for hospitals preparing attestations for calendar year 2025. The NHSN submission window and the all-or-nothing domain scoring are the immediate items hospitals must act on before the May 15, 2026 deadline.
