CMS Star Ratings Put Patient Safety Front and Center: Why Hospitals Must Double Down Safety Now
- EvaluCare
- Dec 10, 2025
- 6 min read
CMS made a major change to the Overall Hospital Quality Star Rating in the CY 2026 Outpatient Prospective Payment System (OPPS) Proposed Rule. The update directly elevates the Safety of Care measure group, preventing hospitals from attaining top-tier ratings if they underperform on patient safety. The intent is clear: strong scores in other domains should not overshadow weak performance in safety.
What’s Changing in the Star Rating Methodology Stage 1 (applies to 2026 Star Scores)
Hospitals in the lowest quartile for the Safety of Care measure group will be capped at a maximum of four stars, even if their overall performance would otherwise qualify them for five stars.
Stage 2 (applies to 2027 Star Scores and beyond; fully replaces Stage 1)
Hospitals in the lowest quartile for Safety of Care will receive an automatic one-star reduction in their overall rating, with a minimum possible rating of one star.
Why This Matters
Visible reputational impact: A hospital can no longer achieve five stars if its Safety of Care domain is in the bottom quartile. In 2027 and forward, an additional one-star penalty will apply for low safety performance.
Perception and strategic consequences: Star ratings influence payer negotiations, network inclusion, public perception, and downstream volume. A one-star drop can reverberate across market position and revenue.
Safety is weighted more than many realize: Hospital-acquired infections (HAIs) account for 75% of the Safety of Care measure group, which itself comprises 22% of the Overall Star Rating. Performance swings in HAIs can disproportionately move your overall star score.
Financial implications:
CMS Pay for Performance programs result in hold backs that hospitals must earn. As of now, CMS programs equate to 6% of federal reimbursement, putting millions at risk. Private insurers who have tendency to follow CMS programming will be sure to adjust quality incentive programs to put private reimbursement at risk.
The HAI Rebaseline
The CDC’s National Healthcare Safety Network (NHSN) is rebaselining HAI measures using 2022 data, the first major refresh since 2015. As of May 2025, only 7% of the rebaseline models were available, with most reports still under development.
The rebaseline:
Updates risk adjustment models for all major HAIs
Reflects changes in surveillance definitions, diagnostic testing, and prevention practices
Accounts for COVID-19-era disruptions and care evolution
Implication: Your HAI performance may look different even if your care has not changed. Expect shifts in standardized infection ratios and comparative rankings independent of actual quality improvement or decline. Combined with CMS’s safety-first Star methodology, this creates a high-stakes environment for infection prevention and safety performance.
Quality Measures to Watch Closely
HAIs: CLABSI, CAUTI, SSI (colon and hysterectomy), MRSA bacteremia, and C. difficile
HACs: Hospital-acquired conditions such as pressure injuries, falls with injury, and device-related harms
PSIs: The PSI-90 composite (e.g., postoperative sepsis, perioperative DVT/PE, iatrogenic pneumothorax), which can be affected by both care processes and documentation accuracy
Why incremental quality improvement is no longer enough A Quality Assurance Approach built for speed is needed to protect your star rating under the new methodology, adopt a QA framework that detects issues early and drives rapid improvement:
Measure what matters daily Build a safety signal pipeline for HACs, HAIs, and PSIs with clear, near real-time dashboards. Measure performance an adherence to clinical guidelines and practices that are drivers to adverse events. Measure and communicate performance continuously.
Review 100% of inpatient discharges Comprehensive care review at discharge surfaces harm, coding/documentation problems, and missed prevention steps before data are finalized. It allows documentation to be changed to increase severity of illness. It provides insights beyond the standard 1-3% of patient care that is currently reviewed.
Tight feedback loops Set expectations for time-to-detect and time-to-mitigate. Escalate quickly to unit leaders and infection prevention when thresholds are crossed.
Standardize detection and documentation Align clinicians, CDI, and coding on present-on-admission (POA) indicators and PSI definitions to reduce avoidable penalties.
Make it multidisciplinary
Include infection prevention, nursing leadership, hospital medicine, perioperative services, pharmacy, case management, CDI, and coding.
Governance and accountability Define who owns each measure, the cadence of reviews, and when issues trigger an enterprise response. Leverage individual personal mastery
Integrate Lean Six Sigma Tools, Techniques & Methodologies Ensure care delivery processes are visible. Integrate bedside audits like K-Cards flow to daily huddles where issues can be rapidly adjudicated.
Rapid Quality Improvement Tactics That Work
Limit PDSA cycles on high-risk units and procedures to days or weeks, not months, supported by frontline care data
Use Improvement and Reliability science for prevention bundles (e.g., CLABSI insertion and maintenance, CAUTI removal criteria, SSI antibiotic timing and normothermia)
Daily device necessity reviews and early removal protocols
Targeted perioperative pathways to reduce complications for hip/knee arthroplasty
Real-time CDI interventions for PSI and POA accuracy
Focused huddles around outliers and near misses; celebrate positive deviance to spread wins
Data Readiness for a Moving Target
Model your Safety of Care quartile now: Use publicly available CMS and hospital-specific data to estimate your star impact under the proposed rules.
Prepare for NHSN rebaseline: Track changes in definitions and risk adjustment, and simulate how they may alter your HAI metrics.
Strengthen abstraction and coding: Align ICD-10-based risk adjustment, POA indicators, and PSI logic with updated performance periods.
Verify measure mapping: Confirm that each safety measure feeds into the correct CMS domain, timestamps, and reporting windows.
What You Can Do Right Now
Assess your current Safety of Care performance and quartile position
Identify top drivers of harm in HAIs, HACs, and PSIs; prioritize high-volume, high-impact areas
Launch targeted QI projects with short cycle times and clear ownership and leveraging improvement science developed by organizations like IHI that leverage the Model for Improvement.
Increase the frequency and breadth of case review to catch issues. Assess your current review of patient care delivery and its ability to catch all care failures.
Engage leadership at the bedside to make safety status reports in daily huddles. Bring attention to every failure.
Engage C-Suite leadership on how star-rating projections are a reflection of patient safety and quality so that it is an standing priority
Participate in the rulemaking process moving forward.
Leverage technology and AI to automate the monitoring and processing of patient care so that data can be converted into meaningful information for clinicians on care delivered.
Broader Regulatory Context The CMS FY2026 Final Rule expands Medicare Advantage inclusion, adopts ICD-10–based risk adjustment, and transitions to two-year performance periods. Taken together, hospitals should expect changes in how performance is measured, attributed, and incentivized—making proactive safety and data readiness essential to long-term success.
The Bottom Line Under CMS’s proposed methodology, hospitals cannot achieve a five-star rating if their Safety of Care measure group is in the lowest quartile—and starting in 2027, they will face an automatic one-star reduction. With HAIs driving the majority of the Safety of Care score and the NHSN rebaseline underway, vigilance, speed, and comprehensive review are no longer optional.
Innovative Solutions EvaluCare’s Software as a Service, Eva, reviews 100% of inpatient care at discharge to surface safety issues, documentation gaps, and improvement opportunities in near real time. By closing the loop between detection and action, Eva helps hospitals strengthen HAC, HAI, and PSI performance, protect star ratings, and accelerate measurable quality gains.
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About the Author
Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.
As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.
In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.
EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.
Jason Minor, EvaluCare Executive Director
Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health
Board Chair Vermont Program for Quality in Health Care Inc.,
Vice Chair Northwestern Counseling & Support Services, Inc
Lecturer UVM College of Nursing & Health Sciences
Quality Peer Reviewer Vermont Care Partners: Centers of Excellence
Recommended Resources
· BMJ Quality & Safety
