Safety is foundational: CMS is changing how patient safety measures affect hospital Star Ratings. Here’s what to know.

Coauthored by Eme Augustini, Director of Public Policy and Government Affairs.

Safety has always been the bedrock of quality care, quietly underpinning every procedure, every patient interaction, every clinical outcome. But too often, it’s been treated as a component of quality rather than its core.

All that’s changing. With new Centers for Medicare & Medicaid Services (CMS) updates to the Hospital Quality Star Ratings, patient safety will no longer simply inform the overall rating, but define its ceiling.

CMS has finalized changes to the annual Overall Hospital Quality Star Rating that will change how patient safety appears in hospitals’ public Star Ratings, starting in 2026. Safety has always been part of the Star Ratings, but it has functioned as one contributing measure group among several. Under the new approach, safety performance will do more than contribute to a hospital’s score. It can now directly limit or reduce it.

For hospitals, it is important to understand what this shift may mean for public reporting and oversight. And it should drive increased leader commitment and investment in safety and high reliability foundational work.

What CMS finalized

Under the current methodology, hospitals are evaluated across five quality domains and assigned 1 to 5 Stars based on relative performance. Historically, strong results in some areas could offset weaker performance in others.

Now, CMS has finalized a two-stage policy change focused on the Safety of Care domain:

• Beginning with the 2026 Star Ratings, hospitals that fall into the lowest performing quartile of the Safety of Care measure group (and that report at least three safety measures) will be capped at a 4-Star maximum, even if they would otherwise receive 5.
• Beginning with the 2027 Star Ratings, those same hospitals will receive an automatic 1-Star reduction, with a minimum rating of 1 Star. This policy will replace the previously described 2026 Star cap.

How the change works

The Safety of Care domain is composed largely of outcome-based measures related to healthcare associated infections and patient harm. These measures, which track hospital-acquired infections (like CAUTI, CLABSI, C. diff, MRSA, SSIs) and surgical complication rates, are standardized and averaged, and hospitals are assigned to overall Star categories using a clustering methodology based on relative performance.

For purposes of this new policy, CMS identifies low performance using quartiles rather than fixed benchmarks. Hospitals are assessed against the national distribution of Safety of Care performance, and those falling in the lowest quartile are subject to the cap or reduction if they report at least three safety measures. As a result, the policy is triggered by their comparative position rather than absolute performance, and its impact can change from year to year as hospitals move within the national rankings.

Estimating the impact

CMS has released estimates based on simulations using data from the prior year. Under those simulations, the 2026 Star cap would have affected a relatively small number of hospitals (about 14), while the 2027 1-Star reduction would apply to a larger group (roughly 450 hospitals). These estimates reflect how the policy would have operated under earlier data and are not forecasts of future outcomes.

Even so, the change has prompted hospitals to take a closer look at how Safety of Care measures factor into their overall rating. This includes examining which measures tend to differentiate performance nationally and how year-to-year variation may influence results.

This change alters how safety data function within the Overall Quality Star Rating. Measures that have long been included in the methodology now play a more direct role in shaping the final rating outcome.

Operational and reputational considerations

Operationally, the policy elevates Safety of Care from one quality domain among several to a constraining factor within the overall framework. Once the 1-Star reduction takes effect, strong performance in other areas will no longer fully offset low relative safety performance.

From a reputational perspective, the annual Star Ratings remain a widely used signal of hospital quality. Although CMS emphasizes that the Overall Star Rating does not directly affect Medicare payment, changes tied explicitly to safety may be difficult to contextualize for patients and other audiences, particularly if/when ratings change from one year to the next.

What this signals

CMS has framed these changes as part of a broader effort to reinforce patient safety as a foundational element of healthcare quality. The policy reflects that priority. At the same time, it marks a shift in how safety performance is used within the Star Ratings, moving from a contributing factor to a direct constraint on overall results.

For those leading patient safety efforts, these changes carry operational urgency and strategic opportunity. Leaders must:

• Strengthen infrastructure for high reliability: Invest in systems that prevent harm consistently and advance the march toward zero harm.
• Prioritize transparency and continuous learning: Build cultures that treat safety data not as punitive, but as fuel for ongoing improvement.
• Engage boards and executives: Make safety performance a top-level metric, with regular visibility and accountability.
• Integrate safety into reputation strategy: Recognize that public perception, consumer trust, and patient loyalty all stem from safety performance.  

This moment reinforces what many of us have long believed: Safety is the chassis of healthcare. To learn more about Press Ganey’s safety solutions, reach out to the team.