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After consideration of public comments, we are finalizing our proposal without modification to make the following two-stage methodologic updates to the Overall Hospital Quality Star Rating to emphasize the Safety of Care measure group (applicable to hospitals with at least three measures in the Safety of Care Measure Group): Stage 1: Implement a 4-star cap for hospitals in the lowest quartile of the Safety of Care measure group performance beginning in 2026 followed by Stage 2: Implement a blanket 1-star reduction for hospitals in the lowest quartile of Safety of Care measure group performance for the 2027 Overall Hospital Quality Star Ratings and later years

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Itoh, K., et al., An Nrf2/small Maf heterodimer mediates the induction of phase II detoxifying enzyme genes through antioxidant response elements