CMS has made severe hyperglycemia and severe hypoglycemia reportable hospital-harm measures. The reporting requirement is here, and the payment consequence arrives in the 2028 determination. A meaningful share of these events originate in the perioperative pathway, where the surgical stress response, the steroids, the prolonged fasting and the insulin transitions around an operation make dysglycemia common and its management genuinely hard.
That is the part of the hospital most quality programs have not been watching for this measure. Perioperative hyperglycemia occurs in 20% to 40% of patients undergoing general surgery and in as many as 80 percent after cardiac surgery, and a sizable fraction of those events occur in patients who carry no diabetes diagnosis at all. The board that prices this measure as a documentation problem for the endocrinology service is pricing the wrong thing.
What the measure is, and when it cuts
Two electronic clinical quality measures sit at the center of this. The first, Hospital Harm — Severe Hypoglycemia (CMS816), counts inpatient hospitalizations in which a patient had a glucose result below 40 milligrams per deciliter within a defined window after receiving a qualifying hypoglycemic medication. The temporal link is the point of the measure, which is built to capture treatment-related harm rather than spontaneous low glucose. The second, Hospital Harm — Severe Hyperglycemia (CMS871), counts inpatient hospital days with a glucose above 300 milligrams per deciliter, on days two through 10 of the stay. Both were finalized in the federal fiscal 2025 inpatient prospective payment system final rule, and both are part of the Hospital Inpatient Quality Reporting program beginning with the 2026 reporting period.
The payment mechanism is worth stating precisely, because it is easy to exaggerate and a keen audience will catch the overstatement. Hospital Inpatient Quality Reporting is a pay-for-reporting program. A hospital that does not satisfy the program’s requirements forfeits a portion of its annual payment update, one-quarter of the market-basket increase. The 2026 reporting period corresponds to the 2028 payment determination. So the honest framing is not that a hospital will be penalized in 2028 for a high hypoglycemia rate the way it is penalized under value-based purchasing for a poor readmission record. The honest framing is that the measure becomes public, comparable and tied to the reporting requirement now, and that the trajectory of CMS measurement runs in one direction. Measures that begin as public reporting become measures that move money.
The size of the reporting stake is worth making concrete, because it is the part a board can act on. The reduction applies to the hospital’s annual Medicare inpatient payment update, a one-quarter forfeiture of the market-basket increase. CMS set the fiscal 2026 market-basket increase at 3.3%, which puts the one-quarter reduction at roughly eight-tenths of a percentage point of the inpatient payment update. For a 200-bed community hospital carrying $70 million to $115 million in annual Medicare revenue, that lands on the order of $575,000 to $950,000 in a single fiscal year, and it scales into the millions for a large tertiary system. That is the price of missing the reporting requirement, before a single dollar is ever tied to the rate itself. The hospitals that wait for the second step, where the number moves payment directly, to plan for the first will be doing remedial work under time pressure.
Why the operating room is where this number is won or lost
Severe dysglycemia is not a surgical measure. It is an inpatient measure, and it captures events on the medical floors, in the intensive care unit and across the whole hospitalization. The reason the perioperative pathway deserves a disproportionate share of the executive team’s attention is that it is both a major source of these events and the part of the hospital with the infrastructure to manage them well.
The surgical stress response raises blood glucose, reliably, even in patients who have never carried a diabetes diagnosis. Lowering perioperative glucose is consistently associated with reduced surgical site infection, and the association is strong enough that the CDC’s surgical site infection guidance recommends perioperative glycemic control with a target below 200 milligrams per deciliter for surgical patients. The harder truth sits one step beyond that recommendation. Pushing glucose down without protocol discipline trades infection risk for hypoglycemia risk and moves events out of one measure and into the other. A hospital that attacks the hyperglycemia measure aggressively, without the protocol discipline to manage the descent, will discover its hypoglycemia rate climbing in response.
The perioperative service line is where that balance is struck in real time, across the highest-acuity cases in the building, by the anesthesia team that manages glucose intraoperatively and the recovery team that manages the transition out. The institutions that already run Enhanced Recovery After Surgery protocols have part of the answer in place, because preoperative carbohydrate loading and the avoidance of prolonged fasting improve insulin sensitivity and reduce postoperative hyperglycemia. The protocol infrastructure that a strong perioperative program has built for recovery is the same infrastructure this measure rewards.
The handoff is where the measure is lost
The transition out of the perioperative environment is the structural weak point. A patient’s glucose is managed attentively in the operating room and the post-anesthesia care unit, where the staffing ratios are rich and the monitoring is continuous. The patient then moves to a floor where an insulin order written for the perioperative state meets a different nursing ratio, a different feeding status, and a different pace of glucose checks. Severe hypoglycemic events cluster at exactly these transitions, when a sliding scale or a basal dose calibrated for one environment carries into another. The measure does not care which side of the handoff produced the event. It counts the result.
Most hospitals cannot yet say what share of their own severe dysglycemia events run through the perioperative pathway, because the data is not organized to answer the question, even though the prevalence literature makes clear the surgical contribution is substantial. That gap is itself the first piece of work, and the answer, when a system goes looking for it, is often larger than expected.
What an operator can do before the 2028 determination
The measure rewards preparation that starts now and punishes the system that waits for the penalty to become real before it builds the response. Five actions are available to most systems this fiscal year. They are listed roughly in order of effort, lowest to highest.
1. Find out where your dysglycemia events originate. Before any protocol changes, commission an analysis that maps severe hyperglycemia and severe hypoglycemia events against the perioperative pathway, surgical versus medical admission, proximity to an operative date, and the location of the event relative to the post-anesthesia care unit handoff. This analysis links anesthesia and operating-room records, admission-discharge-transfer location data, and encounter-level glucose results, which in most systems do not sit in a single warehouse. Assign it to quality analytics with explicit access to the perioperative and EHR data, give it a defined scope and a reporting date, and resist the pull to boil the ocean on the first pass. The deliverable tells the executive team how much of the measure is actually a perioperative measure for their institution.
2. Name a single owner for glycemic management across the perioperative continuum. Responsibility for glucose in the surgical patient is usually distributed across anesthesiology, surgery, hospital medicine, nursing and endocrinology, which leaves it diffuse, and diffuse responsibility falls through the handoffs. Name a physician owner for perioperative glycemic management, give the role decision rights over the perioperative glycemic protocols and the post-anesthesia-care-unit handoff standard, a defined share of protected time rather than an unfunded addition to a full clinical load, and a direct line to the existing diabetes or glycemic-control committee. The chief medical officer should bring this assignment, with its scope and its time commitment, to the next executive team meeting.
3. Standardize the handoff, because that is where the hypoglycemia events live. Build an explicit standard for the insulin and glucose handoff from the post-anesthesia care unit to the receiving floor, including reconciliation of perioperative insulin orders against the patient’s new feeding status and monitoring cadence. This is a protocol and education task, not a capital one, and it addresses the single highest-yield source of severe hypoglycemia events.
4. Use the Enhanced Recovery infrastructure you have already built. A system running ERAS protocols has the carbohydrate-loading, fasting-avoidance, and glucose-monitoring scaffolding that the hyperglycemia measure rewards. Extend the glycemic components of those protocols deliberately to the service lines where they are not yet standard, and connect the ERAS compliance data to the measure rather than tracking the two separately. The marginal cost is low because the foundation exists.
5. Make severe dysglycemia a named, baselined metric in front of the CFO now. The measure will be public and comparable in the 2028 determination window. A hospital that establishes its baseline this fiscal year, reports it to the executive team on a defined cadence and watches the trend has the information to manage the number while there is still time. A hospital that first encounters its own rate when CMS publishes it has surrendered the planning window. The CFO should see this measure on the quality report this quarter, with a baseline and a target.
The strategic argument worth making to the board
The reflexive way to read a new CMS measure is as a reporting obligation, a box the quality department checks so the payment update is not reduced. That reading is available here, and it is a mistake. Severe dysglycemia is a measure of how well an institution manages a genuinely difficult clinical problem at its highest-acuity moments, and the perioperative service line is where that management is most concentrated and most improvable. A system that treats this as a documentation exercise will produce documentation. A system that treats it as a perioperative quality program will produce lower infection rates, fewer hypoglycemic events, shorter stays and a measure that takes care of itself because the underlying care improved.
The window is the part most boards underestimate. The reporting requirement is here, the public comparison arrives with the 2028 determination, and the trajectory of CMS measurement is toward tying this number to payment in the fuller sense over time. The institutions that build the perioperative glycemic program now will be the ones reporting a measure they are already managing. The institutions that wait will be building the program and explaining the number in the same fiscal year. One of those is a strategy. The other is a scramble.
The measure is coming. The place to meet it is the operating room.
David M. Wild, MD, MBA, is Chief Clinical Officer at Essential Anesthesia Management and a practicing transplant anesthesiologist. He writes on healthcare leadership, and on the rooms where decisions about clinicians and patients get made, at Past the Door (pastthedoor.com).
Sources
- CMS, Hospital Harm — Severe Hyperglycemia (CMS871), eCQI Resource Center: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0871v5
- CMS, Hospital Harm — Severe Hypoglycemia (CMS816), eCQI Resource Center: https://ecqi.healthit.gov/ecqm/hosp-inpt/2025/cms0816v4
- CMS, FY 2025 IPPS/LTCH PPS Final Rule (CMS-1808-F), adopting the two eCQMs into Hospital IQR beginning with the 2026 reporting period: https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0
- CMS, FY 2026 IPPS/LTCH PPS Final Rule (CMS-1833-F), FY2026 market-basket increase of 3.3 percent; IQR reduction of one-quarter of the market-basket increase: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0
- Frisch A, et al., Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery, Diabetes Care 2010;33(8):1783-1788: https://diabetesjournals.org/care/article/33/8/1783/39178/Prevalence-and-Clinical-Outcome-of-Hyperglycemia
- Duggan EW, Carlson K, Umpierrez GE, Perioperative Hyperglycemia Management: An Update, Anesthesiology 2017;126(3):547-560: https://pubs.asahq.org/anesthesiology/article/126/3/547/19751/Perioperative-Hyperglycemia-ManagementAn-Update
- Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection, PMID 27901264: https://pubmed.ncbi.nlm.nih.gov/27901264/
- Berrios-Torres SI, et al., CDC Guideline for the Prevention of Surgical Site Infection, 2017, JAMA Surgery 2017;152(8):784-791: https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725
- KFF, Key Facts About the Hospital Industry: https://www.kff.org/health-costs/key-facts-about-hospitals/
- Definitive Healthcare, Revenue Trends at U.S. Hospitals: https://www.definitivehc.com/blog/revenue-trends-at-u.s.-hospitals
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