Quality and Safety

Committed to the Perfect Care Experience

A Vision as high as the Sierra

Our goal is simple and our vision is clear: To serve our region by striving to be the best mountain health system in the nation.

At Tahoe Forest Health System, we strive to deliver the highest quality medical care experience to you and your family. Our strong commitment to patient safety is evidenced in everything we do.  We benchmark ourselves against the best hospitals in the nation, which helps us in our quest to offer every patient and family a Perfect Care Experience.

Our employees and physicians are passionate about providing you with the very best medical care. And they do it because they care about you, their friends, neighbors and visitors.

Patient safety and satisfaction is our highest priority, and we're aiming high.


Meeting Your Needs Through Safe, Timely, Effective, Efficient, Equitable Patient-Centered Care (STEEEP)

At Tahoe Forest Health System, we have adopted the Institute of Medicine's aims for quality and patient safety, called "STEEEP."  This framework is aligned with the Institute for Healthcare Improvement's Triple Aim initiative, whose goal is to improve the health of the population, enhance the patient healthcare experience, and reduce healthcare costs. 

We've also adopted the Institute of Medicine's six specific aims for quality and patient safety called STEEEP™.


Rated 5 Stars for Patient Satisfaction

We are proud of our many recognitions for high quality in rural health care delivery.

Because of our strong focus on quality, performance excellence, innovation and excellent patient care, Tahoe Forest Health System was recently 5 Stars by Centers for Medicare and Medicaid Services. For more information on our quality, performance excellence and patient satisfaction recognitions, click on the links below:

5-Star Rating by Centers for Medicare and Medicaid Services for Patient Satisfaction (2014-2015)
The Centers for Medicare and Medicaid (CMS) awarded its first-ever star ratings to hospitals based on their patient satisfaction scores. Many of the nation's best known hospitals received average ratings, but Tahoe Forest Hospital was one of the few hospitals nationally that received an exceptional 5-star rating.  No other Reno-Tahoe hospital received a 5-star rating, and only eight hospitals in the state of California received one. These scores are meant to help consumers compare hospital quality measurements. Read more about it here.

Named on of America's Top 100 Critical Access Hospitals in 2012
Tahoe Forest Hospital was named one of the Top 100 hospitals in the country by the National Rural Health Association, one of only four in the state of California. Read more about it here.

UC Davis Rural Center of Excellence
Being designated a UC Davis Rural Center of Excellence recognizes a commitment to offering quality care in our community. Bridging gaps in health care services, linking to specialists, and giving physicians access to the latest medical education and training is important. Read more about it here.

Proud Affiliate – UC Davis Comprehensive Cancer Center
We are a proud affiliate of the UC Davis Comprehensive Cancer Center, a network that unites five hospital-based cancer centers dedicated to providing exceptional cancer treatment in rural settings. Read more about it here

UC Davis Rural PRIME Medical Education Program
Tahoe Forest Hospital has partnered with UC Davis School of Medicine to offer an innovative training program for third and fifth year medical students with local primary care physicians. Read more about the Rural Partners in Medical Education Program here.

CAPE Gold Recipient for Performance Excellence
Tahoe Forest is a recognized for world-class service and performance excellence by the California Awards for Performance Excellence (CAPE). For more information, click here.

Commission on Cancer Accreditation with Commendation
click here.

Baby Friendly
Tahoe Forest Hospital is certified "Baby Friendly." For more information about our commitment to the highest quality of care, support and education for infants, read here.

Five Star Service Rated Children's Center
Tahoe Forest Hospital's Children's Center is rated 5 stars by the Nevada County Child Care Coordinating Council, read more here.

Excellence in Innovation and Quality
The National Rural Resource Center awarded Tahoe Forest Hospital with the Excellence in Innovation and Quality award.  Read more here.

America's Best Hospitals for Obstetrics
The TFH Women and Family Center was awarded the Women's Choice Award for being one of the best hospitals for obstetrics.  Read more here.

CALNOC Performance Excellence Award
Tahoe Forest Hospital was recently recognized for excellent performance in the reduction of hospital acquired pressure ulcers, injuries from falls and infections. Read more here.

Tahoe Forest Hospital and Incline Village Community Hospital are accredited by the Healthcare Facilities Accreditation Program (HFAP), an organization authorized by the Centers for Medicare and Medicaid Services (CMS) to survey all hospitals for compliance with the Medicare Conditions of Participation and Coverage. For more information on HFAP, go to www.hfap.org.

Have a question about our Quality Program?

We'd love to hear from you! Providing easily accessible information to our patients and families is just one way of making decisions about your health care. We encourage you to contact our Quality and Regulations Department with questions you may have about the information on these pages.

Janet Van Gelder, RN, DNP, CPHQ, NEA-BC
Director of Quality and Regulations
(530) 582-6629


One of the Nation's Highest Ratings for Patient Satisfaction

Tahoe Forest Health System consistently exceeds national and state averages for patient satisfaction. And through Press Ganey, the country's leading healthcare survey company, we're continually apprised of our performance.

Chart of Tahoe Forest Hospital HCAPS scores
HCAHPS (pronounced "H-caps") stands for the Hospital Consumer Assessment of Healthcare Providers and Systems.  HCAHPS is a core set of quality measures that complement the data hospitals currently collect to support improvements in internal customer services and quality.  HCAHPS is the national standard for collecting and publicly reporting information about a patients experience of care, and allows for valid comparisons to be made across hospitals locally, regionally and nationally.

One of the Nation's Safest Health Systems, Demonstrating the Highest Patient Safety Standards

Quality control for any health system includes preventing health-care associated infections (HAI). At Tahoe Forest Health System, HAI are rare because of our rigorous prevention and control program which includes patient and family centered communication and education. For surgical procedures, pre and post-op preparation as well as post-discharge, patient instruction promotes desirable patient outcomes.

We follow the Centers for Disease Control (CDC) guidelines to track the incidence of HAI and report the results regularly.

Chart of Tahoe Forest Hospital's very low surgical site infection rate
Delivering high quality health care is a top priority for every physician, nurse and other healthcare workers in every department throughout the health system. We're proud of our personalized and compassionate high quality care, and our patients agree. For example, in 2015, total hip and knee replacements totaled 248 surgeries, and no surgical site infections, based on Centers for Disease Control (CDC) criteria, occurred.

Why is Healthcare Infection Prevention (HAI) Important to You?

Every patient or visitor of Tahoe Forest Health System can be assured that our infection control and prevention standards are rigorous and based on evidence-based practice endorsed by the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control (APIC) as well as local and state health agencies.

To combat infections takes intention. Patient care and support staff are trained in infection prevention and control safe practices. While anyone can get an infection, those at higher risk are identified. Infection prevention is a key factor to help our patients recover quickly and stay healthy.

HAI Prevention Practices at Tahoe Forest Health System include:

  • Ongoing personal hygiene education for all of our healthcare providers, including an aggressive seasonal flu prevention program
  • Hospital visitor education that encourages hand hygiene upon entering and exiting a patient room, and not visiting if sick
  • A focus on safe work practices: hand hygiene, cleaning and disinfection, safe injection practices and use of face protection, gloves, and gowns when needed
  • Patient education and infection prevention tools prior to, and upon admission, plus follow-up after discharge
  • Giving the recommended antibiotics at the right time before surgery
  • Stopping antibiotics within the right time after surgery
  • Maintaining patients blood sugar and temperature
  • Removing catheters used to drain the bladder in a timely manner after surgery


We also reduce the risk of cardiac problems associated with surgery by:

  • Making sure that certain prescription drugs are continued before, during and just after the surgery. This includes drugs used to control heart rhythms and blood pressure.
  • Giving drugs that prevent blood clots, and using other methods such as special stockings to increase circulation in the legs.

To learn more, about HCAHPS Star Ratings, click here.

To learn more, about how Tahoe Forest Hospital measures up, click here


Chart of Tahoe Forest Hospital's Surgical Care Improvement program
Patients who are admitted to the hospital for treatment of medical problems sometimes get other serious injuries, complications, conditions, and may even die.  Some patients may experience problems soon after they are discharged and need to be admitted to the hospital again. These events can often be prevented if hospitals follow best practices for treating patients.

How We Demonstrate High Quality Care

Pneumonia is a serious lung infection that causes difficulty breathing and is accompanied by fever, cough and fatigue. This table shows the recommended treatment for pneumonia patients, and how TFHS compares to California hospitals and National averages.

We encourage you to contact our Quality and Regulations Department with questions you may have about the information on these pages.

Char of Tahoe Forest Hospital's Pneumonia Measures program

Lower Than Expected C-Section Rates

While some women voluntarily choose to deliver their baby by c-section, the most common reasons women have a cesarean delivery before going into labor include:

  • The mother had a previous c-section
  • The baby is breech (head is not coming out first)
  • The baby needs to be delivered many weeks before the due date
  • The baby is very large
  • The mother has an infection, such as herpes or HIV, that can be transmitted to the baby during a vaginal birth
  • The mother is carrying to or more babies
  • The mother has a condition called "placenta previa," in which the placenta blocks the baby's way to the vagina and the baby can't get out on its own

Chart of Tahoe Forest Hospital's low c-section rates compared to the National Average
A c-section is a type of surgery used to deliver a baby as an alternative to traditional vaginal delivery. During a c-section, anesthesia is administered so the patient won't feel pain. The doctor makes an incision in the mother's belly and removes the baby from her uterus. About one in three babies in the United States is born through cesarean delivery.

Emergency Department Waiting Time

Coordination of health care is important, and TFHD is dedicated to continuous quality of care improvements to benefit our patients. The Centers for Medicare and Medicaid now publicly report Emergency Department (ED) times from arrival to being seen by an Emergency Department physician, as well as time from the decision to admission to being moved to a inpatient bed or discharged. This is supported by the National Quality Forum, the American College of Emergency Physicians and the Emergency Nurses Association.

Emergency Departments sort patients (triage) according to the severity of illness or trauma with the most severe being seen first. TFHD ED is committed to providing a medical exam of patients as quickly as possible upon arrival, and has maintained an average time from arrival to being seen by a physician to 15 minutes for all patients – well higher than the national average. Average wait times for Emergency Departments with less than 20,000 annual visits is 33.8 minutes. Hospital Emergency Departments with more than 50,000 annual visits report an average wait time of 69. 8 minutes.

Graph of Tahoe Forest Hospital's Emergency Department arrival to evaluation time

Have a question about our Quality Program?

We'd love to hear from you! Providing easily accessible information to our patients and families is just one way of making decisions about your health care. We encourage you to contact our Quality and Regulations Department with questions you may have about the information on these pages.

Janet Van Gelder, RN, DNP, CPHQ, NEA-BC
Director of Quality and Regulations
(530) 582-6629