Quality and Safety

At Tahoe Forest Health System, we know you have choices when it comes to your healthcare. And when you choose us, we promise to offer the highest quality care and best experience from the moment you walk in the door. This commitment to you, the communities we serve, is what sets us apart from the rest.

Quality and Safety Defined

"It’s great seeing a health care provider that makes you feel like [they] have time for you."

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

We have adopted the Institute of Medicine's ‘STEEEP’ framework to deliver quality and patient safety within our hospital district. This means that we are focused on providing the following:

Safe – Your safety comes first
Timely – Care will be delivered in the most-timely manner possible
Effective – Care will be based on the best science available
Efficient – Care will avoid waste of money, time and resources
Equitable – Access to care will be provided in an equitable manner
Patient-Centered – Patients will participate fully in care decisions

"Top notch staff and facility from the front desk, physicians, IV Unit, Radiology, to support. You’ve set the standard for care and treatment. P.S. YOU SAVED MY LIFE! Thanks are not enough!"

Star Rating

The Centers for Medicare and Medicaid Services (CMS) rate facilities on their ability to provide great care with a great patient experience, and it is our goal to make sure you receive both. With the highest rating awarded being 5 Stars, we are pleased to tell you we are typically rated 4 or 5 Stars in patient satisfaction and quality of care.

Visit Care Compare to see Tahoe Forest Hospital's performance here and Incline Village Community Hospital's performance here.

Patient Satisfaction

HCAHPS (pronounced "H-caps") stands for the Hospital Consumer Assessment of Healthcare Providers and Systems and defines a core set of patient satisfaction metrics that complement the quality data hospitals collect to support improvements. HCAHPS is the national standard for collecting and publicly reporting information about a patient’s experience of care, and allows for valid comparisons to be made across hospitals locally, regionally and nationally.

Tahoe Forest Hospital District is proud to announce that we consistently exceed state and national averages in all categories of patient satisfaction.

Data source is Press Ganey. Reporting period is 10/01/2020 – 12/31/2020.
In this context, higher values demonstrate better performance.

Patient Satisfaction Surveys

At Tahoe Forest Health System, we believe that patients should make informed choices about their health care and physicians. We also believe that transparency is critical. For these reasons, we measure all aspects of patient satisfaction using an independent patient satisfaction company named Press Ganey.

Read more about our Patient Satisfaction Surveys.

Patient Family Advisory Council

Our health system values the perspectives of our patients, families, and communities. As part of our commitment to provide every patient and family with the best experience possible, we have a Patient and Family Advisory Council (PFAC) made up of community volunteers that meets regularly to discuss hospital based operations and how to better serve our community.

If you would like to serve on our Patient and Family Advisory Council, or know of anyone else that may be interested, we would appreciate speaking with you to discuss the important work that this Council does to improve the services at Tahoe Forest Hospital District. You can contact our Patient Experience Specialist at (530) 582-6567.

"I was amazed how caring and knowledgeable my care provider was…I felt like she listened well and understood what my symptoms were and how to best treat them."

Surgical Site Infections

At both Tahoe Forest Hospital and Incline Village Community Hospital, hospital-acquired infections (HAI) are rare because of our focus on infection prevention. All caregivers and support staff are trained in infection prevention, early identification, and various control practices. Additionally, our infection control and prevention standards are evidence-based and endorsed by the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control (APIC), and local and state health agencies. Together, these efforts contribute to desirable patient outcomes. We spend time and effort on these practices because infection prevention is a key factor to help our patients recover quickly and stay healthy.

Data source is TFH internal surgical data from 01/01/2012 – 12/31/2020.
In this situation, lower values demonstrate better performance.

Learn more about how Tahoe Forest Hospital District measures up.

If you have questions about HAI, feel free to reach out and talk with our Infection Preventionist at (530) 582-8231.

"Great service from the entire staff – everyone was very helpful and attentive!"

C-Section and NTSV Rates

A Caesarean section (C-section) is a type of surgery used to deliver a baby as an alternative to a vaginal delivery. During a C-section, anesthesia is administered so the patient will not 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.

The nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate has become the obstetric quality measure to watch, representing the low risk population for cesarean birth. The NTSV cesarean delivery rate is influenced by many factors, including provider, nursing and patient variables. In 2010 NTSV Cesarean Rate was adopted as a core measure with required reporting for all hospitals with >300 births annually, setting the California target goal at a rate of 23.6%.

Data source is internal C-Section data from 01/01/2012 – 12/31/2020 and internal NTSV data from 01/01/2018 – 12/31/2020.
The NTSV Benchmark of 16.80% is provided from the California Maternal Data Center and represents the cut-off for the top 25% of California Hospitals.
In this situation, lower values demonstrate better performance.

Emergency Department Waiting Time

On average, the Tahoe Forest Hospital Emergency Department treats approximately 15,000 patients annually and is committed to providing a medical screening exam as quickly as possible upon arrival. Our staff has maintained an average time from arrival to being seen by a physician to 17 minutes for every patient – well below the national average of 19 minutes. The wait times vary data to day, but we are proud of our consistently low wait times in the ED.

Data source is Quantros Required Reporting Manager from 01/01/2013 – 12/31/2020.
In this context, lower values demonstrate better performance.

Emergency Department Transfer Communication

Emergency Department Transfer Communication (EDTC) is an important aspect of care, especially for smaller, rural, Critical Access Hospitals (CAHs). This set of metrics measures our ability to consistently include all necessary paperwork and information to the facility we transfer you too. The current set of metrics include:

Home Medications
Allergies and/or Reactions
Medications Administered in ED
ED Provider Note
Mental Status/Orientation Assessment
Reason for Transfer and/or Plan of Care
Tests and/or Procedures Performed
Tests and/or Procedures Results

For more information, please visit the Stratis Health webpage.

The benchmark performance rate is 100%. In this context, higher is better.

Sepsis Care

Sepsis is your body’s life-threatening response to an infection due to organ failure, and is the leading cause of death in patients with infection around the world (Source: Infection Prevention and Control at a Glance, Wiley 2017). It is estimated that 1.6 million people are diagnosed with sepsis each year in the US alone, and approximately 258,000 of these people will die of sepsis; this makes sepsis the leading cause of death in US hospitals (Source: sepsis.org).

While any infection can eventually lead to sepsis, this dangerous progression of an infection is usually easy to treat if it is detected early, and at Tahoe Forest Hospital District, that is exactly what we strive to do. Our staff has been trained to identify the risk factors for sepsis and how to treat once identified.

Read more about sepsis here.

Data source is Quantros Required Reporting Manager from 01/01/2016 – 12/31/2020.
Sepsis is a life threatening condition that causes your body to injure its own tissue and organs as you fight an infection.
In this situation, higher values demonstrate better performance.

C. diff.

C. diff. is a bacteria that can cause severe cases of diarrhea and inflammation in your colon. When you acquire this, it can be a very serious event. We are required to report all hospital acquired cases to the Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN).

The graph below shows our c. diff. Standardized Infection Rate, or SIR, over time. SIRs let you compare your rate of actual infection to your number of predicted cases with any other facility across the nation. A SIR greater than 1 means we are experiencing a high rate of infections, and SIR less than 1 means we are experiencing a low rate of infections, and a SIR equal to 1 means we are seeing rates of infection comparable to all other facilities in the nation.

The size of our facilities greatly impacts our SIR. According to the CDC, we are allowed approximately 1.5 infections per year before our SIR exceeds 1.

For more information, please visit the CDC’s webpage on c. diff.

In this context, lower values demonstrate better performance.

Culture of Safety

Tahoe Forest Hospital District is a high reliability organization, which means that we are focused on avoiding patient harm. High reliability organizations are committed to safety at all levels, from frontline healthcare providers to managers and executives. In our organization, we believe you have the right to safe and effective care.

If you have any questions about our culture of safety initiatives, reach out to our Patient Safety Officer at (530) 582-6637.

Transparency and Disclosures

It is Tahoe Forest Hospital District's policy to support the rights of patients to be active participants in decisions about their healthcare. As such, we provide the necessary information to make an informed decision about your treatment and care plan. In addition, a patient and/or their family/designee will be informed about any outcome of their treatment, including any unexpected errors in care.

While we take every possible precaution during your treatment, unexpected things do happen. In those situations, it is our policy to promptly communicate an unanticipated outcome to the patient and/or the patient's family or designee.

Crisis Standards of Care

Tahoe Forest Hospital District has developed a disaster plan that includes a surge capacity plan that allows for sudden influx of patients. This plan has been developed in concert with all components of our District Disaster Plan and addresses the ability of the District to address and manage the needs of patients that require care. Download more information (PDF)

Websites/Resources

Every patient has a right to see how we compare to other hospitals. Please reach out to our Quality Analyst at (530) 582-3272 if you have any questions or would like more information about available healthcare websites.

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 at (530) 582-6629 if you have any questions or would like additional information.