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.Care provider comforting patient

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.

"I loved my nurses. All of the nurses for that matter. I couldn't have been taken care of any better. A huge thank you!"


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™.

Institute of Medicine's Framework for Quality and Patient Safety

"I cannot say enough about this facility. The staff is caring, concerned and so friendly. You have something very special here!"


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 has been recognized in many different ways.caring nurse checking on smiling patient

Star Rating by Centers for Medicare and Medicaid Services for Patient Satisfaction 
The Centers for Medicare and Medicaid (CMS) award star ratings to hospitals based on their patient satisfaction scores, and possible ratings are from on the five stars, with five stars being the best. These scores are meant to help consumers compare hospital quality measurements. Many of the nation's best hospitals receive average (three-star) ratings, but Tahoe Forest Hospital is one of the few hospitals that consistently scores at least four stars. 

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
The Commission on Cancer of the American College of Surgeons has granted three-year accreditation to the cancer program at the Gene Upshaw Memorial Tahoe Forest Cancer Center. Read more here.

American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative Certification
Electronic health records are now part of a growing CancerLinQ® database to help physicians uncover patterns and trends and receive real-time quality feedback. Find out more here.


American Society of Radiation Oncology (ASTRO) Accreditation Program for Excellence
The Gene Upshaw Memorial Tahoe Forest Cancer Center achieves four-year accreditation for radiation oncology services. Read more here.


Addario Lung Foundation Center of Excellence
The ALCF Centers of Excellence award recognizes community hospitals for their individualized care and treatment of lung cancer patients. Read more 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, click 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 Joseph Family Center for Women and Newborn Care has been given the Women’s Choice Award for America’s 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. Find out more about HFAP here.

"Your facility is one of the things that make Truckee a great place to live."

Patient Satisfaction Ratings and Involvement

Tahoe Forest Health System consistently exceeds national and state averages in all categories of patient satisfaction. Press Ganey, one of the country's leading healthcare survey companies, continually updates us about our performance based on HCAHPS surveys.

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 patient’s experience of care, and allows for valid comparisons to be made across hospitals locally, regionally and nationally.

Chart of Tahoe Forest Hospital HCAPS scores
You can read more about our overall patient experience here.

Patient Family Advisory Council

Tahoe Forest Health System values the perspectives of the patients, families and communities that we serve. 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) that meets 9 months out of the year for one and a half hours. We do not meet in July, August or December.

We are looking for community members to help us continue to provide the very best care and services to our patients and their families. This volunteer committee, made up of patients, families, staff members and leadership at Tahoe Forest Health System, will help us to improve the overall quality of the patient experience.

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 Health System. You can contact Lorna Tirman:

Lorna Tirman PhD, MHA, RN

Patient Experience Specialist

Tahoe Forest Hospital

(530) 582-6567



"Best nurses ever—prompt responsive, really cared. This is the best hospital I have ever been to. The friendliness of everyone made me feel like family!"

How We Demonstrate High Quality Care

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
Class I surgeries are what healthcare workers call “clean”; having a wound that is classified this way means that there is no inflammation and no entry into the respiratory, alimentary, genital or urinary tracts. Class II surgeries are what healthcare workers call “clean-contaminated”; having a surgery classified this way means that the surgeon entered the respiratory, alimentary, genital or urinary tract under controlled conditions and expects no unusual cross contamination. Class III surgeries are what healthcare workers call “contaminated” surgeries; having a surgery classified this way means that fresh, accidental wounds took place and that the surgeon had at least one major break from sterile technique or that there was spillage of GI contents. Class IV surgeries are what healthcare workers call “dirty” surgeries; this means that the surgery involves traumatic wounds with dead tissue, foreign bodies or fecal contamination.

"The doctors and staff did a wonderful job. We are grateful to all the people in your hospital, and thank them for the care they extended."

Healthcare Infection Prevention (HAI)

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.Smiling doctor helps young boy hold stethoscope to his stuffed toy.

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.

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 patient’s 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.

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.

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


"Everyone greeted me with a smile, made me feel at ease, was personable, professional, our conversation was not rushed, and all my questions were answered."

Lower Than Expected C-Section Rates

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 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

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 two 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

Emergency Department Waiting Time

On average, TFHD Emergency Department treats 16,000 patients annually and is committed to providing a medical exam of patients as quickly as possible upon arrival. The staff has maintained an average time from arrival to being seen by a physician to 15 minutes for all patients – well below the national and state averages of 23 minutes and 24 minutes, respectively.

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

Sepsis Care

Sepsis is your body’s life-threatening response to an infection due to organ dysfunction, and happens to be 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 here at Tahoe Forest Hospital, that is exactly what we strive to do. We are constantly training our staff on indicators for sepsis to raise awareness within our community. Additionally, we perform concurrent chart audits to catch patients before sepsis should even be a concern. Rest assured that you can reach out to our amazing staff if you have any questions about sepsis.

You can read more about sepsis here.

Chart showing appropriate sepsis care

Venous Thromboembolism (VTE) Care

Venous thromboembolisms, or VTEs for short, are essentially blockages of the arteries or veins. This class of health issues includes deep vein thrombosis (blockages in the legs) and pulmonary embolisms (blockages in the pulmonary artery or its branches). Typical symptoms of DVT include leg pain, tenderness and warmth of the erythema, while typical symptoms of PE include chest pain and shortness of breath.

At Tahoe Forest Hospital, we strive to prevent VTEs by following a strict set of rules formed out of nationally-recognized best practices, and it shows! Our regimen of appropriate VTE care includes active VTE prophylaxis post-surgery, appropriate use of anticoagulation medications, dietary advice, follow-up monitoring and adverse drug reaction education among other things.  

Chart showing appropriate VTE care  

You can read more about VTE here.

"The entire team that attended me was first class in every way. Professional, courteous, personable efficient. Really excellent from start to end."

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