Data Sources


Hospital quality performance measures are displayed from three different sources: 1) The Centers for Medicare and Medicaid Services (CMS); 2) The federal Agency for Healthcare Quality and Research (AHRQ); 3) The Nevada State Health Division, and 4) The Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).

CMS Hospital Quality Performance Measures

This section gives you quick access to the most current information available from the Centers for Medicare and Medicaid Services’ (CMS) national quality initiative, Hospital Compare. The data demonstrates Nevada hospitals’ activity relating to specific clinical indicators. Click here for more information on the CMS Hospital Compare website.

The measures currently available through CMS include a variety of specific measurements falling into the following categories: stroke care, heart failure, pneumonia and readmissions. Also included are quality ratings regarding patient experience and other aspects of health care quality that include recommended care, results of care, and delivery of care patterns.

  • Heart attack
  • Stroke Care
  • Heart failure
  • Pneumonia
  • Readmissions
  • Surgical infection prevention
  • Quality ratings regarding patient experience
  • Recommended care
  • Results of Care
  • Delivery of care


AHRQ Hospital Quality Performance Measures

The federal Agency for Healthcare Research and Quality (AHRQ) measures displayed on this web site include specific measures that fall into the “patient safety” category. These measures are based on a readily available data source which is not definitive of health care quality—administrative data based on hospital billing claims. These indicators are used as the starting point for further investigation, leading to the review of medical records to verify the presence of those outcomes. Click here for more information on the AHRQ website.

The data displayed for Nevada hospitals represent each individual hospital’s risk-adjusted rates per 1,000 cases. Risk-adjusted rates take into consideration the estimated performance of hospitals if they had an “average” patient case mix (average mix of patients based on age, gender and health status). The average case mix was estimated from the AHRQ national data base. The lower the number the better Medicare-Hospital-Quality-Chartbook-2014.pdf

Sentinel Events

Hospitals are mandated by legislation to report sentinel events to the Nevada State Health Division.   

Nevada hospitals are committed to patient safety and public reporting and have chosen to display the data by hospital on the NHA Quality Transparency Website by number of events and by a rate. (See attached disclaimer for low volume)

Sentinel events signal the need for immediate investigation and response, and sentinel event reporting can be a useful continuous quality and patient safety improvement tool. Per NRS 439.830, a sentinel event is defined as an event included in Appendix A of “Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report,” published by the National quality Forum. (Branden see below)

  1. Except as otherwise provided in subsection 2, “sentinel event” means an event included in Appendix A of “Serious Reportable Events in Healthcare--2011 Update: A Consensus Report,” published by the National Quality Forum.
  2. If the publication described in subsection 1 is revised, the term “sentinel events” means the most current version of the list of serious reportable events published by the National Quality Forum as it exists on the effective date of the revision which is deemed to be:
          (a) January 1 of the year following the publication of the revision if the revision is published on or after January 1 but before July 1 of the year in which the revision is published; or
          (b) July 1 of the year following the publication of the revision if the revision is published on or after July 1 of the year in which the revision is published but before January 1 of the year after the revision is published.
  3. If the National Quality Forum ceases to exist, the most current version of the list shall be deemed to be the last version of the publication in existence before the National Quality Forum ceased to exist.

      (Added to NRS by 2002 Special Session, 13; A 2005, 599;2013, 217)

The lower the number the better.
 

Infections

Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) (http://www.cdc.gov/nhsn/). CDC’s NHSN is the nation’s most widely used healthcare-associated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts and ultimately eliminate healthcare-associated infections. In addition, NHSN allows healthcare facilities to track blood safety errors and important healthcare process measures such as healthcare personnel influenza vaccine status and control adherence rates.

The lower the number the better.