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); and 3) The Nevada State Health Division.

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:

• Heart attack
• Heart failure
• Pneumonia
• Surgical infection prevention
• Patient satisfaction
• Children’s asthma 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 rate per case. 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.

Sentinel Events

Nevada hospitals are committed to patient safety and public reporting and have chosen to exceed state legislation (SB319) by displaying the data by individual hospital.

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 unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof.” The event is considered unexpected if it is not related to the natural course of the patient’s illness or underlying condition. The lower the number the better.

Hospitals with less than 100 licensed beds are considered low volume.  Low volume refers to the occasion when there is a small number of cases or a smaller denominator.  Low volume could impact patient confidentiality and also limit the ability to reliably identify quality differences. Low volume is a frequent problem in performance measurement, especially when using measures based on rare occurrences such as Sentinel Events. For example, a single hospital may only have one death in a year. It would be difficult to ensure protection of patient confidentially in this instance.