Description of our Quality Measurement Programs

Third Party Hospital Quality Measures in which Rideout Memorial Hospital Participates

CALNOC California Nursing Outcomes Coalition

This study is conducted/coordinated by UCSF/Stanford.

Data is collected by the hospital and submitted directly to CALNOC

Nursing Outcomes Measurements include:

  • Nurse staffing--direct care hours, skill mix, patient days, nurse/patient ratios, and contracted staffing utilization, workload intensity (admissions, discharges, transfers), staff voluntary turnover, and use of sitters
  • RN education level, certification, and years of experience
  • Patient falls -- risk, incidence (rate per 1000 patient. days) and consequences
  • Pressure ulcers -- risk, prevalence, stage, and hospital acquired
  • Pressure ulcers -- incidence of reportable hospital acquired pressure ulcers stage 3 and above (This is a new indicator implemented in 2009 as part of CALNOC's Robert Wood Johnson Foundation-funded INQRI [Interdisciplinary Nursing Quality Research Initiative] project.)
  • Catheter Related Infections -- prevalence on medical-surgical units
  • Medication Administration Accuracy -- observed prevalence of key safe practices and errors

CMS Hospital Core Measures

This is a study of the "Process of Care and Clinical Outcome Measures"

Data is abstracted from discharged Medicare inpatient records and submitted to a third-party data company, Thomson Rueters, for compilation and public reporting at

Currently there are 24 measurements reported, but we collect 48 in these major care categories:

  • Heart Failure (HF)
  • Acute Myocardial Infarction (AMI) (aka Heart Attack)
  • Pneumonia (PN)
  • Surgical Care Improvement Project (SCIP)

HCAHPS [ Hospital Consumer Assessment of Healthcare Providers and Systems]

This is a Survey of Patients' Hospital Experiences

Data is obtained from part of inpatient Medicare patient survey, which is sent directly to and processed by a third-party data vendor, Press Ganey, which in turn publicly reports results at

Measurements include:

  • Patients who reported that their nurses "Always" communicated well.
  • Patients who reported that their doctors "Always" communicated well.
  • Patients who reported that they "Always" received help as soon as they wanted.
  • Patients who reported that their pain was "Always" well controlled.
  • Patients who reported that staff "Always" explained about medicines before giving it to them. Patients who reported that their room and bathroom were "Always" clean.
  • Patients who reported that the area around their room was "Always" quiet at night.
  • Patients at each hospital who reported that YES, they were given information about what to do during their recovery at home.
  • Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).
  • Patients who reported YES, they would definitely recommend the hospital.

CHART [California Hospital Assessment and Reporting Taskforce]

Performance measurements indicative of quality and aligned with national initiatives, such as the Agency for Health Quality and Research, and the National Quality Forum. Conducted/Coordinated by UCSF/Stanford. Data is collected by the hospital and submitted directly to UCSF/Stanford,and results are publicly reported at

Measurements include:

  • Cardiac care
  • Maternity care
  • Pneumonia treatment
  • Intensive care unit (ICU)
  • Pressure ulcer rates
  • Patient safety
  • Surgical infection prevention
  • Patient experience


HealthGrades' hospital ratings and awards reflect the track record of patient outcomes at hospitals in the form of mortality and complication rates. HealthGrades rates hospitals independently based on data that hospitals submit to the federal government. No hospital can opt in or out of being rated, and no hospital pays to be rated.

For 28 procedures and treatments, HealthGrades issues star ratings that reflect the mortality and complication rates for each category of care. Hospitals receiving a 5-star rating have mortality or complication rates that are below the national average, to a statistically significant degree. A 3-Star rating means the hospital performs as expected. One-star ratings indicate the hospitals mortality or complication rates in that procedure or treatment are statistically higher than average. Because the risk profiles of patient populations at hospitals are not alike, HealthGrades risk-adjusts the date to allow for apples-to-apples comparisons.

More information on today's HealthGrades study, including the complete methodology, can be found at