Quality Measures
20
CMS-tracked
VA SOUTHERN NEVADA HEALTHCARE SYSTEM
6900 NORTH PECOS ROAD, N. LAS VEGAS, NV 89086
CLARK County
VA SOUTHERN NEVADA HEALTHCARE SYSTEM is a Acute Care - Veterans Administration located in N. LAS VEGAS, NV, with Veterans Health Administration ownership, according to the Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. CMS overall quality rating: 5 out of 5 stars, based on quality measures covering patient safety, patient experience (HCAHPS), readmission rates, and timeliness of care. Emergency services are available. This hospital performs better than the national average on 3 quality measures.
What the Data Shows About VA SOUTHERN NEVADA HEALTHCARE SYSTEM
VA SOUTHERN NEVADA HEALTHCARE SYSTEM is classified by CMS as a Acute Care - Veterans Administration under Veterans Health Administration ownership, serving N. LAS VEGAS, NV (CLARK County, ZIP 89086). Its overall CMS star rating is 5/5, a composite signal drawn from mortality outcomes, safety of care, readmission rates, patient experience (HCAHPS), and timely & effective care measures. Emergency services are available on site, and the facility does not currently carry the CMS Birthing-Friendly designation.
Across the quality-measure domains CMS tracks, VA SOUTHERN NEVADA HEALTHCARE SYSTEM posts 3 measures better than the national average and 0 measures worse, drawn from mortality (2 better / 0 worse), safety of care (0 better / 0 worse), and readmission (1 better / 0 worse). A total of 20 individual quality measures are reported for this facility, covering everything from sepsis care to surgical complications. The facility also reports 36 healthcare-associated infection measures under the CDC NHSN surveillance system.
Patient-experience data from the HCAHPS survey spans 68 domains at this hospital, including communication with doctors and nurses, staff responsiveness, cleanliness, and discharge information — together these give a real-world read on how patients rate their stay. All figures reflect the CMS Hospital Compare release from , and none of this page constitutes medical advice — always consult a clinician before choosing or changing care.
Type
Acute Care - Veterans Administration
Ownership
Veterans Health Administration
Emergency Services
Yes
Birthing Friendly
N/A
Phone: (702) 791-9024
Patient Experience
68
HCAHPS domains
Infection Measures
36
CDC NHSN
CMS Overall Star Rating 100.0%
5 of 5 stars
Quality Summary
Mortality
Better than National2
Same as National2
Worse than National0
Safety of Care
Better than National0
Same as National4
Worse than National0
Readmission
Better than National1
Same as National4
Worse than National0
Quality Measures
Detailed quality measure performance compared to national benchmarks
| Measure | Score | vs. National |
|---|---|---|
| Abdominopelvic accidental puncture or laceration rate | 0.92 | Same as National |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.81 | Same as National |
| Death rate among surgical inpatients with serious treatable complications | 177.96 | Same as National |
| Death rate for CABG surgery patients | N/A | Not Available |
| Death rate for COPD patients | 6.6 | Same as National |
| Death rate for heart attack patients | 12 | Same as National |
| Death rate for heart failure patients | 8.2 | Better than National |
| Death rate for pneumonia patients | 12.6 | Better than National |
| Death rate for stroke patients | N/A | Not Available |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | N/A | Not Available |
| Iatrogenic pneumothorax rate | 0.24 | Same as National |
| In-hospital fall-associated fracture rate | 0.25 | Same as National |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 3.25 | Same as National |
| Postoperative acute kidney injury requiring dialysis rate | 1.49 | Same as National |
| Postoperative hemorrhage or hematoma rate | 2.08 | Same as National |
Patient Experience (HCAHPS)
Patient satisfaction survey results measuring hospital care quality
| Survey Question | Star Rating |
|---|---|
| Cleanliness - linear mean score Cleanliness - linear mean score | N/A |
| Cleanliness - star rating Cleanliness - star rating | 3 |
| Communication about medicines - linear mean score Communication about medicines - linear mean score | N/A |
| Communication about medicines - star rating Communication about medicines - star rating | 3 |
| Discharge information - linear mean score Discharge information - linear mean score | N/A |
| Discharge information - star rating Discharge information - star rating | 3 |
| Doctor communication - linear mean score Doctor communication - linear mean score | N/A |
| Doctor communication - star rating Doctor communication - star rating | 3 |
| Nurse communication - linear mean score Nurse communication - linear mean score | N/A |
| Nurse communication - star rating Nurse communication - star rating | 4 |
| Overall hospital rating - linear mean score Overall hospital rating - linear mean score | N/A |
| Overall hospital rating - star rating Overall hospital rating - star rating | 4 |
| Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest) Patients who gave a rating of "6" or lower (low) | N/A |
| Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest) Patients who gave a rating of "7" or "8" (medium) | N/A |
| Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) Patients who gave a rating of "9" or "10" (high) | N/A |
| Patients who reported NO, they would probably not or definitely not recommend the hospital "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) | N/A |
| Patients who reported that NO, they did not discuss whether they would need help after discharge No, staff "did not" give patients information about help after discharge | N/A |
| Patients who reported that NO, they did not receive written information about possible symptoms to look out for after discharge No, staff "did not" give patients information about possible symptoms | N/A |
| Patients who reported that NO, they were not given information about what to do during their recovery at home No, staff "did not" give patients this information | N/A |
| Patients who reported that staff "Always" explained about medicines before giving it to them Staff "always" explained | N/A |
| Patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to them Staff "sometimes" or "never" explained | N/A |
| Patients who reported that staff "Usually" explained about medicines before giving it to them Staff "usually" explained | N/A |
| Patients who reported that the area around their room was "Always" quiet at night "Always" quiet at night | N/A |
| Patients who reported that the area around their room was "Sometimes" or "Never" quiet at night "Sometimes" or "never" quiet at night | N/A |
| Patients who reported that the area around their room was "Usually" quiet at night "Usually" quiet at night | N/A |
| Patients who reported that their doctors "Always" communicated well Doctors "always" communicated well | N/A |
| Patients who reported that their doctors "Always" explained things in a way they could understand Doctors "always" explained things so they could understand | N/A |
| Patients who reported that their doctors "Always" listened carefully to them Doctors "always" listened carefully | N/A |
| Patients who reported that their doctors "Always" treated them with courtesy and respect Doctors "always" treated them with courtesy and respect | N/A |
| Patients who reported that their doctors "Sometimes" or "Never" treated them with courtesy and respect Doctors "sometimes" or "never" treated them with courtesy and respect | N/A |
| Patients who reported that their doctors "Sometimes" or "Never" communicated well Doctors "sometimes" or "never" communicated well | N/A |
| Patients who reported that their doctors "Sometimes" or "Never" explained things in a way they could understand Doctors "sometimes" or "never" explained things so they could understand | N/A |
| Patients who reported that their doctors "Sometimes" or "Never" listened carefully to them Doctors "sometimes" or "never" listened carefully | N/A |
| Patients who reported that their doctors "Usually" treated them with courtesy and respect Doctors "usually" treated them with courtesy and respect | N/A |
| Patients who reported that their doctors "Usually" communicated well Doctors "usually" communicated well | N/A |
| Patients who reported that their doctors "Usually" explained things in a way they could understand Doctors "usually" explained things so they could understand | N/A |
| Patients who reported that their doctors "Usually" listened carefully to them Doctors "usually" listened carefully | N/A |
| Patients who reported that their nurses "Always" communicated well Nurses "always" communicated well | N/A |
| Patients who reported that their nurses "Always" explained things in a way they could understand Nurses "always" explained things so they could understand | N/A |
| Patients who reported that their nurses "Always" listened carefully to them Nurses "always" listened carefully | N/A |
| Patients who reported that their nurses "Always" treated them with courtesy and respect Nurses "always" treated them with courtesy and respect | N/A |
| Patients who reported that their nurses "Sometimes" or "Never" treated them with courtesy and respect Nurses "sometimes" or "never" treated them with courtesy and respect | N/A |
| Patients who reported that their nurses "Sometimes" or "Never" communicated well Nurses "sometimes" or "never" communicated well | N/A |
| Patients who reported that their nurses "Sometimes" or "Never" explained things in a way they could understand Nurses "sometimes" or "never" explained things so they could understand | N/A |
| Patients who reported that their nurses "Sometimes" or "Never" listened carefully to them Nurses "sometimes" or "never" listened carefully | N/A |
| Patients who reported that their nurses "Usually" treated them with courtesy and respect Nurses "usually" treated them with courtesy and respect | N/A |
| Patients who reported that their nurses "Usually" communicated well Nurses "usually" communicated well | N/A |
| Patients who reported that their nurses "Usually" explained things in a way they could understand Nurses "usually" explained things so they could understand | N/A |
| Patients who reported that their nurses "Usually" listened carefully to them Nurses "usually" listened carefully | N/A |
| Patients who reported that their room and bathroom were "Always" clean Room was "always" clean | N/A |
| Patients who reported that their room and bathroom were "Sometimes" or "Never" clean Room was "sometimes" or "never" clean | N/A |
| Patients who reported that their room and bathroom were "Usually" clean Room was "usually" clean | N/A |
| Patients who reported that when receiving new medication the staff "Always" communicated what the medication was for Staff "always" explained new medications | N/A |
| Patients who reported that when receiving new medication the staff "Always" discussed possible side effects Staff "always" explained possible side effects | N/A |
| Patients who reported that when receiving new medication the staff "Sometimes" or "Never" communicated what the medication was for Staff "sometimes" or "never" explained new medications | N/A |
| Patients who reported that when receiving new medication the staff "Sometimes" or "Never" discussed possible side effects Staff "sometimes" or "never" explained possible side effects | N/A |
| Patients who reported that when receiving new medication the staff "Usually" communicated what the medication was for. Staff "usually" explained new medications | N/A |
| Patients who reported that when receiving new medication the staff "Usually" discussed possible side effects Staff "usually" explained possible side effects | N/A |
| Patients who reported that YES, they did discuss whether they would need help after discharge Yes, staff "did" give patients information about help after discharge | N/A |
| Patients who reported that YES, they did receive written information about possible symptoms to look out for after discharge Yes, staff "did" give patients information about possible symptoms | N/A |
| Patients who reported that YES, they were given information about what to do during their recovery at home Yes, staff "did" give patients this information | N/A |
| Patients who reported YES, they would definitely recommend the hospital "YES", patients would definitely recommend the hospital | N/A |
| Patients who reported YES, they would probably recommend the hospital "YES", patients would probably recommend the hospital | N/A |
| Quietness - linear mean score Quietness - linear mean score | N/A |
| Quietness - star rating Quietness - star rating | 3 |
| Recommend hospital - linear mean score Recommend hospital - linear mean score | N/A |
| Recommend hospital - star rating Recommend hospital - star rating | 5 |
| Summary star rating Summary star rating | 3 |
Safety & Infections
Healthcare-associated infection rates compared to national benchmarks
| Measure | Score | vs. National |
|---|---|---|
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.454 | Same as National |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.023 | Same as National |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 2097 | Same as National |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 1 | Same as National |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 2.202 | Same as National |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 2.24 | Same as National |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0 | Same as National |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | N/A | Same as National |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 0 | Same as National |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 1.284 | Same as National |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 2.333 | Same as National |
| Central Line Associated Bloodstream Infection: Number of Device Days | 1425 | Same as National |
| Clostridium Difficile (C.Diff) | N/A | Not Available |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | N/A | Not Available |
| Clostridium Difficile (C.Diff): Observed Cases | N/A | Not Available |
| Clostridium Difficile (C.Diff): Patient Days | N/A | Not Available |
| Clostridium Difficile (C.Diff): Predicted Cases | N/A | Not Available |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | N/A | Not Available |
| MRSA Bacteremia | N/A | Not Available |
| MRSA Bacteremia: Lower Confidence Limit | N/A | Not Available |
| MRSA Bacteremia: Observed Cases | N/A | Not Available |
| MRSA Bacteremia: Patient Days | N/A | Not Available |
| MRSA Bacteremia: Predicted Cases | N/A | Not Available |
| MRSA Bacteremia: Upper Confidence Limit | N/A | Not Available |
| SSI - Abdominal Hysterectomy | N/A | Not Available |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | N/A | Not Available |
| SSI - Abdominal Hysterectomy: Number of Procedures | N/A | Not Available |
| SSI - Abdominal Hysterectomy: Observed Cases | N/A | Not Available |
| SSI - Abdominal Hysterectomy: Predicted Cases | N/A | Not Available |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | N/A | Not Available |
| SSI - Colon Surgery | N/A | Not Available |
| SSI - Colon Surgery: Lower Confidence Limit | N/A | Not Available |
| SSI - Colon Surgery: Number of Procedures | N/A | Not Available |
| SSI - Colon Surgery: Observed Cases | N/A | Not Available |
| SSI - Colon Surgery: Predicted Cases | N/A | Not Available |
| SSI - Colon Surgery: Upper Confidence Limit | N/A | Not Available |
Staffing & Spending
Medicare spending per episode and unplanned visit measures
Unplanned Visits & Readmissions
| Measure | Score | vs. National |
|---|---|---|
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 14.7 | Same as National |
| Heart failure (HF) 30-Day Readmission Rate | 18.5 | Same as National |
| Hospital return days for heart attack patients | N/A | Number of Cases Too Small |
| Hospital return days for heart failure patients | -1 | Average Days per 100 Discharges |
| Hospital return days for pneumonia patients | -17.3 | Fewer Days Than Average per 100 Discharges |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.4 | Same as National |
| Pneumonia (PN) 30-Day Readmission Rate | 15.3 | Same as National |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of readmission after hip/knee replacement | 4.3 | Same as National |
| Rate of readmission for CABG | N/A | Not Available |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 17.9 | Same as National |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | N/A | Not Available |
| Ratio of unplanned hospital visits after hospital outpatient surgery | N/A | Not Available |
Nearby Hospitals in Nevada
Other Medicare-certified hospitals in Nevada — tap any card for its full quality profile.
99th Medical Group (Nellis AFB)
Nellis AFB, NV
No rating Acute Care - Department of Defense
BANNER CHURCHILL COMMUNITY HOSPITAL
FALLON, NV
2/5
Critical Access Hospitals
BATTLE MOUNTAIN GENERAL HOSPITAL
BATTE MTN, NV
No rating Critical Access Hospitals
BOULDER CITY HOSPITAL
BOULDER CITY, NV
No rating Critical Access Hospitals
CARSON TAHOE REGIONAL MEDICAL CENTER
CARSON CITY, NV
3/5
Acute Care Hospitals
CARSON VALLEY HEALTH
GARDNERVILLE, NV
4/5
Critical Access Hospitals
Compare VA SOUTHERN NEVADA HEALTHCARE SYSTEM vs 99th Medical Group (Nellis AFB) →
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Frequently Asked Questions
What is the CMS star rating for VA SOUTHERN NEVADA HEALTHCARE SYSTEM?
VA SOUTHERN NEVADA HEALTHCARE SYSTEM has an overall CMS star rating of 5 out of 5. CMS star ratings are based on multiple quality measures including mortality, safety of care, readmission rates, patient experience, and timely and effective care.
How does VA SOUTHERN NEVADA HEALTHCARE SYSTEM perform on quality measures?
VA SOUTHERN NEVADA HEALTHCARE SYSTEM has 3 quality measures rated better than the national average and 0 rated worse. 20 total quality measures are tracked for this facility.
What do patients say about VA SOUTHERN NEVADA HEALTHCARE SYSTEM?
Patient experience at VA SOUTHERN NEVADA HEALTHCARE SYSTEM is measured through HCAHPS surveys covering 68 categories including communication with doctors, responsiveness of staff, cleanliness, and discharge information. Patient survey star ratings range from 3 to 5 out of 5.
What are the infection rates at VA SOUTHERN NEVADA HEALTHCARE SYSTEM?
VA SOUTHERN NEVADA HEALTHCARE SYSTEM tracks 36 healthcare-associated infection measures. 0 are better than the national benchmark, 0 are worse, and 12 are at the national average.
Does VA SOUTHERN NEVADA HEALTHCARE SYSTEM have emergency services?
Yes, VA SOUTHERN NEVADA HEALTHCARE SYSTEM provides emergency services.
What type of hospital is VA SOUTHERN NEVADA HEALTHCARE SYSTEM?
VA SOUTHERN NEVADA HEALTHCARE SYSTEM is a Acute Care - Veterans Administration facility with Veterans Health Administration ownership, located in N. LAS VEGAS, NV.
Data Sources
Source: Centers for Medicare & Medicaid Services (CMS) Hospital Compare. Last refreshed from CMS: .
Hospital quality data is sourced from the CMS Hospital Compare program, with patient-experience scores drawn from the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Data includes overall star ratings, quality measures, healthcare-associated infections, unplanned visits, Medicare spending, and maternal health measures.
Source: CMS Hospital Compare. This information is not medical advice. Learn more
Read our methodology — how this data is sourced, computed, and verified.
All federal data sources used on this page
- CMS Hospital General Information (HGI) — hospital identifier + ownership + general info. data.cms.gov/hospital-general-information
- CMS Care Compare — Hospital Quality — patient experience + safety + outcome measures. medicare.gov/care-compare
- CMS Provider Data Catalog — all hospital-related Medicare provider data. data.cms.gov/provider-data
- AHRQ HCUP — hospital utilization + readmission rates. hcup-us.ahrq.gov
- CDC National Healthcare Safety Network (NHSN) — hospital-acquired infection surveillance. cdc.gov/nhsn
- HRSA Health Resources Files — hospital service-area + workforce data. data.hrsa.gov
