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Quality Measures

Our Commitment to Quality

VCU Health Community Memorial Hospital has been serving this region since 1954. We have earned a reputation in the region for taking the lead on healthcare quality. We are committed to providing the highest quality care to those in need. Quality is often measured in many ways. There are national agencies that rate hospital quality on a variety of measures. CMH volunteered to report our data; we invite you to review these results.

Hospital Compare 

The Hospital Compare Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS), along with the Hospital Quality Alliance (HQA) provides information about hospital performance. The HQA is a public-private collaboration established to promote reporting on hospital quality of care representing consumers, hospitals, doctors and nurses, employers, accrediting organizations, and Federal agencies. CMH voluntarily submits data on various measures of care. 

Home Health Compare

The Home Health Compare website was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS). Home Health Compare has information about the quality of care provided by "Medicare-certified" home health agencies throughout the nation.  "Medicare-certified" means the home health agency is approved by Medicare and meets certain Federal health and safety requirements.  

Nursing Home Compare

The Nursing Home Compare website has detailed information about every Medicare and Medicaid certified nursing home in the country.  Consumers can compare the quality of the nursing homes using the Five-Star Quality Ratings, health inspection results, nursing home staff data, quality measures and fire safety inspection results. 

Hospital Safety Score

Hospital Safety Scores are assigned to more than 2,500 hospitals across the nation twice annually. Performance measures produce a single score representing a hospital’s overall performance in keeping patients safe from preventable harm and medical errors. The Hospital Safety Score includes 28 measures, all currently in use by national measurement and reporting programs. 

AHCA Quality Initiative Recognition – Skilled Care

The Quality Initiative Recognition Program is designed to recognize AHCA nursing center members that demonstrate the attainment of one or more of the four AHCA Quality Initiative goals:

  • Safely Reduce Hospital Readmissions by 15%

  • Increase Staff Stability by 15% 

  • Increase Customer Satisfaction to 90% 

  • Safely Reduce the Off-Label Use of Antipsychotics by 15% 

The recognition of achievers is a tiered-approach, where member centers will increase their recognition as they accomplish multiple Quality Initiative goals. 

Anthem Quality-In-Sight® Hospital Incentive Program (Q-HIP) 

The Anthem Quality-In-Sights®: Hospital Incentive Program (Q-HIP®) mission is to improve hospital-based clinical quality and health outcomes. Hospitals are recognized and rewarded for excellence in clinical outcomes, patient safety, and patient satisfaction through performance-based reimbursement.

VCU Health Community Memorial Hospital was one of the first hospitals in Virginia to participate in Q-HIP.  The program started in 2003 with only 16 hospitals; by 2023, there were 79 Q-HIP hospitals in Virginia and 966 hospitals across the United States.  

Q-HIP focuses on evaluating hospital processes for patient safety, as well as specific indicators of care for patients with the following common conditions:  heart attack, heart failure, pneumonia, COPD, surgical infection prevention, sepsis, stroke, and maternal/OB safety outcomes. VCU CMH’s performance is measured on nationally endorsed, well recognized evidence-based measures with the goal of high quality and safe health care for all customers/patients.


Health Grades  

Health Grades is a healthcare ratings, information, and advisory services company which measures and assesses healthcare quality, on popular medical conditions.

You, the patient, have the right to know how our health system compares to state and national quality performance measures (as determined by The Joint Commission, Centers for Medicare and Medicaid Services, and other national agencies reporting on quality) to help you make an informed health care decision.

Quality Check

In July 2004, The Joint Commission started a new web based reporting system called Quality Check. It is a comprehensive guide to the nearly 16,000 Joint Commission-accredited health care organizations and programs throughout the United States. Quality Reports feature a user-friendly format with checks, pluses and minuses to help the general public compare health care organization performance in a number of key areas including quality of care and patient safety.


Quality Respiratory Care Recognition (QRCR) 


VCU Health Community Memorial Hospital has earned Quality Respiratory Care Recognition (QRCR) under a national program aimed at helping patients and families make informed decisions about the quality of the respiratory care services available in hospitals. About 500 hospitals or approximately 10% of hospitals in the United States have applied for and received this award. CMH is 1 out of 19 hospitals recognized in Virginia. 

The QRCR program was started by the American Association for Respiratory Care (AARC) in 2003 to help consumers identify those facilities using qualified respiratory therapists to provide respiratory care. Hospitals earning the QRCR designation ensure patient safety by agreeing to adhere to a strict set of criteria governing their respiratory care services. To qualify for the recognition, VCU Community Memorial Hospital provided documentation showing it meets the following conditions:

  • All respiratory therapists employed by the hospital to deliver bedside respiratory care services are either legally recognized by the state as competent to provide respiratory care services or hold the CRT or RRT credential.

  • Respiratory therapists are available 24 hours.

  • Other personnel qualified to perform specific respiratory procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing.

A doctor of medicine or osteopathy is designated as medical director of respiratory care services. 


Advancing Excellence in America’s Nursing Homes

VCU Health Community Memorial Hospital's Extended Care Facility, The Hundley Center, has joined the Advancing Excellence in America’s Nursing Homes campaign, a national quality initiative.
The quality campaign, launched in September 2006, is designed to improve the quality of life for nursing home residents and staff. CMH has joined this campaign because of its continued commitment to improving quality. This effort is an unparalleled collaboration between long-term care providers, caregivers, medical and quality improvement experts, government agencies and consumers. Each of these groups play an important role in creating awareness about quality and the resources that are available to providers to aid in improving patient care.