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A Historical Overview of Quality Initiatives at SwedishAmerican

1980s  |  1990s  |  2000s  |   2010s

"The very essence of our mission is to treat the patients we serve as we would want to be treated ourselves. In order for quality to have meaning we must hold ourselves accountable not only for the processes we measure, but for the outcome of our efforts. That continuous accountability for outcomes creates the environment for unremitting improvement in what we do. Our efforts are about doing the right thing for the patients, community and region we are privileged to serve."

Bill Gorski, M.D.
President and CEO
March 2000:
TQM team implemented for improving process of education and uniform management of Unit Clerks throughout hospital.

Surgical Specialty Area/Operating Room TQM team presents at Quality Leadership Council (QLC) with successful accomplishment of mission – timely provision of instrumentation and supplies for operating room.

April 2000:
Heart Management Center (for treatment of heart failure) begins at hospital as new outpatient service to provide follow-up and monitoring for patients who had been hospitalized for heart failure.

June 2000:
SwedishAmerican hosts Quality Expo 2000, launching the health system's Web site and promoting its "centers of excellence."

July 2000:
Pediatric and newborn floors implement high security program to prevent infant abduction. Infant security had been an issue in Chicago.

September 2000:
Final report from Medication Error Team with recommendation to implement bar coding for patient identification.

October 2000:
Classes offered throughout system again for TQM and facilitator training. Board member also attended classes.

Safety Fair successfully completed by all employees with theme of "Medieval Times."

November 2000:
Vern Cassens is thanked for his many years as the Chairman of the Quality Leadership Council. Pat Derry is introduced as the new chairman of this committee.

January 2001:
In response to feedback report from Lincoln Foundation, the TQM facilitators create a method to assess teams after completion. A form titled "Evaluation and Improving Team Effectiveness" is implemented.

March 2001:
Pain management update given to Quality Leadership Council since SAH will expand knowledge and attitude assessment to clinics and not just hospital. Pain Management has been an important quality improvement focus at SAHS.

May 2001:
SwedishAmerican Hospital's safety officer, a member of Local Emergency Planning Committee (LEPC), leads a panel discussion at 3rd annual Midwest Conference for Emergency Preparedness.

SAH heightens process to recruit and retain RNs (tuition reimbursement, recruiting from regional schools, sign-on bonuses) due to nursing shortage.

June 2001:
SAH's Group Against Sharps Injuries Team is nationally recognized and receives the Bronze Award for sharps safety ideas by the Association for Professionals in Infection Control (APIC).

July 2001:
Dr. Henry Anderson welcomes Dr. Kathy Kelly to Quality Leadership Council in her new role as director of clinical integration and improvement.

SAH receives favorable grades on healthgrades.com – a national report card that grades hospitals online.

September 2001:
In keeping with national focus on safety, Dr. H. Anderson implements a "Medical Patient Safety Management Committee" to ensure highest priority for safety at SAH. Also, QLC is renamed Quality and Safety Leadership Council (QSLC).

October 2001:
SAH develops first clinical scorecard for quality indicators.

SAH Safety Fair provided to employees with theme of "2001 A Safety Odyssey."

November 2001:
New TQM team formed for "Nutrition for Critically Ill Patients."

December 2001:
Dr. Kelly identifies five projects for 2001 from Agency for Healthcare Research and Quality's (AHRQ) evidence based safety practices.

January 2002:
Report of pathway "Carotid Endarterectomy" provided to QSLC. The team creates "best practice" for this surgical procedure.

The Joint Commission four day survey is successful and SAH receives three-year accreditation.

February 2002:
"The Lift Team," a new TQM team is sanctioned by Committee for Quality Improvement (CQI) for addressing the needs of very large patients and reducing staff injuries relative to managing and moving these patients.

April 2002:
Dr. Anderson communicates SAHS' commitment to supporting the "Speak-up" program being sponsored by the Joint Commission nationwide. This program enjoins patients to become more involved in their care and to speak-up to doctors and caregivers when they have concerns and questions.

May 2002:
The First Quality Dashboard (quality indicator measurements) is presented at QSLC.

June 2002:
"Wrong Site Surgery" is chosen as SAHS' first Failure Modes and Effects Analysis (FMEA) project. Goal is to "mistake-proof" the process so that no wrong site surgery ever occurs at SAH.

At Quality Expo, a special new award – "The Henry Anderson Quality Award" – is presented to Dr. Anderson and becomes an annual award. Dr. Gorski announces Dr. Anderson's transition from full-time to part-time and publicly thanks him for many years of service and commitment to quality.

Dr. Kathleen Kelly assumes Dr. Anderson's role as Chief Medical Officer and Chief Quality Officer.

July 2002:
Final report of the "Improving Surgical Prophylaxis Team" (use of antibiotics) is given to QSLC. This was a critical team since it is known that measurements of timeliness and correct antibiotics will become part of Joint Commission indicators that will be made public.

August 2002:
AMI and CHF protocols are approved. This is done in conjunction with AMI and CHF patient data being collected and submitted to the Joint Commission beginning with July 1 discharges. The Joint Commission ultimately will share the results publicly and process will allow hospital-to-hospital comparisons.

September 2002:
CT Scanning Department shares results of a successful Six Sigma improvement project accomplished in their department.

December 2002:
In ongoing commitment to safety, SAHS announces it will convert to safer Alaris Medley Guardrail IV pumps, which are programmable.

February 2003:
Pharmacy director announces a successful program his department is supporting for getting pneumonia vaccinations to high-risk (Medicare) population.

March 2003:
Dr. Kelly shares impact of Leap Frog Group on the quality and safety endeavors of every hospital.

May 2003:
SAHS leaders attend ECOH program on Six Sigma and Quality in Healthcare, which is presented by Martin Merry, MD.

June 2003:
CQI Committee chooses topic of "Mistake-Proofing Process of Blood Transfusion" as SAHS next FMEA team.

TQM facilitators transition team to CQI facilitators and revise the quality teaching manual "Quality Begins With You." The 3rd edition is widely distributed.

On behalf of SAHS Dr. Kathy Kelly signs IHA's pledge form to commit to an "Organizational Framework for a Culture of Safety" which requires SAHS to invest human and financial resources for improving patient safety.

July 2003:
Dr. Kelly provides Board with an overview of many quality and safety measurements and results.

September 2003:
The cardiovascular center of excellence shares first results of comparative data now that SAH is participating in two national databases for benchmarking: the Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC).

October 2003:
Safety Fair is again created for all employees. This year's theme is "Cyber Safety" – a virtual reality.

November 2003:
SAHS is honored when Homeland Security officials visit to learn more about SAHS' role in community disaster preparedness and terrorism preparedness.

December 2003:
SwedishAmerican President and CEO Dr. Gorski takes a small group, including board members, to SSM Corporate Headquarters to learn more about the Baldrige philosophy and business model for healthcare organizations. SSM offers a Baldrige Sharing Day for organizations that wish to be more knowledgeable of the processes and discipline that Baldrige requires.

February 2004:
SAH is participating in the National Voluntary Quality Reporting Initiative and the first results are made available to the public on the CMS Web site. SAHS compares very favorably.

March 2004:
SAHS implements "Get a Lift" – a safety program that uses lifts and not staff for moving and transporting very large patients. SAHS is the first healthcare organization in Illinois to aim for a "lift-free" environment.

April 2004:
SwedishAmerican joins with other area health systems to create the Northern Illinois Patient Safety Collaborative. The mission of the collaborative is to pursue the safe delivery of healthcare in the community.

June 2004:
The QA 101 program is presented by SAH staff to new residents, so they can learn the basics of quality improvement and the specifics of the quality improvement expectations of SwedishAmerican Hospital medical staff.

July 2004:
SwedishAmerican begins participation in the newest Joint Commission core measures called Surgical Infection Prevention (SIP). After SAH results are submitted to a central database, feedback is received comparing SAH to other participating hospitals.

October 2004:
SAH provides its first "online" Safety Fair for employees. Many teams and disciplines work to get their safety information modules ready for a computer environment that allows employees to be tested online.

November 2004:
SAH completes its Organizational Profile as step one toward developing a Baldrige business model. The Baldrige National Quality Program is the gold standard by which healthcare organizations are assessed. A Baldrige examiner was engaged as a consultant to educate and assess the SAH plan for incorporating Baldrige into SwedishAmerican Health System's culture.

December 2004:
The Electronic Plan of Care, a component of nursing's charting system that is accessible to the healthcare team and includes short- and long-term patient care goals, is implemented.

January 2005:
The Joint Commission on Accreditation of Hospitals surveys SwedishAmerican Hospital, which is granted a three-year accreditation and is found to be in compliance with all standards and requirements for quality and safety in patient care.

February 2005:
SAHS enters into a contract with the Solucient Top 100 Hospitals Program.

March 2005:
In an effort to improve throughput in the Cath Lab, a Six Sigma Throughput project was undertaken and resulted in a reduction in the amount of time a patient is in the Cath Lab for the procedure and turn-around time between cases.

April 2005:
Leapfrog Hospital Survey Results show SAHS making good progress in implementing the recommended quality and safety leap. The Leapfrog Group represents large payors nationwide and attempts to motivate healthcare providers to leap forward in the safety, quality and affordability of healthcare.

Two inpatient hospital floors begin using an electronic bar coding system to reduce the possiblitiy of errors when collecting lab specimens from patients.

May 2005:
In order to reduce delays and expedite appropriate treatment in potentially critical situations involving bleeding, SAHS Laboratory is now able to perform an HIT (heparin-induced thrombocytopenia) test on-site.

June 2005:
SAHS joins hospitals nationwide in the launch of 100,000 Lives Campaign and makes a commitment to implement changes proven to reduce the number of avoidable deaths.

July 2005:
Patient satisfaction survey results show SAHS with a 99.6% overall patient satisfaction rate.

October 2005:
The Decubitus Ulcer Prevention Quality Team is formed.

SBAR communication tool, a process for communicating critical patient information to physicians, is approved for use by all nursing units.

December 2005:
The American College of Surgeons' Commission on Cancer gives the SAHS cancer program a three-year award with commendation for meeting or exceeding all standards evaluated.

Diabetes Self Management Center awarded continued recognition from the American Diabetes Association for a three-year period for meeting criteria for the highest standard of diabetes care.

January 2006:
With the goal of moving to a patient safety-minded model of care, the "First Do No Harm" video series is presented to SAH staff.

As the first Illinois hospital to adopt the national Get with the Guidelines Heart Failure program, the SAHS cardiac staff makes a presentation at the American Heart Association meeting in Chicago about our success with the program.

February 2006:
An Early Response Team is initiated as part of the 100,000 Lives Campaign to reduce avoidable hospital deaths.

March 2006:
SAHS agrees to participate in the 9-month Illinois Hospital Association's Patient Safety Collaborative to improve communication at times of hand-offs.

June 2006:
As a participant in the CDC-sponsored Paul Coverdale Capture Stroke Study, SwedishAmerican presents a session titled "Developing the QI Plan at your Hospital" for the Capture Stroke Quality Improvement Education Workshop in Glen Ellyn, Illinois.

A comprehensive hospital risk assessment is being undertaken to identify common hazards, severity of risks, and protective measures for each area in the hospital.

July 2006:
Identified through a Joint Commission Sentinel Event Alert, tubing misconnections is chosen as our next FMEA.

September 2006:
A Pressure Ulcer/Wound Care online clinical caregiver education program is created by the Pressure Ulcer Team to reduce occurrences of decubitus ulcers.

October 2006:
Point of Care Testing of Cardiac Markers is implemented in the Emergency Department to substantially reduce the turn-around time for key lab tests.

November 2006:
Smoke Free Campus policy is instituted.

December 2006:
Bar coding is implemented for patient bedside medication verification in the ED.

January 2007:
SAH adopts the National Quality Forum (NQF), an endorsed set of 30 Safe Practices for patients at SwedishAmerican Hospital.

March 2007:
Joint Commission Survey for Point of Care testing for laboratory services.

April 2007:
The Northern Illinois Patient Safety Collaborative (NIPSC), on which Swedish American Hospital is an active member, chooses compliance with healthcare hand hygiene recommendations as a goal for 2007.

June 2007:
The FY 2008 Plan for Improving Organizational Performance is approved and adopted. The plan commits SwedishAmerican Hospital to participate in additional quality benchmarking opportunities: Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.

September 2007:
An EAM grant-supported pilot program is launched, which offers SAH inpatients various research-based healing therapies to complement traditional medical care (no charge to patient).

October 2007:
Dr. Kathleen Kelly, Chief Medical Officer, announces that SAH will apply to the Joint Commission to become certified as a Stroke Center.

November 2007:
HealthGrades announces that, in its Tenth Annual HealthGrades Hospital Quality in America Study, SAH ranks among the top 5 percent in the nation for cardiac surgery.

SwedishAmerican implements a bedside medication verification system. This state-of-the-art medication delivery system includes bar code scanners and mobile computers to help promote patient safety for medications.

A pre-surgical pilot program is introduced, which offers therapeutic massage, aromatherapy, televised music and visual therapy to pre-surgical patients as a way to reduce their perception of pain and anxiety (no charge to patient).

January 2008:
Due to overwhelming program satisfaction (patients, physicians, nurses, family members) HHS receives approval to expand the pilot program in June 2008 (to offer aforementioned services to inpatients seven days per week and to select outpatient areas – Breast Health Center, Radiation Oncology, Medical Oncology – on a scheduled weekly basis.

May 2008:
SwedishAmerican Hospital and Home Health Care were accredited by the Joint Commission for three more years after a rigorous four-day site visit by a team of Joint Commission surveyors. Joint Commission Accreditation is the gold seal of approval for the quality and safety of healthcare organizations.

June 2008:
SwedishAmerican welcoms the Joint Commission surveyors for a site visit to evaluate our Primary Stroke Center for certification. Disease-specific certification (stroke care) is a separate program from hospital accreditation.

August 2008:
SwedishAmerican Hospital receives notification of "certification" as a Primary Stroke Center.

October 2008:
SwedishAmerican Health System receives HealthGrades’ 2009 Clinical Excellence Award for Cardiac Surgery for ranking in the top five percent nationally for cardiac surgery.

December 2008:
The U.S. Department of Health and Human Service Organ Transplantation Breakthrough Collaborative recognizes SwedishAmerican Hospital with a Medal of Honor for its work in achieving a 75 percent organ donation rate.

February 2009:
A team led by Pharmacy completes an extensive assessment of the potential errors that can occur with the many different types of anticoagulants (anti-clotting drugs). Many processes are changed as a result of the team's work, in order to make ordering and delivery of this type of medication safer for all patients.

August 2009:
SwedishAmerican Medical Center/Belvidere is surveyed by the Joint Commission in July and receives full accreditation in August.

October 2009:
In October, SwedishAmerican is one of eight U.S. hospitals and health systems to receive a site visit from Malcolm Baldrige National Quality Award examiners.

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1401 East State Street
Rockford, IL 61104
(779) 696-4400


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