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Accreditation Quality Report
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Quality Report

Summary of Accreditation Quality Information
CGH Medical Center
Org ID: 7435
100 East LeFevre Rd
Sterling, IL  61081
(815)625-0400
www.cghmc.com

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 4/9/2011 4/8/2011   4/8/2011  
Hospital
Accredited 4/9/2011 4/8/2011   1/14/2013  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital





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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Home Care
2011 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2013 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Oct  2011 -
Sep  2012
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  Survey of Patients' Hospital Experiences (see details)
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
CGH Health Center, LTD
3010 Lynn Boulevard
Sterling, IL  61081
    Services:
    • Outpatient Clinics (Outpatient)
    CGH Health Centers, LTD.
    505 East Old Mill Street
    Milledgeville, IL  61051
      Services:
      • Outpatient Clinics (Outpatient)
      CGH Health Centers, LTD.
      105 S. Heaton Street
      Morrison, IL  61270
        Services:
        • Outpatient Clinics (Outpatient)
        CGH Health Centers, LTD.
        711 Division Street
        Polo, IL  61064
          Services:
          • Outpatient Clinics (Outpatient)
          CGH Health Centers, LTD.
          15 W. Third Street
          Sterling, IL  61081
            Services:
            • Outpatient Clinics (Outpatient)
            CGH Health Centers, LTD.
            212 East Railroad Street
            Prophetstown, IL  61277
              Services:
              • Outpatient Clinics (Outpatient)
              CGH Health Centers, LTD.
              100 W. 1st Street
              Rock Falls, IL  61071
                Services:
                • Outpatient Clinics (Outpatient)
                CGH Health Centers, LTD.
                123 South Main Street
                Tampico, IL  61283
                  Services:
                  • Outpatient Clinics (Outpatient)
                  CGH Health Centers, LTD.
                  10 W. 3rd Street
                  Sterling, IL  61081
                    Services:
                    • Anesthesia (Outpatient)
                    • Outpatient Clinics (Outpatient)
                    CGH Health Centers, LTD.
                    131 Jackson Street
                    Walnut, IL  61376
                      Services:
                      • Outpatient Clinics (Outpatient)
                      CGH Health Centers, LTD.
                      1321 N. Galena Avenue
                      Dixon, IL  61021
                        Services:
                        • Administration of High Risk Medications (Outpatient)
                        • Outpatient Clinics (Outpatient)
                        • Perform Invasive Procedure (Outpatient)
                        CGH Health Centers, Ltd.
                        1809 N. Locust Street
                        Sterling, IL  61081
                          Services:
                          • Outpatient Clinics (Outpatient)
                          CGH Home Nursing and Home Infusion
                          3010 E. Lynn Blvd
                          Sterling, IL  61081
                            Services:
                            • Durable Medical Equipment
                            • Enteral Equipment and/or Supplies
                            • Enteral Nutrients
                            • External Infusion Pumps and/or Supplies
                            • Home Health, Non-Hospice Services
                            • Parenteral Equipment and/or Supplies
                            • Parenteral Nutrients
                            • Pharmacy, Clinical Consulting Services
                            • Pharmacy/Dispensary,General Services
                            • Supplies
                            CGH Medical Center
                            101 E. Miller Road
                            Sterling, IL  61081
                              Services:
                              • Administration of High Risk Medications (Outpatient)
                              • Outpatient Clinics (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              CGH Medical Center  *
                              100 East LeFevre Road
                              Sterling, IL  61081-1279
                                Services:
                                • Cardiac Catheterization Lab (Surgical Services)
                                • CT Scanner (Imaging/Diagnostic Services)
                                • Ear/Nose/Throat Surgery (Surgical Services)
                                • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                • Gastroenterology (Surgical Services)
                                • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                • Gynecological Surgery (Surgical Services)
                                • Gynecology (Inpatient)
                                • Labor & Delivery (Inpatient)
                                • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                • Medical /Surgical Unit (Inpatient)
                                • Medical ICU (Intensive Care Unit)
                                • Normal Newborn Nursery (Inpatient)
                                • Nuclear Medicine (Imaging/Diagnostic Services)
                                • Orthopedic Surgery (Surgical Services)
                                • Pediatric Unit (Inpatient)
                                • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                                • Post Anesthesia Care Unit (PACU) (Inpatient)
                                • Sleep Laboratory (Sleep Laboratory)
                                • Surgical Unit (Inpatient)
                                • Teleradiology (Imaging/Diagnostic Services)
                                • Thoracic Surgery (Surgical Services)
                                • Ultrasound (Imaging/Diagnostic Services)
                                • Urology (Surgical Services)
                                • Vascular Surgery (Surgical Services)
                                CGH Wound Healing Center
                                1809 N. Locust Street
                                Sterling, IL  61081
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  • Perform Invasive Procedure (Outpatient)

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