Sonoma Valley Hospital Is A Model For Safety and Quality

May 13, 2016 | From the SVH CEO | 0 comments

(This is a guest blog by Jane Hirsch, Sonoma Valley Health Care District Board Chair.)

Two years ago Consumer Reports named SVH one of the safest hospitals in the country, and over the past several years the Centers for Medicare and Medicaid Services (CMS) has consistently placed us in the top 25 percent of all hospitals in the country for safety and quality. So we were surprised and disappointed when the Leapfrog Group, an industry group, recently gave our hospital a “D” rating safety score.

As you may have heard, we dispute this rating based on both the methodology used, which emphasizes process over outcomes, and what we feel is an inherent bias in the methodology against small hospitals like ours.

I believe it is important that our community understand the strong focus on safety and quality at SVH, and the excellent results we have achieved based on the programs and safeguards we have in place.

I have to say that this topic is personal for me. While I am the current board chair of the Sonoma Valley Hospital Health Care District, I am a nurse and also have served for three years as the chair of the Hospital’s Quality Committee, so I have a thorough understanding of the high level of quality and safety practiced at the Hospital.

The quality standards at SVH reflect the high standards and evidence-based practices embraced by a number of leading national and California organizations, including CMS (Centers for Medicare and Medicaid Services), NHSM (National Healthcare Safety Network/CDC), California’s Office of Statewide Health Planning and Development (OSHPD), and the California Department of Public Health, among others.

Sonoma Valley Hospital is fully accredited by the Center for Improvement in Healthcare Quality and meets and exceeds these national standards. Although SVH is a small community hospital, the same national quality standards apply to all hospitals, regardless of size, and we compare very well with hospitals nationally. For example, our Surgical Care Quality Outcome Measures meet and exceed national benchmarks, and our Hospital Acquired Infection Rate is lower than national benchmarks.


Quality Oversight At SVH

Consistent with the mission of the District, the Hospital’s quality program is strong and effective. The Quality Committee oversees the excellent work performed by the Hospital’s leaders and staff. The committee consists of two members of the SVHCD Board of Directors, the Hospital’s Chief Quality Officer, Chief Medical Officer, Chief Nursing Officer and the Vice Chief of the Medical Staff.  Seven members of the Sonoma community also serve as members. These individuals are informed and important members of the committee. Several have relevant health care and quality/safety backgrounds and have much to offer in terms of expertise and oversight. Members of the public are welcome to attend the committee meetings at any time, and the monthly meeting agenda and reports are posted on the SVH website.

Each year, the Committee drafts an overall work plan, which includes reports from Hospital departments. Department presentations must include the quality and safety indicators and metrics that are tracked throughout the year, along with any performance improvement activities that are underway.  Examples are an annual Infection Control Report, Medication Safety Report, an annual review of the Hospital’s overall Quality Assurance/Performance Improvement Program, and then an annual evaluation of the overall plan at the end of each year.

The Quality Committee also reviews and oversees quarterly “scorecards,” tracking relevant indicators.  Most of these are quality and safety elements that must be submitted to CMS and impact the Hospital’s reimbursement.  For the last several years, SVH’s high scores have earned it bonus payments from CMS.

There are several important elements to the Hospital’s robust quality and safety program. 

  • Each year since 2009, staff members complete the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety survey. The goal is to monitor and evaluate the overall safe culture for patients, staff and visitors at the Hospital. 
  • There is a hospital-wide Safety Committee that meets monthly, with representatives from all departments.
  • The Quality Department holds an annual Performance Improvement (PI) Fair, with projects reflecting progress in evaluation and improvement activities submitted by each department. This fall the PI Fair will be open to the public and provides a great opportunity to see the strong emphasis on continuous improvement in both patient care-related and administrative activities. 
  • The Hospital also has a “Good Catch” program, which is positive, public acknowledgement of staff members who recognize and prevent events that could have potentially been harmful to a patient, employee or visitor. Studies have shown that proactive reporting of “near misses” can prevent more serious errors, and the program is considered a national best practice endorsed by the Institute for Healthcare Improvement.

I hope this provides insight into how seriously SVH takes quality and safety, and helps explain why SVH leadership and staff, as well as the Sonoma community, can take great pride in the strength and depth of our quality and safety activities and outcomes. 

Please feel free to contact me if you have questions about the Quality Committee and Hospital safety programs.



Jane Hirsch, RN, MS
Chair of the SVHCD Board of Directors