solid green background with faint springfield clinic leaves

    Quality of Care

    About Us

    Quality improvement in health care is not just a project. It must be the primary function of every health care organization to continuously assess and improve its effectiveness and efficiency to improve health outcomes. We have a team of people in the Quality Management (QM) department at Springfield Clinic overseeing this function. 

    In keeping with our mission to provide the highest quality health care to the people of central Illinois -- we have systems and structures in place to monitor and minimize risks with regard to preventable adverse events, avoidable deaths and customer service that exceeds the expectations of our patients.

    Let Our Staff Ease Your Mind 

    Our friendly and compassionate staff will take your call, listen to your problem and recommend the best course of action. The sooner you reach out, the faster we can help. Call us early and let us help you find a resolution that will work for everyone involved. 

    If you have an issue, we have an answer. When you have a situation at any Springfield Clinic facility or affiliate that has not been addressed or resolved to your satisfaction, call 217.528.7541 or 800.444.7541 and ask for extension 1 or Quality Management. 

    Extension 1 at Springfield Clinic is staffed Monday - Friday from 8:00 am - 5:00 pm. 

    You can also contact us through our online feedback form.

    Accountable Care Organization

    Springfield Clinic is participating in the Medicare Shared Savings Program, an Accountable Care Organization (ACO). An ACO is a group of doctors, hospitals, and/or other health care providers that work together to improve the quality and experience of care you receive. ACOs receive a portion of any savings that result from reducing costs and meeting quality requirements.

    • Medicare evaluates how well each ACO meets these goals every year. Those ACOs that do a good job can earn a financial bonus. ACOs that earn a bonus may use the payment to invest more in your care or share a portion directly with your providers. ACOs may owe a penalty if their care increases costs.

    • Springfield Clinic’s participation in the Medicare Shared Savings Program doesn’t limit your choice of health care providers. Your Medicare benefits are not changing. You still have the right to visit any doctor, hospital, or other provider that accepts Medicare at any time, just like you do now.

    • To help us coordinate your health care better, Medicare shares information about your care with your providers. If you don’t want Medicare to share your health care information, call 1-800-MEDICARE (1-800-633-4227).

    ACO Literature

    Frequently Asked Questions

    • An ACO isn’t a Medicare Advantage plan which is an “all in one” alternative to Original Medicare, offered by private companies approved by Medicare. An ACO isn’t an HMO plan, or an insurance plan of any kind.

    • ACOs have agreements with Medicare to be financially accountable for the quality, cost, and experience of care you receive.

    • Coordinated care can avoid wasted time and costs for repeated tests and unneeded appointments. It may make it easier to spot potential problems before they become more serious – like drug interactions that can happen if one doctor isn’t aware of what another has prescribed.

    • ACOs may use electronic health records, case managers, and electronic prescriptions to help you stay healthy. Some ACOs have special programs to encourage you to have a primary care visit or use their care management team. Participation in these programs is optional.

    • Medicare shares information about your care with your health care providers; like dates and times you visited a health care provider, your medical conditions, and a list of past and current prescriptions. This information helps Springfield Clinic track the care and tests that you’ve already had.

    • Sharing your data helps make sure all the providers involved in your care have access to your health information when and where they need it.

    • We value your privacy. ACOs must put important safeguards in place to make sure all your health care information is safe. We respect your choice on how your health care information is used for care coordination and quality improvement. If you want Medicare to share your health care information with Springfield Clinic or other ACOs in which your health care providers participate, there’s nothing more you need to do.

    • If you don’t want Medicare to share your health care information, call 1-800-MEDICARE (1-800-633-4227). Tell the representative that your health care provider is part of an ACO and you don’t want Medicare to share your health care information. TTY users should call 1-877-486-2048.

    • If you change your mind and want to let Medicare share your health information again, call 1-800-MEDICARE to let Medicare know. We aren’t allowed to tell Medicare for you.

    • Even if you decline to share your health care information, Medicare will still use your information for some purposes, like assessing the financial and quality of care performance of the health care providers participating in ACOs. Also, Medicare may share some of your health care information with ACOs when measuring the quality of care given by health care providers participating in those ACOs.

    • Ask your clinician if they have a secure online portal that gives you 24-hour access to your personal health information, including lab results and provider recommendations. This will help you make informed decisions about your health care, track your treatment, and monitor your health outcomes.

    • As a Medicare beneficiary, you can choose or change your primary clinician or “main doctor” at any time. Your primary clinician is the health care provider that you believe is responsible for coordinating your overall care. If you choose a primary clinician, that clinician may have more tools or services to help with your care. You can learn more in the Voluntary Alignment Beneficiary Fact Sheet.

    • For step-by-step instructions on how to select or change your "main doctor," refer to the Choosing a Primary Clinician video

    • If you have concerns about the quality of care or other services you receive from your ACO or provider, you can contact your Medicare Beneficiary Ombudsman who can assist you with Medicare-related questions, concerns, and challenges. The Medicare Beneficiary Ombudsman works closely with the Medicare program, including, 1-800-MEDICARE, and State Health Insurance Assistance Program (SHIPs), to help make sure information and assistance are available for you. Visit for information on how the Medicare Beneficiary Ombudsman can help you.

    • If you suspect Medicare fraud or abuse from your ACO or any Medicare provider, we encourage you to make a report by contacting the HHS Office of Inspector General (1-800-HHS-TIPS) or your local Senior Medicare Patrol (SMP).

    Accreditation & Awards

    Accreditation Association for Ambulatory Health Care (AAAHC) is the country’s largest and most respected accreditation association, whose purpose is the promotion of patient safety, quality of care and measurement of performance. 

    In the 2021 survey, Springfield Clinic was granted a full, three-year accreditation, the highest level of achievement available from AAAHC, marking more than 30 consecutive years of accreditation for Springfield Clinic. 

    Accreditation is a voluntary process that measures the quality of an ambulatory health care organization’s services and performance against nationally recognized standards. The process involves a self-assessment and a rigorous on-site review by highly trained and experienced survey professionals. It symbolizes Springfield Clinic’s commitment to high quality health care to its patients. 

    PCMH (Patient Centered Medical Home) is issued through the National Committee for Quality Assurance (NCQA). All 15 of Springfield Clinic’s primary care locations have achieved Annual Reporting Recognition for delivering quality health care at the highest level possible. PCMH definition: not a building or place, it is an approach to providing comprehensive primary care for children, youth and adults.

    A leading gastrointestinal medical society, has recognized Springfield Clinic’s Ambulatory Surgery & Endoscopy Center. ASGE’s Endoscopy Unit Recognition Program (EURP) honors endoscopy units that have demonstrated a commitment to patient safety and quality in endoscopy, as evidenced by meeting the program’s rigorous criteria, which includes following the ASGE guidelines on privileging, quality assurance, endoscope reprocessing, CDC (Centers for Disease Control) infection control guidelines and ensuring endoscopy staff competency. 

    Springfield Clinic’s Ambulatory Surgery & Endoscopy Center, located on the 2nd floor of Springfield Clinic’s Main Campus – East Building, was Springfield’s first free-standing facility designed for the convenience, privacy, and comfort of its patients. 

    National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons, granted the Breast Health Center at Springfield Clinic another full three-year accreditation in 2020.  The Breast Health Center first earned its initial accreditation in 2011. 

    The Breast Health Center at Springfield Clinic ensures a multidisciplinary team of physicians and nurses who will confirm treatment is timely and thorough. The Breast Health Center offers all aspects of treatment for breast cancer, including services for radiology, surgery, reconstruction, medical oncology, radiation therapy, clinical research, and nurse navigation. 

    Accreditation by the NAPBC is only given to those centers that have voluntarily committed to provide the highest level of quality breast care and that undergo a rigorous evaluation process and review of their performance. A breast center that achieves NAPBC accreditation has demonstrated a firm commitment to offer its patients every significant advantage in their battle against breast disease. 

    The Quality Oncology Practice Initiative (QOPI) is an oncologist led; practice-based quality program created by the American Society of Clinical Oncologists (ASCO). In 2018, the Cancer Center was described as exceptional by QOPI auditors and three-year re-certification for outpatient hematology-oncology practices. Using nationally approved standards, the program validates the practice's processes, which demonstrates a commitment to quality for patients, payer, and colleagues. 

    Springfield Clinic's Cancer Center works diligently in maintaining this nationally recognized certification. The Cancer Center earned its initial QOPI Certification in 2011. 

    PCMH Recognition

    Achievement of Annual Recognition  

    Each year, the practice sustains recognition by demonstrating continuous alignment with PCMH through the combination of attestation and submission of information, data and evidence for selected key criteria that support each concept in the PCMH program. 

    15 Primary Care locations: 

    • Moweaqua, Effingham, Macomb, Hillsboro East and West, Carlinville, Decatur, Springfield Clinic Main Campus, Springfield Clinic Family Practice, Sherman, Jacksonville, Taylorville, Wabash, Springfield Clinic Pediatrics and Adolescent Center and Lincoln. 

    • Our practices are recognized by NCQA (National Committee of Quality Assurance). This organization is a non-profit dedicated to improving health care quality. 

    • All 15 SC primary care sites are recognized in NCQA’s Recognition Directory. 

    Annual Standards Reporting 

    There are six categories of standards for annual reporting.  They include:

    Team-Based Care and Practice Organization 

    Knowing and Managing Your Patients  

    Patient-Centered Access and Continuity

    Care Management and Support  

    Care Coordination and Care Transition 

    Performance Measurement and Quality Improvement 

    PCMH Annual Recognition has specific expectations for providing timely access to care and continuous quality improvement. Practices that earn recognition have made a commitment to providing high-quality, patient-centered care. 


    Accessibility Services

    Springfield Clinic’s mission is to provide the highest quality health care to the people of central Illinois, without regard to disability. Springfield Clinic is equipped to meet the needs of our patients with disabilities. View Springfield Clinic's Nondiscrimination and Accessibility Information.

    Discrimination Grievance Procedure

    If you believe we have not been able to assist you, then you may submit a grievance to let us know what the problem is by following the Discrimination Grievance Procedure (see below) and submitting a Grievance Regarding Lack of Health Care Access Based on Disability Form.

    Discrimination Grievance Procedure

    It is the policy of Springfield Clinic not to discriminate on the basis of race, color, national origin, sex, age, or disability.  Springfield Clinic has an internal grievance procedure providing for prompt and equitable resolution of grievances alleging any action prohibited by the Rehabilitation Act of 1973, the U. S. Department of Human Services regulations implementing the Act; or the Affordable Care Act of 2010, or the Americans with Disabilities Act of 1991, all as amended from time to time.

    Any person believing that they, a family member, or someone to whom they provide care (referred to as “you” from here on) has been subjected to discrimination may file a grievance under this procedure.  A failure to reasonably accommodate an individual with a disability to provide access to healthcare may constitute discrimination based on disability.  It is against the law for Springfield Clinic to retaliate against you for filing a grievance or against anyone who cooperates in the investigation of a grievance.

    The Quality Management (“QM”) Director acts as the Section 504 Coordinator as well as the Section 1557 Coordinator (“Coordinator”) and is responsible for processing grievances.

    You must submit the grievance to the QM Department within 7 days of the date you become aware of the alleged discriminatory action. All grievances will be forwarded promptly to the Coordinator. 

    You must put your grievance in writing and you must include your name, the patient’s name (if you are not the patient), your address, and telephone number or email address, whichever you prefer.  You must state the event or action alleged to be discriminatory and the accommodation, remedy or relief sought.  You are encouraged to use Springfield Clinic’s Grievance Regarding Lack of Health Care Access Based on Disability Form.

    The Coordinator will investigate the grievance.  This investigation may be informal, but it will be thorough.  It will allow you, and/or others you believe would have information, to submit evidence related to the grievance.  The Coordinator will give you the results of the investigation in writing no later than 30 days after the grievance was filed.

    You may appeal the Coordinator’s decision by writing to the Chief Executive Officer within 15 days of receiving the decision.  The Chief Executive Officer shall issue a written decision in response to the appeal no later than 30 days after its filing at:

    Springfield Clinic, LLP
    Chief Executive Officer
    Section 504/1557 Appeals
    P.O. Box 19248
    Springfield, IL  62794-9248

    Interpreter Services

    Springfield Clinic provides free aids and services to people with disabilities to communicate effectively with us, such as:

    • Qualified sign language interpreters

    • Written information in other formats

    • TTY: 1.866.548.4655

    Springfield Clinic provides free language services to people whose primary language is not English, such as:

    • Qualified interpreters

    • Two dedicated language lines
      Spanish: 1.855.226.1738
      French: 1.866.802.3558

    Request an Accommodation

    To request an accommodation, please complete and submit the online Request for Healthcare Access Accommodation form. This form is not intended to be used to request medical records. If you need to request medical records, click here.

    Need Help? Contact Us

    If you do not believe you have received the accommodations you need to enable your access to health, let’s work together to make it right!  Please contact the QM team and speak with any member of our staff to let them know what you need or what has happened.  We will work with you to find a reasonable accommodation to ensure you have equal access to Springfield Clinic’s quality health care services.

    • Springfield Clinic Quality Management Department
      1025 South 6th Street, Springfield, IL 62794
      Phone: 217.528.7541 or 800.444.7541
      Fax: 217.528.5833