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Recognizing and identifying the signs and symptoms 
of Sepsis was a priority this year. Sepsis is the 
body’s overwhelming and life-threatening response 
to infection that can lead to tissue damage, organ 
failure, and death. In other words, it’s your body’s 
overactive and toxic response to an infection. 
Recognizing and identifying Sepsis is imperative to a 
patient’s successful outcome of fighting the infection. 
Our quality, clinic team, and medical staff reviewed 
industry best practices for recognizing and identifying 
and treating Sepsis. Based on their research this team 
implemented a Sepsis protocol that heavily relies on 
nursing staff to:

 — Screen for Sepsis during patient triage and 

admission.

 — Recognize early signs and symptoms
 — Reassess patients at least every 12 hours
 — Utilize the Sepsis screening tools
 — Speak up and Ask Questions of Medical Staff
 — Provide Rapid Treatment

 In addition, to nursing assessments tools have been 

provided in the protocol to:

 — Review the patient’s algorithm
 — Physician order set
 — Nursing Screening Tool
 — Nursing Report Handoff Tool

 As the leading cause of death in U.S. hospitals with 

over 258,000 patients dying in the U.S. each year, and 
having an economic impact of $24 billion per year, we 

Quality and Safety

At Good Shepherd Health Care System we strive to provide you with the highest quality experience while utilizing the 
safest proven techniques and procedures for delivering your care. As an organization, we measure quality and safety in 
several ways; patient perceptions and experiences, and through national measurements and benchmarks that compare us 
to healthcare organizations throughout the nation. We believe it is our duty to always strive for excellence and continuous 
improvement—ensuring we are providing the highest quality care services with the safest methods for delivering that care 
as possible. 

As we reflect on the 2017-2018 Fiscal Year, we have made many notable improvement and achievements.

believe it is our responsibility to recognize, identify, 
and care for Sepsis using proven and successful 
methods for caring for this infection.

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Our Good Shepherd Medical Group clinics and 
medical staff underwent a change in how the Centers 
for Medicare and Medicaid Services reimburses 
medical groups and physicians based on a law 
implementing a quality payment incentive program, 
referred to as the Quality Payment Program, which 
rewards value and outcomes through a Merit-based 
Incentive Payment System (MIPS). 

 Under MIPS, a clinician’s performance is measured 

based on data collected in four areas; Quality of the 
care delivered to patients, Improvement Activities 
assesses how well a clinician improves their care 
they provide and enhance patient engagement, 
Promoting Interoperability focuses on the ability for 
clinicians to engage patients electronically and how 
well we exchange health information using a certified 
electronic health record technology, and cost of care 
provided at a clinic based on Medicare claims. 

 During our first submission period in March 2018, we 

received a 97.2 percent pass rate.

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As part of our focus on enhancing the customer 
experience, we placed an emphasis on the review and 
revision of our customer Complaint, Grievance, and 
Billing Issue policy. Emphasis was placed on increased 
accountability upon department managers to 
address and resolve complaints that originate in their