• Achieved a 4-Star Rating for patient satisfaction.
• We saw a 7% decrease in patient complaints over the 

prior fiscal year.

• One of our major quality initiatives this year was the 

implementation of organization-wide LEAN processes. 
This was done in conjunction with our Service Excellence 
Initiative through Custom Learning Systems. Each 
department now has a Customer Experience Board and 
conducts Daily Service Huddles – focusing on quality, 
efficiency, elimination of waste and improvements in 
customer satisfaction.

• As part of our Epic Electronic Health Record (EHR) 

system migration, we transitioned from NRC Health to 
Press Ganey for our patient satisfaction surveys. The 
change has allowed us to conduct surveys on additional 
areas such as Good Shepherd Urgent Care and the 
Treatment Center. Press Ganey has provided new 
categories and targets, including Idaho, Oregon and 
Washington results and Critical Access Hospital (CAH) 
averages. In addition, we now have the opportunity to 
conduct surveys in new mediums such as electronic 
emailed surveys. 

• We contributed to the success of the Eastern Oregon 

Coordinated Care Organization (EOCCO), ensuring that 
recipient members of the Oregon Health Plan living in 
Eastern Oregon have access to affordable, high-quality 
care. We participated and assisted EOCCO in achieving 
14 out of 17 quality metrics, receiving a 100% maximum 
quality bonus award. 

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 2018-2019 fiscal year, we have made many notable improvement and achievements.

• Ongoing Quality & Patient Safety Initiatives:
 — Hand Hygiene
 — Restraint and Seclusion
 — Sepsis
 — Standardization of Key Processes
 — Reduce Harm
 — Falls Prevention
 — Medication Error Prevention
 — Pain Management Effectiveness
 — Hospital-Acquired Infection Prevention
 — Quality Control (ISO) Audits to Ensure Continuous 

Quality Improvement

• Partnerships with External Organizations:
 — Northwest Quality and Safety Partnership through the 

Washington and Oregon Hospital Associations

 — Oregon Patient Safety Commission

EMPOWERING EMPLOYEES TO PROVIDE EXCEPTIONAL CUSTOMER SERVICE

This year, we began our journey of implementing LEAN 
process improvement methodology throughout the 
organization. LEAN stands for “Leveraging Empowerment 
and Accountability Now” and it allows us to empower our 
employees to take whatever action is necessary to improve 
processes. Training provided to employees has focused 
on minimizing the root cause of waste in every process 
through an ongoing system of improvement, and ensuring 
that every task adds value to serve our patients’ needs.

In order for Good Shepherd to implement LEAN, we 
began by installing Customer Experience Boards in every 
department of the organization. These boards are the 
focal point of daily “service huddles” that occur at set 
times in each department. These quick, daily meetings 
give employees a chance to review departmental goals, 
patient satisfaction scores, departmental key performance 

indicators and performance improvement projects, as 
well as announcements and safety alerts. Collecting, 
displaying and briefly analyzing this data on a daily basis 
keeps the departments’ focus top of mind and encourages 
employees to consider their performance each day. 
This visual presentation provides a strong motivator for 
improvement so that we can provide the best patient care 
possible. Members of the leadership team regularly round 
on each department’s daily service huddle, seeking to 
understand current performance so that they can provide 
the appropriate resources needed to help solve problems 
system-wide. 

The Customer Experience Boards and LEAN process have 
translated into a more satisfied and engaged workforce, 
and has re-energized performance improvement projects at 
Good Shepherd Health Care System. 

PICTURED ABOVE:

 Epic Go-Live Team preparing for the launch 

on November 3, 2018 when we transitioned to our new Electronic 
Health Record (EHR) system, Epic. 

Quality and Safety

LEAN Daily Management

PICTURED ABOVE:

 Good Shepherd Personal Home Care 

provides in-home care services for individuals of all ages 
that need help with domestic needs, medical support and 
housekeeping.