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18

Quality and Safety

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Outpatient Quality Coordinator hired in June 2020
who is responsible for quality management in the
outpatient setting, specifically Good Shepherd
Medical Group

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Scored 100/100 on our Merit-based Incentive
Payment System (MIPS) for 2019. MIPS is a
performance-based payment system composed of
four categories (quality, improvement activities, cost,
and promoting interoperability) that rewards value
and outcomes. MIPS was designed to tie payments
to quality and cost efficient care, drive improvement
in care processes and health outcomes, increase the
use of healthcare information, and reduce the cost
of care.”

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Achieved ISO 9001:2015 certification. Achieving ISO
9001:2015 certification means that an organization
has demonstrated that it follows the guidelines of
the ISO 9001 standard, fulfills its own requirements,
meets customer requirements and statutory
and regulatory requirements and maintains
documentation. This certification enhances an
organization’s credibility by showing customers that
its products and services meet expectations

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Successful DNV-GL (Medicare certifying authority)
survey.

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Moved Infection Prevention & Employee Health,
as well as the Clinical Educator under Quality
Management

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Ongoing Quality & Patient Safety Initiatives:
–Hand Hygiene
– Restraint and Seclusion
–Ventilators
–Sepsis
–Falls Prevention
–Medication Reconciliation and Medication Error

Prevention

–Pain Management Effectiveness
–Skin Integrity
–Bedside Medication Verification (barcode scanning)
–Antimicrobial Stewardship
–Blood Transfusions
–Hospital Acquired Infections
–Patient Flow (Trauma, Stroke, Mental Health, STEMI)
–Patient Satisfaction
–Patient Relations and Grievance Team
–Readmissions
–Unplanned Returns to Surgery
–Accreditation

Patient Experience Survey  

(Press Ganey/CAHPS) Results

The patient experience encompasses a range of 
interactions patients have with GSHCS, including 
good communication with health care providers, 
coordinated care from staff, the ability to schedule timely 
appointments, and access to their health information. 
GSHCS continues to evaluate the patient experience 
through various survey and data collection methods 
such as the Consumer Assessment of Healthcare 
Providers and Systems (CAHPS). We are proud to have 
seen marked improvements in the “global measures” of 
“Rate the Hospital 0-10” and “Would You Recommend” 
questions. These questions are single-item indicators of 
the hospital experience and summary judgments of the 
care received. 

Marcus Engel Presentations

On October 31, 2019 Marcus Engel shared with 
employees how his own tragic accident and remarkable 

recovery led to a career in teaching caregivers about 
compassionate communication. Traveling to Good 
Shepherd from Florida with his Seeing Eye dog, Elliott, 
and his assistant, Taylor, Marcus gave two inspiring 
presentations describing how an ER Tech named 
Jennifer and other caregivers comforted him in his most 
vulnerable moments, simply by being present. Marcus’s 
goal is to remind health care professionals how important 
their presence is to patients and families. “If we are in the 
moment when we talk to patients, they will feel that,” 
shared Marcus. 

Dr. Michael Klein Presentations 

for Providers

This year GSHCS engaged the services of Dr. Michael 
Klein to present two-hour workshops for providers 
and practice managers on the subject of emotional 
intelligence. Nearly 40 attendees acquired new skills 
and knowledge in preventing burnout, emotional self-
awareness, stress management, empathy, and wellbeing. 

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Implemented processes and procedures to protect our staff and
adequately care for our patients with COVID-19

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Partnered with GSMG Urgent Care to facilitate COVID-19 testing
for employees

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Relocated Treatment Center and designated Unit C to be a COVID-19 unit

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Submit data daily to three different portals (state, federal, laboratory data)

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Quality/Infection Prevention helped plan the drive-thru community testing
event

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Collaboration with UCPH on many aspects, including creating a COVID-19
business toolkit for local businesses

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Kept up-to-date on the daily changing recommendations and guidelines
from the CDC and OHA

COVID-19 Pandemic

Infection Prevention

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Hired new Infection Preventionist
after previous IP retired after
40 years of service

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No reportable healthcare acquired
infections in the 2019 calendar
year.

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Integral in processes for COVID-19
pandemic

GSHCS employees attending the Top Workplaces Awards Banquet in Portland, Oregon, hosted by The Oregonian/

OregonLive last fall. GSHCS accepted the 2019 Top Workplace award, the third year in a row. The designation is based 

solely on employee feedback gathered through a third-party survey administered by research partner, Energage, LLC.