15

14

•Diabetes Education added body 

composition analysis using the 

InBody scale as a new service. 

InBody scale uses bioelectrical 

impedance analysis (BIA) to 

measure body composition. InBody 

is one of the easiest and most 

accurate BIA scales available and is 

a valuable tool for monitoring body 

composition changes/trends over 

time for weight management and/or 

chronic disease prevention/

treatment.

•Total general surgery cases 

(including endoscopy) were 1,363, 
with 637 being endoscopies.

•Auxiliary volunteers made over 800 

masks for hospital employees to 

help protect against COVID-19.

•Auxiliary awarded three $2,000 

scholarships to individuals pursuing 

a medical career

•During COVID, the Auxiliary has 

continued to support each other 

through phone calls, even providing 

meals for one of their members after 

being hospitalized, providing food 

for a funeral, etc.

•CareVan Transportation Services 

made 458 deliveries to patients 

needing their medications and 

provided 631 transports to the 

GSHCS Pharmacy or to get a COVID 

vaccine at GSHCS.

•GSHCS switched to Press Ganey 

surveying to better evaluate our 

patient satisfaction.

•GSHCS partnered with the Chartis 

Group to help evaluate our market 

share, value, quality and cost.

•Our practice managers have worked

diligently to provide Foreign

Language Interpreters to each area

of the hospital. Our interpreters

assist with patient appointments

and phone calls related to

scheduling, etc.

•Restructured Clinical Education,

hiring two additional RN Clinical

Educators, for a total of three.

The clinical education team has

restructured and developed:
— New Graduate Program
— Simulation Resource Team (SRT)

(Multiple department/community 

resource involvement and/or 

department-specific)

— General Nursing Orientation 
— New learning management system 

HealthStream

— New quarterly certification 

process for ACLS, BLS, and PALS 

through RQI

•Staff Education provided 117 days

of coursework including ACLS,

PALS, BLS (staff & community),

CPI, Skills Fair (Online), OHSU DNP

Information Program, STABLE,

TNCC, and US IV Class. A total

of 1,255 individuals were trained

throughout the fiscal year.

•Four staff members in our Quality

Department completed the ‘DNV

Infection Prevention and Control

Bootcamp’ July of 2021.

•Hospice earned a Top Box score

of 91.55% for “Rate Hospice 0-10”,

and 97.14% for “Would Recommend

to Friends or Family”. This means

that nearly every patient or family

member who returned their 

survey gave them the highest 

praise possible. The team was 

then awarded a quarterly Service 

Excellence Award.

•During the Year IV Service Summit:

Resilience, the People’s Choice

Award went to Good Shepherd

Women’s Center and the Service

Excellence Council Choice Award

went to Good Shepherd Urgent

Care.

•Tim Durkin provided six “Mental

Management” presentations for

staff.

•Two members of the Quality Team

recently became Certified Patient

Experience Professionals (CPXP),

thanks in part to funding through

the Oregon Office of Rural Health

(ORH). The CPXP certification is

offered through the Nashville-

based Patient Experience Institute

and is designed for “formal and

informal leaders who influence the

systems, processes, and behaviors

that cultivate consistently positive

experiences as defined by the

patient.”

•GSHCS transitioned to PolicyStat

policy management system in

March 2021.

•Our Treatment Center is working

to certify all Home Health and

Treatment Center Nurses in Wound

Care, and all Infusion Center Nurses

are working to be certified as Board

Certified Infusion Nurses.

•Implementing a “Soul Care” Model

into our Chaplaincy program.

Building a Lean Culture 

•Two Lean Fundamentals education sessions

have been completed so far (on June 18 &
July 22). Main topics included Value Stream
Mapping, Standard Work, A3 Thinking, 7
Wastes, 5S, Visibility Walls, Linked Checking,
and the concepts of “Genchi Genbutsu”,
“Gemba”, and “Kaizen”.

•A four-day workshop held June 28 – July 1

brought together a group of 15 staff members,
including a physician and Board of Trustees
member, to map the admissions process (from
the decision to admit a patient in the ED to
patient arrival on the floor/orders completed).

•The team completed nearly 59 hours of

observation time in the ED, Med/Surg, and ICU
(including interviews conducted with gracious
patients willing to provide honest feedback) to
identify waste and build a current state value
stream map.

•Improvement ideas identified will be applied

and tested in the coming months to enhance
patient flow, safety, and satisfaction while
reducing ambiguity, interruptions, and other
patient and employee dissatisfiers.

•Six GSHCS employees are also in the process of

becoming Lean certified through Moss Adams
to obtain the skills and knowledge needed to
lead our own kaizen events and workshops.

•These certification candidates will spend 12-16

months building their portfolios and will present
their individual projects before achieving
certification.

Driven by our desire to increase value, as defined by our patients, we have continued our quest to build 
a culture of continuous improvement through the application of lean methodology. 

In partnership with the Lean Health Care Practice of Moss Adams, we are focused on empowering all 
team members to solve problems and improve efficiency across the organization, one process at a time.

Education sessions and workshops have taken place as Covid-19 considerations allowed.