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•Good Shepherd Health Care System

completed our DNV survey on

November 4 and 5, 2021. All non-

conformities from CY 2020 were

reviewed and closed.

•Awarded MIPS (Merit Based

Incentive Payment System)

“Exceptional Performer” Status for

CY 2021 earning 100/100 points for

quality initiatives and performance

improvement activities. This adds

Medicare bonus dollars for FY 2023

and is the 4thconsecutive year

GSHCS has been designated an

exceptional performer.

•Over 60 physicians & providers have

privileges at our hospital

•Our Emergency Room cared for

nearly 20,000 patients

•On average we completed 900+

inpatient surgeries per year

•Our Medical/Surgical Unit cared for

2,700 patients this past year

•2,500 outpatient surgeries
•Our Critical Care Unit cared for

nearly 300 patients this past year

•Family Birth Center assisted in the

delivery of 400 babies

•67,400 outpatient visits in our

clinics

•Quality created over 170 Epic

reports to either replace Web

Intelligence reports that are no

longer supported, or for new quality

metric tracking needs.

•Discharge phone calls were

implemented for ED and inpatients

through a third-party vendor,

capturing additional feedback from

patients on their experience.

•Four staff from the Quality team

and Infection Prevention/Employee

Health team completed the ‘DNV

Infection Prevention and Control

Bootcamp’ in July of 2021.

•Two Quality staff members

obtained their CPHQ certification

(Certified Professional in Healthcare

Quality)

•Our Quality team, in partnership

with Pharmacy and the Infection

Prevention/Employee Health

teams, organized 48 COVID mass

vaccination clinics and administered

over 10,500 COVID vaccinations to

GSHCS staff and patients (this is

CALENDAR YEAR 2021)

•GSHCS transitioned from PolicyTech

to PolicyStat, successfully

converting over 2,000 documents

and developing a new policy on

policies. A Standards Oversight

Committee was also created

to oversee and improve the

policy/standards workflow and

effectiveness.

•Began restructure of Quality Council

to better align with strategic goals

and increase accountability for

performance improvement within

operational departments.

•Restructured Infection Prevention/

Employee Health to better serve our

patients and staff.

•Three Quality employees are in the

process of completing requirements

for lean certification through Moss

Adams

•Organized five Lean education

sessions for Executive team and

Management

•Organized two four-day Value

Stream Mapping Workshops

•Organized and helped lead several

multi-day and single-day Kaizen

Workshops

•Patient Relations & Grievance Team

investigated and resolved over 150

complaints/grievances in FY 2022

•Chosen by the Oregon Office of

Rural Health to be one of nine

Critical Access Hospitals in Oregon

to participate in a Virtual Patient &

Family Engagement (PFE) Cohort

•Developed a Quarterly Great Catch

Award staff to recognize staff who

demonstrate their commitment to

safety by speaking up to prevent

potential harm to a patient or fellow

employee.

•Created and distributed COVID Care

Kits for patients, which include a

pulse oximeter, thermometer, mask,

and a symptom tracking form.

•Helped Start Resilience Education

and Peer Support (REPS) Program

•Helped start Workplace Violence

Prevent Committee and recruited

members

•Partnered with other departments

on patient experience improvement

projects including Pediatric

Behavioral Health/Mental Health

Safe Activities Project, ED patient

recliner, toys for pediatric patients,

Commit to Sit Project (stools for

Hospitalists), and Housekeeping

Cards in EVS

•Partnered with Marketing to utilize

patient and family testimonials in

social media channels

Accomplishments