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• Improved in several areas of the Emergency Department 

patient experience scores, most notably in nursing 

courtesy, listening, attention to patient needs, concern for 

privacy, and responses to questions and concerns. 

• In November 2022, we received recertification (renewal) 

for ISO 9001:2015 and reaccreditation (renewal) for Det 

Norske Veritas NIAHO CAH.

A Journey to Lean Process Improvement

Good Shepherd has been on a journey to transform our 
healthcare system through the use of Lean since 2021. 
Lean, in healthcare, is all about putting the patient first and 
encompasses a range of big-picture characteristics and 
day-to-day practices. In the last year, we have conducted 
seven 3-4 day workshops with staff spending over 3,000 
hours focused on processes that occur in Acute Care 
Services, the Good Shepherd Medical Group, and Surgical 
Services. We have worked to:

• Add value from the patient perspective with changes such 

as increased staff, family, and patient education related 

to fall prevention while admitted, improved discharge 

planning so that patients are able to discharge when they 

are ready, streamlining the surgical pathway to ensure a 

smooth surgical experience for our patients, and reduced 

inefficiencies created by excess supplies, equipment, or 

paperwork, which allows staff to have more time to spend 

at the bedside.

• Align leaders and staff around a shared vision by  

ensuring that each department’s daily work supports  

our organization’s mission of improving the health of  

our community. 

• Empower the frontline to drive improvement efforts by 

physically going to the place where staff deliver care to 

patients every day and encouraging staff to lead the way 

to a better process. 

• Exercise flexibility and willingness to change by realizing 

that sometimes a change does not work as intended and 

being willing to try a new possible solution. 

ER Pit Stop for Stroke Patients

With a Stroke, “Time is Brain”

A stroke is a disease that occurs when the brain’s blood 
supply is interrupted by factors such as blood clot 
or a hemorrhage. Treatments exist to prevent further 
damage for these patients; however, these treatments 
must be given quickly to be effective. That’s why 
GSHCS developed a stroke “pit stop” in our Emergency 
Department. Through the implementation of standard 
work (a defined sequence of steps, including the time 
required for each step, the location, and expected 
outcome), we were able to drastically reduce the 
amount of time to get a patient from door to CT or MRI. 
This crucial imaging helps our providers determine a 
diagnosis quickly.

There are numerous measures GSHCS uses to determine 
if our stroke protocols are in line with national guidelines. 
The number of minutes that elapse between patient 
arrival and diagnostic imaging results is just one of those 
measures we are working to improve.