Shepherd Center Wins Statewide Patient Safety Awards

The Georgia Hospital Association presented Shepherd Center with a Circle of Excellence award, an honor given to hospitals and health systems that have demonstrated a sustained commitment to quality and patient safety as evidenced by not only winning a patient safety award this year, but by earning three or more GHA Patient Safety and Quality Awards within the previous five years.

“We are pleased to honor Shepherd Center for their innovative approach to improving patient safety,” said Georgia Hospital Association President and CEO Caylee Noggle. “Their efforts have improved patient outcomes and enhanced the care journey for their patients. We are grateful for their efforts.”

In addition to the Circle of Excellence award, Shepherd Center won both second and third place awards in the Specialty category of the GHA Patient Safety and Quality Awards. The project “Workflow-Driven Improvements in Modified Diet Monitoring and Documentation,” which enhanced patients’ dietary protocols as part of overall care, won second place. The project “Turning the Tide on Pressure Injuries: A Multidisciplinary Approach Through PDSA Cycles,” which helped reduce the incidence of pressure injuries in patients, took home third place.

These annual awards recognize Georgia health care organizations for achievement in reducing the risk of medical errors and improving patient safety and medical outcomes.

“This recognition from GHA is a tremendous honor and a reflection of Shepherd Center’s deep commitment to building systems that prioritize patient safety at every level,” said Mariana Volpini Gattegno, MPH, CPHQ, CLSSBB, director of quality and outcomes management at Shepherd Center. “These projects demonstrate that when we align frontline expertise with structured improvement methods, we can achieve measurable outcomes that directly impact the lives of the patients and families we serve.”

Consistent Care for Patients with Modified Diets

The goal of the project “Workflow-Driven Improvements in Modified Diet Monitoring and Documentation” was to enhance the reliability and consistency of care for inpatients on modified diets due to swallowing precautions.

“Our patient population is at high risk for swallowing impairments due to the nature of the injury or progression of disease, respiratory compromise, deconditioning, or cognitive impairment, among other reasons,” said speech-language pathologist Melissa Kast, MA, CCC-SLP, CBIS. “Aspiration is the most problematic swallowing impairment. It increases the risk of pneumonia, complicates recovery, and can lead to malnutrition and dehydration. Our goal is for our patients to achieve the best outcomes possible, and adhering to swallowing precautions or modified diets reduces the risk of aspiration and improves overall outcomes.”

The project was a continuation of a 2023 GHA award-winning project on modified diets, specifically thickened liquids.

“This project started from our Quality Improvement Champions Program (QICP), which is our frontline education for different staff members on the science of improvement and the use of different improvement tools,” said Anna Murdock, BS, LSSBB, senior internal improvement consultant and Quality Improvement Champions Program co-lead. “In our first year, [registered dietitian] Jill Newsome was one of our champions. She identified potential process issues regarding our swallowing precautions, specifically related to thickened liquids.”

Two subsequent QICP participants continued the project — for phase two, Kast focused on improving communication processes, and for phase three, food service supervisor Shannon Garland concentrated on identifying and implementing a better flag for frontline clinicians to know when a patient needs assistance during mealtimes.

A multidisciplinary team, including Garland, Kast, Murdock, and Newsome, collaborated with clinicians, Information Systems staff, and Food and Nutrition Services staff to address gaps caused by documentation inconsistencies and communication breakdowns.

They streamlined documentation by using an electronic medical record (EMR)-generated report that consolidated swallowing precautions into a single printable document. The document was then placed on the back of the patient’s wheelchair.

Then, the Food and Nutrition Services team began serving meals for patients requiring swallowing precautions on bright yellow trays. The trays served as a visual cue for staff.

“When you see yellow, you think caution, slow,” Garland explains. “The tray can get crowded with food, and sometimes you can’t see that stamp that lets [staff] know there’s a swallowing issue. So, if you see a different color tray, that lets the nursing staff know they need to take care and pay special attention to this patient during mealtimes.”

The initiative demonstrated that system-level changes, such as automation and visual identification, can significantly improve patient safety and workflow efficiency. Challenges with data collection and staff awareness were addressed through structured reporting, interdisciplinary collaboration, and ongoing education. The project met its objectives and is now embedded in hospital-wide training and orientation.

“This project has standardized the way we communicate modified diets and swallowing precautions and has increased cross-disciplinary communication as a result,” said Kast. “This cross-disciplinary communication has reduced the number of errors and serves as a model for how data-driven conversations improve the overall safety and outcomes for our patients.”

Preventing Pressure Injuries

The project, “Turning the Tide on Pressure Injuries: A Multidisciplinary Approach Through PDSA Cycles,” aimed to reduce Hospital-Acquired Pressure Injury (HAPI) incidence through iterative Plan-Do-Study-Act (PDSA) cycles.

For people with limited mobility or sensation, chronic conditions, or post-operative recovery needs, hospital-acquired pressure injuries are a persistent challenge.

“Our population is one of the most at-risk patient populations for developing pressure injuries post-injury,” said Kimberly Levenson, RN, BSN, CRRN, CWOCN, CFCN.

The project workgroup included nursing, therapy, wound care specialists (WOCNs), managers, and frontline staff, who collaborated to design and implement evidence-based interventions. Murdock and Tiffany LeCroy, MSN, RN, CRRN, FNP-C, ACNS-BC, FARN, chief nursing officer, served as coaches, providing strategic guidance and securing financial support through grants and donations.

“The cross-department collaboration by our workgroup members has been pivotal in the success of these initiatives and improvements. Full engagement of the various disciplines ensures consistency of practice and communication to address skin integrity and prevent pressure injuries,” said Murdock.

Key interventions included various wound-focused equipment to mitigate risks related to patient turn schedules, patient positioning, and patient repositioning. These technologies were selected for their proven effectiveness in reducing pressure injuries and improving staff safety.

Additional process improvements included wound caddies, labeled supply cabinets, and translated patient education materials.

And, according to Levenson, staff worked to educate patients and care partners about many of the interventions so they could continue best practices after discharge.

“We've been trying to hardwire a lot of these pressure injury prevention tools and habits, so that when they go home, they will carry over and reduce the risk at home, too,” said Levenson.

The initiative led to measurable improvements in structure, process, and outcomes. Equipment upgrades enhanced patient safety and staff efficiency, while streamlined workflows and targeted education improved compliance and care quality. HAPI rates declined significantly, from a goal of 1.83 to a final rate of 0.66 per 1,000 patient days in FY2025, below national averages for Shepherd Center’s high-risk population.

“The success of this program is really attributable to all of the hard-working staff,” says Levenson. “Not only working within the work group but taking that [information] back to their respective units and really engaging and getting the buy-in of the staff, the patients, and the families.”

About GHA

Founded in 1929, GHA serves more than 150 Georgia hospitals and works to shape a healthier Georgia by serving as the leading advocate and supporter for all Georgia hospitals and health systems. For more information, call 770-249-4500 or visit gha.org.