Quality & Performance Improvement

2020: The Year of The Nurse

With frontline workers recognized as heroes for their selfless acts of care and kindness throughout the COVID-19 pandemic, it is fitting that 2020 was named “The Year of the Nurse.”

Nurses are an essential, core component of patient care. Among their lengthy list of responsibilities and expectations, our nurses provided direct and indirect care to patients in the combined 450,000 visits to our Emergency and Express Care departments and inpatient and outpatient surgeries, as well as outpatient and physician office visits during the last fiscal year.

Faced with a global community health crisis, our nurses demonstrated their commitment to our patients, their expertise in the administration of curative therapies, and the resilience to practice their profession faithfully and protect each patient’s safety.


DAISY Awards

Three of our nurses were recognized as DAISY Award recipients: Brittney Averill, RN; Carolyn Baxter, RN; and Jennifer Varras, RN. This award is given to nurses who exhibit exemplary care and compassion toward their patients, as nominated by patients, visitors, or colleagues.

In June 2020, these nurses were joined by colleagues, patients, family, and friends in a socially distanced ceremony. Each received their award plaque and the prestigious statuette, “The Healer’s Touch,” that symbolizes the characteristics one must possess to be considered for this recognition.

Nurse Residency Program (NRP)

In an effort to recruit and retain the most qualified, highly skilled nurses, South County Health introduced a Nurse Residency Program (NRP) in June 2020. The first cohort of the Nurse Residency Program included six recent graduates who received their Bachelor of Science in nursing (BSN) and were assigned to the Intensive Care Unit, Emergency Department, Orthopedics, Telemetry, and Medical/Surgical Unit.

With successful completion of the preceptor phase of the program, the nurses engaged in monthly educational sessions to expand their knowledge and skill sets. Now in the last phase of the year-long program, each participant is working with the nurse facilitator on a special project that builds on their professional advancement in researching for evidence-based data that will improve a process in their respective units or identify to their leader how this project can make a difference in the nursing practice.


Targeting Zero Hospital Acquired Infections (HAIs)

Among the successful initiatives in South County Health’s continuous effort to improve patient care and safety was to sustain “zero” Clostridioides difficile (C. diff) infections.

In 2017, recognizing that Rhode Island ranked as having the highest C. diff rates in the United States, South County Health began to focus on the issues and drivers that created this condition. After a two-year, multidisciplinary team effort, the group identified conditions that contributed to the C. diff rate and developed a process to lessen the occurrence of this hospital-acquired infection (HAI).

Through collaboration, diligence, and the implementation of this newly developed process, South County Health realized sustainability in lowering HAIs to zero for a 16-month period. South County Health is the first healthcare system in Rhode Island to achieve this milestone.

An article authored by South County Health’s Infection Prevention Team, Lee Ann Quinn, BS, RN, CIC; Stephanie Parente, MSN, RN, CIC; and Mary Ellen Casey, MSN, RN, MED, CIC, was published in the Summer 2020 edition of Prevention Strategist. Entitled, “Improving hospital-onset C. diff rates: Lessons from one organization’s journey to success,” the article describes the research and results of the team’s journey to affect a zero hospital-acquired C. diff environment at South County Hospital.


Ours is a continuous pursuit to improve the quality of care we provide to our patients and the experience they receive when they come through our doors.

Although we are confident that our “patient-first” philosophy lends itself to achieving the goals we set for ourselves, it is the objective third-party assessments, using quantifiable data that compares South County Health to other healthcare systems across the country, that assures us of our success.

The Centers for Medicare and Medicaid Services analyzes data from hospitals across the country, assigning each a star rating that enables healthcare consumers to easily identify top-ranked hospitals.

South County Hospital is the only hospital in Rhode Island and one of only 19 hospitals in the U.S. to receive a five-star rating in two categories—Hospital Quality and Patient Experience—earning that distinction in 2017, 2019, and 2020.

Among the quality measures, CMS reported that South County Hospital scored above the national average in:

  • Safety of Care
  • Low Readmission Rates
  • Patient Experience

An important component to patient care and recovery is the follow-up treatment they receive when discharged to their homes. Our team of visiting nurses and therapists continue the exceptional care beyond the hospital setting.

The Centers for Medicare and Medicaid Services also recognized South County Home Health as a high-quality provider, awarding the agency “5-Star Rated” for Patient Experience.


South County Health was recognized with the Guardian of Excellence and Pinnacle of Excellence awards from Press Ganey for excellence in inpatient care experience. These awards honor healthcare facilities that consistently rank in the top 5% for patient experience.

South County Health received The Guardian of Excellence award for reaching the 95th percentile in patient feedback surveys that capture their experiences related to communication, wait times, respect and courtesy, patient privacy, and pain control.

The Pinnacle of Excellence Award recognizes South County Health as a top-performing organization based on extraordinary achievement and consistently high levels of excellence over a three-year period. This is the third time South County Health has received this honor.

These awards illustrate our focus to deliver high-quality care and an exceptional experience while patients are in our care. By listening to patient concerns and compliments and obtaining solicited feedback through surveys, post-discharge visits, and phone calls, we are able to gain a patient’s perspective and then work with departments across the system to support any changes that will improve a patient’s experience.


In June 2020, the South County Health Wound Care Center received two awards in recognition of its extraordinary performance in exceeding expectations on key clinical performance indicators.

Healogics, the nation’s leading provider of advanced wound care, presented the 2020 Center of Distinction Award andthe Robert A. Warriner Center of Excellence Award.

In addition to measurable success in key clinical performance indicators, the Wound Care Center maintained patient satisfaction scores greater than or equal to 92%; reported a healing rate greater than or equal to 91%; and consistently and successfully heal patients’ wounds in less than or equal to 30 days on average.

Flu shots infographic


Quality and Patient Safety

The Pharmacy Department upgraded its 45 Pyxis MedStation dispensing machines and software across the hospital system. The automated dispensing system supports decentralized medication management, using barcode scanning to help ensure accurate medication delivery. Active alerts offer an added safety precaution when dispensing high-risk medications. This technology supports safe and efficient medication management.

Education and Training Resource

The Pharmacy Department continued its Post Graduate Year One Pharmacy Residency Program (PGY1) where residents work closely with specialized pharmacy preceptors who mentor and train future pharmacist practitioners. Enhancements to the post-graduate educational opportunities were added with the on-boarding of a University of Rhode Island College of Pharmacy faculty to oversee Advanced Pharmacy Practice Experiential Education.

COVID-19 Medication and Vaccine

The Pharmacy Department was instrumental in treating COVID-19 patients throughout the pandemic, performing supply chain management of medications such as Remdesivir, an antiviral medication approved by FDA to treat COVID-19, and COVID-19 vaccines.

In coordination with the Infection Prevention team, vaccination clinics were held for South County Health staff, healthcare workers in the surrounding communities, and for the public, under the guidelines of the Rhode Island Department of Health.

Antimicrobial Stewardship (ABS)

South County Health’s Pharmacy Department continues to monitor and minimize the use of antibiotics, voluntarily reporting all of its antimicrobial use to the Centers for Disease Control on a monthly basis. Among its successes:

  • We received exceptional Joint Commission survey report with regard to our Antimicrobial Stewardship program and zero medication-related findings.
  • In FY2020, we initiated pharmacist involvement in the Emergency Department variance process, where a pharmacist reviews outpatient culture results and associated antibiotic prescriptions for appropriateness.
  • Our inpatient antibiotic use is tracked on a monthly basis and was consistently at or below expected use throughout FY2020.


Visual Management

One of South County Health’s key strategic initiatives is to become a high-performing health system and consistently achieve the top decile of performance nationally, in the areas of safety, quality, patient experience, and efficiency.

To help facilitate the transformation, a continuous improvement tool was deployed as part of a daily visual management system.

The overall concept of daily visual management is 1) to give staff a daily update on their current performance; 2) identify gaps in performance compared to top decile goals; 3) empower staff to continuously improve; and 4) ensure leadership is accountable for reinforcing standard daily work aimed at closing identified gaps in performance.

In May 2020, Telemetry was the first unit to go live with the daily visual management system. Shortly after, the Operating Room, Emergency Department, Laboratory, Post-Acute Care Unit (PACU), Orthopedics, Central Sterile, Medical/Surgical Unit, Cancer Center and Home Health followed.

The daily visual management system supports leaders in making demonstrable improvements within their respective departments. It will continue to be deployed during FY2021, with the focus shifting from hospital-based departments to South County Medical Group and off-site ancillary departments.

High-Reliability Organization (HRO)

South County Health continues its journey to become a High-reliability organization (HRO) with the long-term goal of zero preventable harm to patients. By definition, an HRO is an organization that operates in a complex and high-risk environment while consistently delivering an exceptionally safe and high-quality level of care and service.

By implementing practices that are consistent with our goals to become a High-reliability organization, South County Health has achieved a 79% reduction in serious safety events, and the time between serious safety events has been as much as 200 days.

Quality care, patient safety, and delivering an exceptional patient experience continue to be the top priorities we are committed to.

Annual Report 2020

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Serving our South County Community

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