Quality & Performance Improvement

Patient safety is at the core of our efforts to become a High Reliability Organization.

The innovations and technologies available at South County Health play a significant role in our ability to keep patients safe and enhance the body’s natural ability to heal. As part of South County Health’s commitment to becoming a High Reliability Organization, clinical precautions and process improvements are continually modified to minimize the risk of Hospital Acquired Infections and Serious Safety Events (SSE) that may occur.

During FY2021, the ongoing training and process improvements of staff across the organization successfully decreased the SSE rate by 45% compared to the prior year. In order to sustain our low SSE rate and maintain a culture of safety, the Performance Improvement Department re-implemented the high reliability training program across the health system.


To reduce the incidence of falls for high-risk patients with altered mental status, Avasure, a remote tele-sitting technology, was integrated along with strategies to improve fall prevention interventions. These strategies, including the assessment of patients’ ambulatory readiness prior to walking post-operatively, resulted in a 15% decrease in the fall rate for inpatient units.

Similarly, the Telemetry Unit decreased its fall rate by 43% and the Intensive Care Unit exceeded 365 days withouta patient fall.


Code Blue

During a “Code Blue” when a patient is in distress, a swift and appropriate response is critical for the care of the patient. To ensure that a swift and appropriate response is possible, a Code Blue Competency module was incorporated into the Lippincott Procedures for key inpatient and procedural unit staff. These training opportunities educate patient care teams in the basic steps to take in caring for a patient while awaiting the arrival of the Code team.

Stroke Recognition

South County Health’s Stroke Program continues to demonstrate exceptional patient care, earning recertification by the Joint Commission.

The Emergency Department, recognized as a Primary Stroke Center, and Inpatient teams significantly increased the Hospital’s NeuroCheck and Vital Sign compliance rate to 78%, successfully meeting all quality measures in stroke patient care.

In FY2021, stroke recognition training was added to the annual stroke competency for nurses, primary care technicians, and medical assistants within the hospital and medical group practices to ensure that staff can identify the symptoms and can take timely action to assist a patient exhibiting signs of a stroke.

Tracheostomy Care

The Professional Development team partnered with Respiratory Therapy to provide nursing education and competency assessment related to caring for a patient with a tracheostomy tube. With this additional training, nursing staff are now prepared to provide this specialty level of care.


To improve the breadth of cancer-related programs and services offered within the South County Health Cancer Center, the first steps toward obtaining the Quality Oncology Practice Initiative Certification, a quality program designed to foster a culture of self-examination and improvement, is underway.

Participating multi-disciplinary practices report on evidence-based quality measures and receive individual performance scores by practice and provider, as well as benchmarked scores aggregated from all participating practices.

Performance data is used to identify opportunities for improvement and ensure we are providing the very best care for our patients.


South County Medical Group Primary Care

Colorectal cancer is the third leading cause of cancer-related deaths for men and women in the United States. When detected early, over 90% of all colon cancer is curable, yet more than 21 million people between the ages of 50-75 have never been screened.

SCMG Primary Care has recognized this as an opportunity to improve patient care and outcomes.

The Primary Care Teams are actively engaged in identifying areas of improvement within their practices and workflows to increase patient awareness of colon cancer and the importance of screening to detect early signs of the disease.

Open discussions and the importance of regular screenings have become part of the primary care visit, in an effort to encourage patients to become proactive in colorectal cancer prevention.


A grant-funded, technician-driven medication refill authorization program was initiated through a partnership with the Pharmacy Department and South County Medical Group Primary Care practices. The purpose of the program is to improve the efficiency of prescriptions within the Primary Care office and support medication adherence in our patients.

Under the program, a protocol-based approach determines if the pharmacy can authorize a refill for chronic medications under the prescriber-approved protocol or if the refill request needs to be reviewed by the prescriber. This approach takes the burden off the nurses and providers so they can have more patient facing time.

Antimicrobial Stewardship

Marissa Palm, Pharm.D., South County Health’s Antimicrobial Stewardship Pharmacist, earned the prestigious Society of Infectious Diseases Pharmacists Certification in Antimicrobial Stewardship, adding validity and strength to our program.

Marissa implemented an initiative that requires an infection indication to be selected for each antibiotic order, aligning our hospital with the Joint Commission standard by supporting prospective audit and review of each antibiotic order during pharmacist verification. This also supports nursing and transitions of care by providing context for all antibiotic orders.

The Stewardship Team also developed guideline-driven treatment algorithms for common infectious diseases, making them easily accessible for all clinical staff.

Pharmacy Residents

The pharmacy Post Graduate Year 1 Residency Program completed another successful match with two residents who graduated from the University of Rhode Island.

In addition, three posters were accepted at the American Society of Health System Pharmacists Clinical meeting. One of the posters was selected for ASHP-sponsored podcast that discussed a novel preceptor tool.

The Pharmacy Department continues its relationship with the URI School of Pharmacy and is actively involved with precepting clinical rotations in Internal Medicine and Institutional Pharmacy. Future rotations will expand into Emergency Medicine and Antimicrobial Stewardship.

pharmacy statistics

The Quality & Performance Improvement process is an ongoing effort that staff in every role are challenged to achieve. South County Health is fortunate to have teams of committed, motivated individuals who, as a whole, make South County Health the pinnacle of exceptional healthcare.

Annual Report 2021

Next up:

Professional Development, Patient Experience, and Volunteers

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