Strategic Report: Clinical Services Overview

“Mediclinic has developed a strong focus on clinical performance to ensure efficient, effective and safe patient care of the highest standard.”

Dr Ronnie van der Merwe
Chief Clinical Officer and CEO Designate

INTRODUCTION

Mediclinic provides a wide range of clinical services throughout its operating divisions. These services include acute care inpatient services, highly specialised services, day case surgery, hospital-based emergency centres, pre-hospital emergency services, and outpatient consultation services. Support services include laboratories, radiology and nuclear medicine.

Mediclinic strives to ensure that the clinical services provided throughout the Group are efficient, effective, appropriate, evidence-based, and in line with modern technological advances. To this end, we emphasise measuring and improving clinical performance throughout our organisation. On a monthly basis, a comprehensive set of clinical performance indicators are collected, measured, analysed and reported on. These clinical performance reports outline and track the performance of healthcare facilities, inform operational decisions, identify opportunities for clinical quality improvement initiatives, and inform our strategic direction.

During the year under review, the clinical performance of the business across all operating divisions was satisfactory. We made considerable progress in further developing underlying structures and processes to enable clinical performance improvements. Much of the progress can be attributed to the strong collaborative effort of the clinical services teams of the divisions.

All indicators included in this Clinical Services Overview are reported per calendar year to ensure completeness and consistency, as a significant time lag needs to be provided for in the collection of clinical data.

Mediclinic developed a framework to support a structured approach to clinical management, the clinical management model. The model comprises two elements: clinical governance and clinical performance. The clinical governance foundation layer provides the structure required for clinical performance. Mediclinic does not use the standard definition for clinical governance. We define and stratify it as: governance including oversight and assurance; systems improvement; medico-legal processes and ethics; research; clinical information; clinical processes and education; and continued medical education.

Clinical management model

Clinical performance refers to the quality of the clinical processes and outcomes and is supported by the clinical performance model. The four components of the model are patient safety, effectiveness, cost efficiency and value-based care.

This report provides an overview of the Group’s clinical performance for the year under review. The detailed Clinical Services Report, provides a more in-depth description.

HIRSLANDEN

Clinical performance

Hirslanden has the highest case mix in the Group, reflecting the complexity of cases treated. However, clinical outcomes remain excellent, as evidenced by low infection rates and other outcome measures, e.g. patient falls, healthcare-associated infections (“HAI”), etc.

Patient safety

A patient safety culture is well established in the operating division as reflected by the low rate of never events (serious incidents, such as wrong site surgery and retained instrument post operation, that are wholly preventable) and serious adverse events (“SAE”). We report near misses, or critical incidents routinely, and lessons learnt are disseminated to make systems safer and to improve patient outcomes.

The fall rate increased by 6.36% compared to 2016. The increase in the rate is believed to be due to increased awareness and better reporting. The prevention of falls and a reduction in the reported rate remain focus areas. The in-hospital pressure ulcer rate decreased by 23.9% (see Figure 1). This decrease is statistically significant and in line with focused initiatives to decrease the incidence of in-hospital pressure ulcers.

Infection prevention and control

Healthcare-associated infections

The HAI and related conditions rate remained stable in 2017. As these conditions are rare, a single infection causes a high rate based on small denominators.

Figure 2 reflects an increase in the catheter-associated urinary tract infections (“CAUTI”) and ventilator-associated pneumonia (“VAP”) rates compared to the prior year. Neither of these increases is statistically significant. The central line-associated bloodstream infections (“CLABSI”) rate remains stable.

Clinical effectiveness

The SAPS II is used to measure clinical outcomes of critical care units (“CCU”). The SAPS II mortality rate remains low at 2.50% and the index is well below the Swiss benchmark of 0.42 at 0.32.

In-hospital mortality is reported as a crude rate, and remained low at 0.93%, a decrease of 2.1% when compared to 2016.

The re-admission rate is reported as a 15-day unscheduled re-admission rate, as defined by the International Quality Indicator Project. The 15-day interval was chosen according to the 18-day re-admission criteria of the SwissDRG (diagnosis-related groups) system to provide input to the case management process. The rate increased by 19.4%, is not statistically significant, and no concerns were raised.

Progress against objectives

Patients First at Mediclinic

  • Reviewed the compliance of the hospitals with the patient safety policy – the majority of the hospitals implemented every item of the policy or was busy with the implementation of the remaining items.
  • Checked the adherence to safe surgery checklist during unannounced inspections – compared to the previous inspection, further improvement was noted.
  • Initiated a pilot project on patient-related outcome measurement – patients were surveyed on quality of life before and after joint replacement. The results show a significant improvement of pain and movement after the procedure.

Value-based care

  • Compiled a policy on indication quality and introduction of indication boards – the implementation is planned for 2018.
  • Successfully started the project on the introduction of fast-track orthopaedics in one of the orthopaedic hospitals of the group.
  • Introduced a common structure for highly specialised medicine services.

Clinical information systems

  • Compiled the definition of the future documentation in catheterisation laboratories and emergency departments – the manufacturer is implementing this in our electronic patient record.
  • Completed the re-evaluation of the radiology information system and selected a new system – the pilot project has started.
  • Reviewed the integration of medical source data – Hirslanden decided to connect this project to its transformation exercise.

Future objectives

Patients First at Mediclinic

  • Identify patient pathways qualifying for standardisation.
  • Complete the introduction of a continuous patient experience survey for all inpatients.

Value-based care

Hirslanden will continue with the definitions of the requirements of the system provider model; and develop evaluation criteria to determine the introduction status per hospital.

Clinical information systems

  • Continue with the rollout of the radiology information system in a second hospital.
  • Introduce a standardised documentation approach for doctors in the electronic patient record.
  • Continue with the rollout of the patient data management system (“PDMS”).
  • Conceptualise the integration of the PDMS and the electronic patient record.

MEDICLINIC SOUTHERN AFRICA

Clinical performance

Mediclinic and the greater Southern Africa healthcare community experienced significant and ever-increasing cost pressures; continued shortage of healthcare professionals (especially specialised disciplines); outmigration of care, resulting in hospitals caring for more complex cases; and an increase in the elderly population. Despite these challenges, Mediclinic Southern Africa improved clinical performance of the operating division compared to the 2016 calendar year.

Patient safety

We prioritise the continuous improvement of patient safety. Adverse events, as illustrated in Figure 3, are reported and tracked as a barometer of safe patient care.

In 2017, we reported a significant increase of 35.59% in the medication error rate, mainly due to increased awareness and reporting, driven by focused audits. This rate is expected to increase even further as additional sources of information, obtained from the audits, are included in the report.

The fall rate and in-hospital pressure ulcer rate are regarded as nursing sensitive indicators and correlate with the number and skills of available nursing staff. The fall rate decreased by 7% in 2017, however, the decrease is not statistically significant. The prevention of falls remains a priority.

The in-hospital pressure ulcer rate decreased by 25.92%. This decrease is statistically significant, and is mainly due to continued focus on the early detection and prevention of incontinence-associated dermatitis, one of the main drivers of in-hospital pressure ulcers.

Infection prevention and control

Healthcare-associated infections

HAI remain one of the highest risks. Hand hygiene compliance, which is a focus area for improvement, is an important measure in the prevention of HAI, and remained stable at 75.3%.

The HAI rate, reflected in Figure 4, increased by 7.57% over the 2017 calendar year. The increase is statistically significant. The adherence to evidence-based practices, such as care bundles to reduce device-associated infections, remain a focus area. HAI rates and compliance with hand hygiene principles are closely monitored by audits, and hospitals are supported in dealing with outbreaks timeously and efficiently.

Antimicrobial stewardship

Considering the high burden of infectious disease in Southern Africa, effectively managing antimicrobial resources and preventing multidrug resistance are critical. Antimicrobial resistance increases with using all antimicrobials and not only certain classes of antimicrobials. The total antimicrobial consumption needs to be reduced. The total antimicrobial usage and utilisation decreased by 1.6% in 2017.

Clinical effectiveness

The clinical performance measurement of CCUs was refined by implementing the Simplified Acute Physiology Score (“SAPS”) 3 physiological mortality prediction model, instead of the previously used APACHE®IV. SAPS 3 is statistically better suited to the Mediclinic population and predicts mortality more accurately. During 2017, the average mortality rate for patients admitted to CCUs was 16.97% compared to the expected mortality rate of 17.85%. The resultant SAPS 3 mortality index was 0.95.

The in-hospital mortality prediction model calculates the expected mortality rate based on administrative data. This model was reviewed and refined in 2016. The 2015 values can therefore not be compared directly to the 2016/2017 values due to the change in methodology. When compared to the 2017 index, a 6% decrease is noted. This decrease is statistically significant (see Figure 5).

The 30-day all-cause re-admission rate increased by 0.08% in 2017. Re-admissions within seven days of discharge account for half the re-admissions, and remains a focus area for improvement. The extended stay rate is expressed as an index, and decreased by 0.88% compared to 2016.

Progress against objectives

Patients First at Mediclinic

  • Implemented the surgical safety checklist in all hospitals.
  • Improved reporting of SAE through many initiatives and valuable information was gathered that will guide the future strategy.
  • Implemented a successful quality improvement project, which enhanced patient safety and patient care further.
  • Developed and implemented a new nursing workforce model to ensure accurate allocation of scarce nursing skills.
  • Successfully launched a national hand hygiene campaign; and developed compliance measures to track improvement.
  • Implemented the combined BetterObs and Mediclinic obstetric enhancement projects, which will further mitigate risks identified in obstetric care.
  • Implemented a specific infection prevention and control strategy, which was critical in managing the ever-increasing risk of infectious diseases and multidrug-resistant organisms.

Value-based care

  • Implemented a new clinical performance oversight and governance model in collaboration with supporting doctors.
  • Developed (in collaboration with supporting doctors) and implemented two clinical pathways led by doctors.
  • Developed a comprehensive and integrated critical care strategy.
  • Developed a national stroke management strategy.

Clinical information systems

Mediclinic Southern Africa developed a clinical information readiness strategy and a proposed roadmap for evaluating potential solutions.

Future objectives

Patients First at Mediclinic

  • Complete the implementation of specific patient safety initiatives aimed at preventing adverse events.
  • Implement specific training initiatives that will further enable staff to drive quality improvement continuously.
  • Develop and implement action plans that will improve hand hygiene compliance further.
  • Develop action plans to improve medication safety.
  • Further refine clinical performance measures.
  • Share more detailed clinical information with doctors.
  • Further reduce infection rates through the implementation of a comprehensive infection prevention and control strategy.

Value-based care

  • Proceed with further appointments of hospital clinical managers.
  • Proceed with the further implementation of the new clinical performance, oversight and governance model in collaboration with supporting doctors.
  • Develop (in collaboration with supporting doctors) and implement more clinical pathways led by doctors.
  • Develop a structured implementation plan for the integrated comprehensive critical care strategy.
  • Implement the national stroke management strategy.

Clinical information systems

Mediclinic Southern Africa will engage with specific service providers to evaluate potential solutions for the South African market and commence a thorough assessment of proposed solutions.

MEDICLINIC MIDDLE EAST

Clinical performance

Mediclinic Middle East has the lowest case mix index in the Group, and serves a younger, healthier community. The clinical performance is satisfactory as demonstrated by low infection rates and other outcome measures, e.g. patient falls, HAI, etc.

Patient safety

Providing safe care remains a priority across the division and is reflected in a “Just Culture” supported by management. “Just Culture” is a culture in which staff are not punished for actions, omissions or decisions taken by them which are in line with their experience and training, but where gross negligence and wilful violations are not tolerated.

Figure 6 reflects the rate of adverse events per 1 000 patient days.

Medication errors increased significantly by 169.23% when compared to 2016. The increase is due to an auditing and reporting drive, with the main contributor being prescribing errors. Most medication errors are identified and reported by the pharmacy and prevented from reaching patients. Medication management remains a key focus area for the group.

The fall rate increased by 25% but is not statistically significant. Fall awareness and prevention remain a key focus area for Mediclinic Middle East. The fall awareness campaign includes educational videos for staff, fall prevention posters in patient rooms and a fall prevention booklet for patients and visitors.

The in-hospital pressure ulcer rate increased by 150%, when compared with the 2016 rate, which is statistically significant. The division initiated various quality improvement projects, specifically in the CCUs, where the patient population has higher acuity levels with multiple co-morbidities. A steady decline in the in-hospital pressure ulcer rate was noted in the latter part of 2017 and the trend will be closely monitored.

Infection prevention and control

Healthcare-associated infections

Preventing HAI remains a key patient safety objective for Mediclinic Middle East. This includes standardised processes around infection control (based on international best practices), implementing care bundles (Surgical Site Infections, VAP, CLASBI and CAUTI), and a surveillance programme with a multilayer methodology. This methodology includes surveillance that is active and passive, patient and laboratory-based, prospective and retrospective, priority-directed and comprehensive.

When compared to 2016, the HAI rate decreased by 12.5%; the CAUTI rate decreased by 15.9%; the CLABSI rate decreased by 13.6%; and VAP rate decreased by 76.1% (see Figure 7). Although the decrease in the CLABSI and CAUTI rates are not statistically significant, the decrease in the VAP rate is. A change in the Centres for Disease Control and Prevention definition of HAI, especially for VAP, contributed significantly to the decline in the rate.

Clinical effectiveness

SAPS 3 was implemented in all the CCU in Mediclinic Middle East since October 2016. It replaced the APACHE IV Scoring system, which was implemented only in the Dubai facilities.

This will ensure that outcomes can be benchmarked across the Mediclinic Group. The data collected for 2016 was only part of the calendar year and not suitable for including as a comparative value for 2017. The performance of the SAPS 3 model was calibrated. Even though the mortality index is 1.4, the crude mortality rate is low at 3.0%. The predicted mortality rate is influenced by the accuracy of the data and the validation of data quality is a focus area for 2018.

The in-hospital mortality rate decreased by 4.16% during the period under review and remained low at 0.23% in line with the young population and low case mix of the operating division (see Figure 8).

The re-admission rate increased by 12.24% when compared to 2016. The increase is not statistically significant and no concerns were raised.

Progress against objectives

Patients First at Mediclinic

  • Appointed quality and patient safety officers, established a quality department on corporate level and updated its patient safety strategy.
  • Mediclinic Al Noor Hospital was successfully re-accredited by JCI in November 2017.
  • Standardised clinical indicators across the group; and created a central repository.
  • Implemented SAPS 3 in all CCUs across all the division’s hospitals.
  • Implemented the Vermont Oxford Network databases in all facilities.
  • Combined the clinical services departments of the group, which was implemented, expanded and embedded all the clinical oversight committee structures.
  • Developed clinical key performance indicators for doctors, and will be part of the formal doctors’ appraisal process implementation plan for 2018.

Value-based care

  • The division expanded the affiliation agreement with the Mohammed Bin Rashid University of Health Sciences (“MBRUHS”) in Dubai. Mediclinic City Hospital is an accredited external training facility for medical students, and the second intake of medical students was enrolled in September 2017.
  • Mediclinic Middle East hosted a successful first annual research day in February 2018 at MBRUHS.
  • We developed the current breast and metabolic centres at Mediclinic City Hospital to streamline clinical processes.
  • The division commissioned a stroke centre at Mediclinic City Hospital and achieved the certification of the German Stroke Association in January 2018.
  • Mediclinic Middle East successfully commissioned and opened the new Comprehensive Cancer Centre in the north wing expansion at Mediclinic City Hospital.
  • The division signed off a cancer strategy that includes the clinical oversight structure, site-specific tumour board structure and function, as well as scope of service delivery at the different facilities.
  • The division implemented the centralisation and consolidation strategy of laboratory services for the group.
  • Mediclinic City Hospital laboratory was successfully re-accredited by The College of American Pathologists in August 2017.
  • Successfully obtained the ISO certification for all laboratories in the Abu Dhabi, Al Ain and Western Region.
  • Mediclinic Middle East relocated and commissioned the in-vitro fertilisation (“IVF”) and dialysis centres (previously located in Mediclinic Al Noor hospital in Abu Dhabi) to Mediclinic Al Ain hospital.
  • Mediclinic is in the process of reviewing the existing clinical pathways and developed additional pathways in preparation for the implementation of DRG and implementing the new electronic health record (“EHR”) system.

Clinical information systems

  • Mediclinic Middle East selected a new EHR system for the group.

Future objectives

Patients First at Mediclinic

  • Implement the standardised doctors’ appraisal process across the group.
  • Finalise the scope and project plan for the nursing performance management system.
  • Expand and implement new clinical indicators across the group.
  • Expand the outcome database participation and roll out the obstetrics dashboard.
  • Formulate the JCI re-accreditation preparedness plan for all facilities in the group.
  • Update the quality and patient safety strategy for the group.
  • Develop a strategy for managing quality indicators (as defined by the regulators) and agree on a quality management framework for the group.
  • Align the clinical risk management strategy to the Group.
  • Define a clear strategy for the establishment of centres of excellence in the division.

Value-based care

  • Finalise the formulation of the clinical strategy for certain key service lines for the group (IVF, metabolic centre, vascular surgery, cosmetics, etc.).
  • Continue developing the metabolic surgery service at Mediclinic Airport Road hospital and prepare for the accreditation of the centre.
  • Further develop and expand coordinated care initiatives across the group (breast centre, comprehensive cancer centre, metabolic centre, etc.).
  • Continue the centralisation and consolidation strategy for laboratory services in the division.
  • Define a strategy for doctors benchmarking.
  • Develop a strategy to centralise radiology services across the division.

Clinical information systems

Mediclinic Middle East will implement the newly selected EHR system across the group as per the agreed project plan.

MEDICLINIC INTERNATIONAL

Mediclinic International’s clinical services department consists of a small team that coordinates clinical services across the divisions. The team provides strategic direction, oversight and accountability; coordinates collaboration across operating divisions; and is directly involved in selected projects.

Progress against objectives

  • A master data management programme, compiling and governing data relating to doctors, was implemented in Southern Africa.
  • Clinical performance measures and operational dashboards were refined.
  • We established a patient safety sub-committee to standardise and enhance collaboration across the Group.
  • An initiative was started to coordinate collaboration of nursing services across operating divisions.
  • We established a collaborative forum for clinical risk management across the Group.
  • We sourced a clinical adverse event and clinical risk management solution suitable for the Group.
  • Initiatives are underway to coordinate health technology assessments centrally. These initiatives will be further refined.
  • Thought leadership, oversight and close collaboration were provided in the selection of an EHR system in the Middle East and Southern Africa divisions.
  • Continued collaboration and support are provided to Hirslanden with the implementation of its EHR systems.

Future objectives

  • Implement a clinical adverse event and clinical risk management across the Group.
  • Further refine and optimise the clinical performance model and clinical performance indicators.
  • Further drive collaboration on nursing across the Group.
  • Support the operating divisions in eradicating never events and decreasing the number of SAE.
  • Refine and optimise the medication management process across the Group.
  • Develop an integrated clinical digital roadmap, including artificial intelligence, machine learning and telemedicine.
  • Continue to collaborate with and provide support to Mediclinic Middle East and Hirslanden with the implementation of their EHR systems.
  • Refine and optimise the clinical governance structure to enforce the Ward-to-Board accountability framework across the Group.
  • Centrally advise and coordinate clinical research across the Group.