Quality – South Africa | Life Healthcare

QUALITY – South Africa
In pursuit of clinical excellence, we focus on providing world-class healthcare to our patients while positioning Life Healthcare as a preferred healthcare provider. We aim to holistically address the needs of our patients and their families by improving patient experience through rigorous quality reporting and benchmarking.

OUR 2019 PRIORITIES		OUR PROGRESS

Refine the flow of patients through emergency units and roll-out enhanced service offering to patients		The value stream mapping process for the flow of patients at emergency units has been completed An emergency department strategy is in place which is focused on prioritisation of patients and management of triaged patients, especially low acuity

Report on degree of harm on patient incidents (no harm/ none, low harm/mild, moderate harm, severe harm, and death)		Year-on-year decrease in the number of serious reportable events (SREs) Reporting on patient safety adverse events, patient falls, medication adverse events, pressure ulcers, procedure-related adverse events, healthcare-associated infections (HAIs), ventilator-associated pneumonia (VAP), surgical site infection (SSI), central line-associated bloodstream infections (CLABSI), and catheter-associated urinary tract infection (CAUTI) rates

Adjusted mortality rates for specific diagnostic groups		Started reporting on the risk-adjusted mortality rate as far as it relates to strokes

Refinement of quality, clinical outcomes, nursing sensitive and environmental sustainability scorecards		An all-hospital scorecard has been developed, which includes all clinical and quality metrics, with indicators to highlight areas where targets are achieved, partially achieved or not achieved Quality single score developed to compare hospitals based on their performance across different quality metrics, taking into account patient experience, patient safety, clinical outcomes and employee safety

Begin reporting other relevant patient health and safety metrics on the website		Continued to report quality measures on our website per hospital

Increased focus on clinical outcome measures and report on BetterObs, Major Joints for Life, care of the new-born and stroke		With regards to Major Joints for Life, initiated reporting on post-op quality of life indicators using patient-reported outcome measures (PROMs) Measuring all-cause 30-day re-admission rates and one-year condition-specific re-admission rates

Targeting growth in occupancies to improve operational leverage through doctor efficiencies and clinical products		Focused on increasing occupancies of existing facilities, together with improved optimisation and utilisation

Publishing of clinical quality and patient experience scores on a per hospital basis		Publishing the infection prevention bundle compliance and antimicrobial stewardship (AMS) compliance per acute facility, as well as on a Group level Daily updates of patient experience scores

OUR 2020 PRIORITIES

Develop a standard operating procedure for the patient journey throughout Life Healthcare’s emergency units
Deliver clinical quality excellence and leading patient experience
Benchmark the performance of facilities of the same size
Continue reporting and updating our published data post-external assurance audit
Drive enhanced compliance with established processes and systems at the point of care

Clinical excellence

Clinical governance and quality management systems (QMS)

Our clinical governance function holds the Group accountable for continuously improving the quality of our services and safeguarding high standards of care by creating an environment in which clinical excellence can flourish. Our clinical governance and quality management hierarchy and activities are as follows:

For more information refer to our AMS programme and committee.

Life Healthcare manages all quality-related elements through a single QMS and aligns all processes and systems that may impact the delivery of quality services to our patients with the system. Our quality department is tasked with administering these processes and systems and implements internal clinical and quality strategies throughout the business. Our quality department is supported by the board’s clinical governance, quality and safety committee, which meets regularly to promote clinical and quality leadership and excellence, thus ensuring that Life Healthcare remains responsible and accountable for quality care and patient safety.

In 2019, we realigned our safety and risk focus to address the changing profiles of our patients. We did this by enhancing our processes and systems already in place which, in turn, allows us to remain relevant in our dynamic operating environment. Our focus for 2020 will be on driving enhanced compliance with established processes and systems at the point of care.

The quality department also supports the clinical directorate on the journey to grow clinical outcome and process measures. Our priority is to truly understand the underlying causes of our risks to be able to respond appropriately and timeously. Our quality and clinical governance structure on national, regional and hospital levels ensures that all relevant functions are integrated to address areas such as patient safety, clinical outcomes, patient experience, employee safety, and assurance. At a Group level, we thus have a comprehensive, standardised view of processes and outcomes to ensure our continuous improvement. The board’s clinical, quality and safety committee adds strategic value and direction to the existing clinical and quality governance structure.

This year, we also established 12 clinical review panels covering 12 different disciplines. The objectives of these panels are to build relationships with doctors to increase clinical and operational excellence in our facilities.

The above initiatives already improved the quality of care for those risks identified at our 10 largest hospitals in terms of revenue. Through this structured approach, we hope to replicate best practices throughout the Group to ultimately improve our overall quality.

Our regional clinical managers are now firmly entrenched throughout the business. They are responsible for identifying opportunities to improve efficiencies within our hospitals and play a key role in building and managing relationships with health professionals, as well as research and development of clinical products. At a hospital level, our hospital managers are, among others, responsible for driving improvement initiatives and identifying and mitigating risk factors involving patients, customers and employees.

We conduct internal and external audits based on international best practice to assess our hospitals’ overall compliance with quality and environmental management standards, adequate allocation of leadership responsibilities, and industry-specific quality standards. We also conduct management self-assessment audits. Furthermore, we have external quality audits on our ISO 9001 and ISO 14001 certifications. Each hospital is audited at least once every three years.

Standards

We are proud to retain multi-site ISO 9001:2008 quality management Group certification for our acute hospitals and our occupational health clinics. Furthermore, Life Employee Health Solutions occupational health division also retained its ISO 45001 occupational health and safety management system certification. In 2018, we began implementing the new ISO high-level structure to comply with the 2015 standards. We made good progress in 2019, with all of our hospitals aligned to the 2015 ISO 9001 standards.

Up until the 2018 financial year, the minimum standards for quality in all hospitals were promulgated by the 2011 DOH National Core Standards. However, in 2019 this was replaced by the Minister of Health-promulgated Norms and Standards Regulations. Life Healthcare has entrenched these norms and standards into our QMS processes, making it part of our standard operating procedures. We conduct periodic internal audits to ensure we comply with these regulations.

Patient safety adverse events

Offering our patients quality care is top-of-mind, and we are dedicated to ensuring the best possible outcomes for our patients and preventing harm from occurring to them while in our care. Great patient experiences are critical to the success of our business, and Life Healthcare entrenches a patient-first culture throughout the Group. In support of this, we specifically target certain roles with tailormade training interventions to further establish professional and positive behaviours.

This year, the patient safety adverse events rate decreased by 9.0%. We report on all patient safety adverse events, which are investigated by the responsible managers at hospital and Group level. This allows us to identify the cause of any incident which, in turn, enables us to implement corrective action to mitigate the risk of recurrence. In addition, a proactive alert reporting system is in place in our hospitals.

Indicator (per 1 000 PPDs)	Year-on- year trend	2019	2018	2017
Patient safety adverse events¹		2.44	2.68	2.69
Medication adverse events		0.92	1.10	1.13
Falling adverse events		0.71	0.68	0.71
Pressure ulcer rate		0.10	0.12	0.13
Procedure-related adverse events		0.46	0.55	0.51

¹ This indicator is externally assured.

Clinical infections

In terms of reporting, we primarily focus on HAIs as these metrics are the most material for proactively managing clinical infections. This metric encompasses all HAIs determined according to the Centre for Disease Control and Prevention (CDC) guidelines, including VAP, SSI, CLABSIs, CAUTIs, as well as various hospital-acquired infections.

Clinical indicators¹ (per 1 000 PPDs)	Year-on- year trend	2020 target	2019	2018	2017
Patient safety adverse events^2,3		2.25	2.44	2.68	2.69
HAIs³		0.40	0.41	0.41	0.42

¹	For more information refer to quality indicators.
²	Includes unintended or unexpected events which did, or could have, resulted in harm, such as falls, behaviour, medication, pressure ulcers, death due to unnatural causes, burns, procedure-related incidents, other patient incidents, patients absconding, and other patient information incidents.
³	Indicator is externally assured.

For more information refer to our key performance indicators.

Our electronic surveillance system (ICNet) captures patient data on inpatient admissions, laboratory results, surgical procedures, and SSIs. A contributing factor for this implementation of the new module introduced to ICNet last year, is the increase in SSIs from 0.99 in 2018 to 1.05 in 2019. The most common SSIs were identified as caesarean sections, spinal and colorectal surgeries. ICNet also functions as a re-admission alert management system, and notifies the hospital’s IPS when a patient is re-admitted post-surgery, as this can be indicative of a possible HAI.

We monitor the cleanliness of high-touch areas in patient care zones, along with the cleanliness thereof, on a weekly basis and report on it monthly. This drives environmental cleanliness and is dependent on a multi-disciplinary approach.

The methodology involves the systematic application of an invisible fluorescent ink prior to cleaning, and an assessment of residual ink through the use of a UV light highlighting the high quality of AMS related interventions that are being suggested, and the commitment of the multifunctional team to stewardship.

Life Healthcare’s AMS programme

Due to the increasing incidence of antimicrobial resistance globally, the World Health Organization (WHO) highlights the importance of a one-health approach to address the issue. The WHO Global Action Plan and Antimicrobial Resistance document emphasises that antimicrobial resistance is a crisis that must be managed with the utmost urgency, and that an all-out effort is needed.

During the year, Life Healthcare continued to build on its well-established and multi-functional AMS programme, tracking compliance with internationally recognised key stewardship principles. The number of inpatients assessed for AMS bundle compliance increased by 14.2% (2018: 10.3%). The AMS bundle compliance percentage increased by 2.0% to 95.0% (2018: 93.0%), above the Group target of 93.0%. We continue to develop interventions to address any non-compliance. The acceptance of interventions suggested by pharmacy or nursing personnel to address non-compliance decreased slightly to 80.4% (2018: 83.3%), which is above the Group target of 80.0%, highlighting the high-quality of AMS related interventions that are being suggested, and the commitment of the multinational team to stewardship.

One of the key objectives of the WHO’s Global Action Plan on Antimicrobial Resistance is to optimise the use of antimicrobial medicines in human health. For Life Healthcare to align with this global action plan, one of our key focus areas is to reduce inappropriate antibiotic utilisation, with particular focus on carbapenems, an antibiotic class that should be reserved as therapy for serious infections only, and often only indicated as last-line therapy. Through rigorous AMS practices, carbapenem load (number of units per PPD) decreased by 5.4%, and overall antibiotic load by 1.4%.

Due to antimicrobial exposure being one of the main risk factors for clostridium difficile (c.difficile) infections, the c.difficile infection rate per 1 000 PPDs is being monitored as an AMS programme outcomes measure. The c.difficile infection rate per 1 000 PPDs has decreased by 13.8% compared to last year.

We also invested in a clinical decision support system (CDSS) to enable the expansion of clinical pharmacy services to more patients, which will further improve patient safety and quality care. Our ICNet ABX software alerts pharmacists of clinically significant medication-related potential interventions required, combining laboratory tests, drug therapy, key drug interactions, medical conditions and co-morbidities, surgery and demographics. The system will assist clinical pharmacists with prioritisation of patients and facilitates efficient practice. For AMS specifically, the system prompts pharmacists when a micro-organism is resistant to an antimicrobial, or when a micro-organism was cultured and the patient is not yet receiving the appropriate antimicrobial treatment.

Patient-reported outcomes measures

Our clinical pharmacy programme continues to focus on improving patient outcomes. This year, the number of interventions increased to 64.9% (2018: 62.9%). Progress is further reflected in the number of ward rounds that pharmacists have conducted with our doctors, which increased by 45.8% during the year.

In our Major Joints for Life programme, we continue to conduct telephonic follow-ups six months post-surgery for hip or knee replacements, using an internationally accepted rating system of the outcome of the surgery to perform the evaluation. In 2019, we started reporting on post-operative quality of life indicators using PROMs. We also measure all-cause 30-day re-admission rates, along with one-year condition-specific re-admission rates.

The BetterObs programme

The BetterObs programme was established in 2015 in collaboration with the South African Society of Obstetricians and Gynaecologists (SASOG), and aims to reduce the number of maternal deaths and complications. The programme is centred around four main pillars, namely the obstetrician, the paediatrician, the hospital and the patient, and comprises unambiguous practice guidelines that, together with good teamwork, promote professional integrity while delivering optimal patient care in labour wards.

Life Healthcare has run the BetterObs programme in its maternity units since 2017 and 2019 proved to be another successful year. We expect full compliance with the prescribed protocols, and regularly conduct observational audits to ensure such compliance. We continue to see significant reductions in labour ward-related adverse events, including fewer morbidity and mortality incidents affecting both mother and child.

Our midwives continue to be upskilled through continuing professional development (CPD) training. Furthermore, we run periodic drills to simulate obstetric emergencies.

Improving patient experience

Our commitment to our core value of quality to the power of e (ethics, excellence, empowerment, empathy and energy) allows us to provide excellent experiences for those patients treated in our facilities. This is further facilitated by various programmes implemented throughout our business, as well as transparent measuring and monitoring of our patients’ experiences. These disclosures assist our patients to make more informed decisions, and directly support the delivery of excellent patient experience.

Measuring and improving patient experience

Over recent years, Life Healthcare has developed robust internal processes for measuring and reporting quality measures. We report all quality incidents using an online reporting system, which provides standardised categories to allow for effective data management. Quality incidents are classified as either a major or minor incident and we annually identify data trends for proactive management.

Clinical indicators¹	Year-on- year trend	2020 target	2019	2018	2017
Definitely recommend (%)		71.6	70.7	70.7	70.0
Patient experience measure (PXM)		8.5	8.4	8.4	8.4

¹	Mortality rates, re-admission rates and other quality measures are monitored according to American standards, which are aligned with those used by Medicare in the United States of America.

For information on our quality measures, as well as real-time PXM scores, refer to our website www.lifehealthcare.co.za/quality-measures/.

We communicate electronically with our patients once they are discharged from one of our facilities. Life Healthcare has contracted independent, third-party service providers to conduct patient surveys, which are based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in the United States. We also include additional questions in the survey, relating specifically to the hospital admissions process and food. Our acute facilities, emergency units, mental health facilities and acute rehabilitation facilities participate in the electronic post-discharge survey, and responses have remained stable year on year.

We also provide manual comment cards in our facilities to give patients and their families the opportunity to provide qualitative feedback about their experience. In 2019, the number of comment cards completed decreased by 3.6%. The number of positive responses to our comment cards amounted to 89.8% this year, slightly down from 90.0% in 2018, against a target of 91.0%

We noted a slight decrease in overall patient experience during the year. There were eight hospitals that scored <8.0 versus seven hospitals in 2018. Scores for ‘definitely recommend’ (a measure which means that patients would definitely recommend the hospital they were treated at to their friends and family) remained constant – 21 hospitals achieved scores >71% versus 22 in 2018. Furthermore, five hospitals scored <60% versus six hospitals in 2018.

Over time, we have developed key indicators and internal targets to measure our performance from a quality perspective. While the business is consistently improving against most quality targets, the lack of insight into international best practice in quality reporting has made it difficult for stakeholders to interpret our performance in a broader context. From 2020, we will be able to use the data we have already collected relating to our degree of harm – a known international metric supported by the WHO – to benchmark ourselves against international performance.

This year, we developed an all-hospital scorecard that includes all clinical and quality metrics. We also introduced the quality single score, which compares the performance of our hospitals across the quality measurement dashboard.

CARE programme

Our CARE programme promotes positive patient interaction, encourages improved employee engagement and influences patient experience and client feedback. Over the years, it has matured from a project to an internal process and is now considered to be part of our standard way of doing business.

We continued to hold monthly CARE sessions for all departments to facilitate straightforward dialogue that translates into committed actions to better employee and patient experiences.

Our front-line employees have a high impact on our patients as the first point of contact. Therefore, during the year we introduced our iConnect programme to ensure that these employees understand the importance of a positive patient experience throughout a patient’s stay at one of our facilities. The programme focuses on emotional experiences, and emphasises the importance of professional and positive behaviours when interacting with our patients.

In pursuit of clinical excellence, we focus on providing world-class healthcare to our patients while positioning Life Healthcare as a preferred healthcare provider. We aim to holistically address the needs of our patients and their families by improving patient experience through rigorous quality reporting and benchmarking.