2020 CLINICAL SERVICES REPORT ABOUT THIS REPORT
Mediclinic International plc (‘Mediclinic’ or the ‘Company’) is proud to publish a Clinical Services Report annually as part of a suite of reports in respect of both the 2019 calendar year and 2020 financial year.
The reporting suite listed below is available on the Group’s website. • 2020 Annual Report and Financial Statements • 2020 Clinical Services Report • 2020 Sustainable Development Report • 2020 Notice of Annual General Meeting
SCOPE The goal of this Report is to provide Mediclinic stakeholders with an overview of the most important clinical performance characteristics across its divisions in Switzerland, Southern Africa (South Africa and Namibia) and the United Arab Emirates (‘UAE’) (collectively, the ‘Group’) for the 2019 calendar year. Information is disclosed on a calendar year basis, unless stated otherwise.
Mediclinic reports on its material issues at a Group level, but also discloses information on divisional initiatives and performance, as this is the level at which data is collected.
This Report does not include information on initiatives undertaken by Spire Healthcare Group plc, a leading private healthcare group based in the United Kingdom and listed on the London Stock Exchange (‘LSE’), in which Mediclinic holds a 29.9% interest.
COVID-19 It is also important to note that the COVID-19 pandemic falls outside this reporting period and will be discussed in detail in the 2021 Clinical Services Report.
APPROVAL Mediclinic’s Clinical Performance and Sustainable Development Committee approved this Report on 13 May 2020.
GLOSSARY OF TERMS Capitalised terms used in this Report are defined in the Glossary of terms on page 62.
YOUR VIEW IS VALUABLE Mediclinic welcomes the opinions of its stakeholders. Please contact Dr René Toua on tel: +27 21 809 6500 or email: [email protected] with queries or suggestions. CONTENTS
2020 CLINICAL SERVICES REPORT 23 2 Accomplishments BETTER WAYS 3 Foreword TO CONNECT 4 Introduction Employees keep clients 4 Q&A with Dr René Toua at the heart of all Mediclinic does. That is 6 At a glance the commitment behind putting Patients First. 8 Business model 10 Divisional overview 16 The healthcare landscape
18 The value equation
19 Analytics
20 Performance summary 23 Better ways to connect 30 24 Patient experience BETTER WAYS TO 30 Better ways to unlock value UNLOCK VALUE 32 Better ways to care Projects focus on improving 32 Clinical performance the quality of care, reducing costs for clients and 35 Clinical outcomes providing innovative services. 52 Facility focus
54 Assurance
60 Clinical ethics summary
62 Glossary of terms CLINIQUE DES GRANGETTES 64 Contact details 32 BETTER WAYS TO CARE Superior clinical performance is essential to achieve Mediclinic’s purpose of enhancing the quality of life.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 1 ACCOMPLISHMENTS A YEAR OF FIRSTS
Across the divisions, the Mediclinic clinical teams achieved a number of milestones over the past year.
NEW HOPE FOR LYMPHOMA EXCELLENCE IN STEM CELL CERTIFIED FOR TRAUMA 1 Since the beginning of 2 TRANSPLANTS 3 As the first Mediclinic hospital in December 2019, Klinik Hirslanden Klinik Hirslanden has earned JACIE Southern Africa with Level 2 Trauma has been offering CAR T-cell therapy, accreditation (refer to page 54) for status, Mediclinic Pietermaritzburg making it the first private hospital in its autologous blood stem cell is uniquely qualified to handle Switzerland to offer this treatment for transplant service, the only private emergencies. The accreditation by two types of lymphoma. The therapy hospital in Switzerland with these the Trauma Society of South Africa uses genetically reprogrammed white credentials. In this type of transplant, recognises the hospital’s ability to blood cells, or T-cells, to track down stem cells are harvested from a provide definitive trauma care and eliminate malignant cells. patient, treated and reinfused. The regardless of the severity of injury. quality of the procedure is critical and patients can rest assured that Klinik Hirslanden carries this stamp of approval.
IMPROVING PROSTATE SPINE REPAIRED TAKING ON HEARING 4 BIOPSIES 5 BEFORE BIRTH 6 LOSS Dr Mahesh Dhanjee, urologist at In a first for Africa, Prof. Ermos A multidisciplinary team at Mediclinic Newcastle, is the first in Nicolaou and his team at Mediclinic Mediclinic Al Jowhara successfully South Africa to use the BK fusion Morningside in South Africa carried carried out cochlear implants for system for prostate biopsies daily. out surgery on a 25-week-old foetus bilateral sensory neural hearing loss, This technology fuses MRI scans with with spina bifida. The delicate the first such case for Mediclinic real-time ultrasound images to procedure on 13 April 2019 was led by Middle East. Diagnosed with hearing increase the accuracy of the biopsy. Prof. Mike Belfort of the United loss at birth, the child of a year and According to Dr Dhanjee, the system States. By repairing the hole in the a half can now hear in both ears. has increased the detection of spine before birth, the operation prostate cancer from 39% to 59% for dramatically improves the child’s some doctors. outlook and the chance of being able to walk independently.
RELIEF FROM ENLARGED BETTER REMOVAL OF QUICKER RECOVERY 7 PROSTATE 8 BILE DUCT STONES 9 FROM LIVER OP Mediclinic Middle East made Dr Mazin Aljabiri became the first On 20 February 2020, history by performing the first doctor in a private hospital in the Prof. Amir Nisar and Dr Zakir Rezum procedure in the UAE UAE to use SpyGlass in the removal Mohamed of Mediclinic Parkview at Mediclinic Parkview Hospital. of bile duct stones and diagnosis of performed the UAE’s first ever On 26 January 2020, difficult cases. Using a probe laparoscopic resection of liver Dr Adib Al Attar carried out the attached to a tiny camera, this metastasis at the same time as colon 15-minute procedure, which uses innovative technology enables direct cancer resection. The minimally radio-frequency heated steam to visualisation within the ducts for invasive procedure meant the patient ablate prostate tissue and reduce accurate (99–100%) diagnosis. was ready for discharge just three the size of the gland. days after the seven-hour surgery to the liver and a section of his colon.
MEDICLINIC INTERNATIONAL PLC 2 2020 CLINICAL SERVICES REPORT ACCOMPLISHMENTS FOREWORD
Dr Felicity Harvey Chair of the Clinical Performance and Sustainability Committee
The healthcare environment is being It is essential our clients know transformed by a variety of forces. that Mediclinic is a healthcare Not only is the global population provider they can trust – one that is It is essential our ageing, but people are also living transparent about the quality of clients know that longer with multiple long-term care provided and that considers conditions. Free information, apps patient safety paramount. In 2019, Mediclinic is a and devices are empowering the Company did crucial work in healthcare provider individuals to monitor their fitness this regard by strengthening they can trust – one Ward-to-Board accountability. and health, which shapes their that is transparent engagement with healthcare. Every division now has a Clinical At the same time technological Performance Committee (‘CPC’), about the quality of breakthroughs are enabling us as where possible assisted by external care provided and that advisors who have a direct link healthcare companies to do things considers patient differently. to the Clinical Performance and Sustainability Committee, and then safety paramount. Around the world the regulatory through to the main Board. This environment is changing in response framework is vital for underpinning to the rate of technological and the patient safety culture and pharmaceutical development, the ensuring constant improvement. governments in the regions where changes in service delivery that the Company is active, Mediclinic The power of Mediclinic is that we this enables and the needs of their has been part of the solution from work as one, not three separate populations. We must address all the beginning. divisions. Close working relationships these issues in a fragile world where between the Group and divisional In this, as in every healthcare there is a real need to use resources chief clinical officers and Clinical situation where clients turn to us, more sustainably. Services functions enable learning they can rest assured that we are Mediclinic is extremely well positioned to be shared across the Group. ever improving and enhancing the to manage these changes while This means that when there are quality of our services. Our values delivering clinical excellence. To challenges, we learn once and then – of being client centred, trusting address demand for healthcare that share the lessons across the Group. and respectful, performance driven, team orientated and patient safety is more convenient, the Group is This cross-country insight is hugely focused – are not just empty expanding across the continuum of beneficial in the current healthcare statements, they are at the core of care, with the mix of in-hospital and crisis. The COVID-19 pandemic is the who we are and what we do. out-of-hospital treatment in step with biggest infectious threat the world the changing environment, patient has ever seen and calls for new convenience and governmental solutions and closer collaboration regulations. Both on our own and with than ever before. In countries partners, we are seeking to provide everywhere, public and private care for every step of the journey, healthcare are working together Dr Felicity Harvey from wellbeing and prevention to for the public good. Thanks to Chair of the Clinical Performance acute care and recovery. close working relationships with and Sustainability Committee
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 3 INTRODUCTION OUR CLIENTS AT THE CENTRE Dr René Toua, Group Chief Clinical Officer, reflects on developments in healthcare and how Mediclinic strives to enhance the quality of life of clients.
Dr René Toua, Group Chief Clinical Officer You worked in emergency How are developing medicine for several years. How healthcare needs informing did that experience shape your Mediclinic’s business? thinking around clinical care? The Group is expanding across the Emergency medicine is marked continuum of care so that care is by complexity, uncertainty and delivered in the most appropriate experiencing people when they care setting at an appropriate cost. are at their most vulnerable. The focus in healthcare is shifting I saw the full spectrum of trauma from ‘sick care’ to ‘health care’ with cases, from the humorous to the the prevention of disease and heart-wrenching. The ones that an increase in wellbeing becoming I remember the best are the ones the top priorities. Our modern that keep me humble, where lifestyle takes a toll on mental health I learned how easy it is to make and the need for mental health a mistake, and the ones in which services is ever increasing. a life was saved. Expansion across the continuum of care will widen the focus, improve I learned to see each patient as an accessibility and create the individual, considering their physical, opportunity to form a lasting mental and social circumstances to relationship with our clients and not be able to offer ‘whole person care’, only when they become patients. and involving them in deciding what treatment plans are best for their The COVID-19 pandemic has unique circumstances. put the spotlight on healthcare services. What does it mean for Mediclinic strives to always Mediclinic? put Patients First. What does that We are well positioned to handle the mean to you? crisis thanks to our global footprint To be truly patient centric, all which allows for collective learning processes need to start with the from divisions that are in various patient in the middle. Enough time stages of the pandemic. All divisions must be spent to understand the have strong clinical management true needs of the patient. Even teams at hospital and Corporate though patient centricity is lived in Office level supported by experts I saw the full Mediclinic, more can be done to in the Group. The availability of understand patient needs. resources and equipment is a critical spectrum of trauma success factor in the handling of the cases, from the pandemic, and this is well managed by a centrally coordinated humorous to the procurement team. heart-wrenching.
MEDICLINIC INTERNATIONAL PLC 4 2020 CLINICAL SERVICES REPORT The pandemic has also made superior performance across the has also invested in machine the world more aware of infection organisation. Incorporating best learning capability to enable patient- prevention and control (‘IPC’). practices in everyday work and facing analytics, which is an exciting How does Mediclinic ensure that giving positive feedback to staff are move to a more proactive system IPC is implemented to the highest some of the practical ways in which based on prevention, wellness, standard? the excellence is translated across faster diagnosis and precision of IPC is always top of mind across all the entire network. treatment. divisions and is part of standard care. This is especially true for How do you see digitalisation Why do top medical Southern Africa where we have a transforming care at Mediclinic? practitioners choose to work with high burden of infectious diseases, Digital solutions are necessary for and at Mediclinic? particularly tuberculosis and HIV. the next stage in healthcare. Mediclinic and Hirslanden are IPC experts are deployed at various electronic health records (‘EHRs’) very strong brands associated levels across the organisation and enable significantly improved care; with ethical business and other follow international guidelines and allow for digital transformation; practices. Our infrastructure and best practices. create a rich dataset that can be equipment are well maintained and mined for better insight; provide fit-for-purpose. Medical practitioners The Group provides care in data and opportunities for research; are respected, valued partners in three different regions. How do and allow us to build a long-term patient care and are supported by you ensure quality across all the relationship with clients. In addition, clinical and other management divisions? EHRs create opportunities to reduce teams. Mediclinic furthermore Mediclinic ascribes to basic care cost and for greater efficiency supports evidence-based medicine standards that may vary slightly through automation. With the and a culture of patient safety. across divisions in detail but are COVID-19 pandemic, we are also universally accepted as the core exploring telemedicine options. What does achieving this standards and processes that must level of quality care mean for be in place. We have a central The use of analytics is one of investors? governance structure that reaches the pillars supporting the Group’s The healthcare industry is across the organisation and into clinical services. What are some transforming from fee-for-service hospitals, and which is supported by of the most exciting applications? to value-based remuneration. external experts. In addition, we Our use of analytics goes beyond Organisations are evaluated on the closely collaborate with regulators, measuring and benchmarking value they create, not only for professional societies, medical clinical performance – it informs how patients but in their approach to the practice insurers and healthcare we profile clinical risk, develop wider industry and the community. funders to externally monitor the treatment pathways, analyse Mediclinic’s focus on clinical quality of our care and the healthcare trends and create performance and patient-centred perception of the Company. alternative reimbursement models. care contributes to better clinical Shared learnings are essential to In short, it enables us to optimise outcomes, better patient experience embed quality improvement and our care and offer our clients the and lower cost, which means better other initiatives and to spread best possible treatment. Mediclinic financial outcomes.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 5 INTRODUCTION CONTINUED
AT A GLANCE1
A UNIQUELY INTEGRATED INTERNATIONAL HEALTHCARE PARTNER
Mediclinic is an international private healthcare services group, established in South Africa in 1983, with divisions in Switzerland, UK Southern Africa (South Africa and Namibia) and the UAE.
Switzerland SWITZERLAND Hirslanden, the leading private healthcare provider in Switzerland, is recognised for clinical excellence and outstanding patient experience www.hirslanden.ch
SOUTH AFRICA AND NAMIBIA The UAE Mediclinic Southern Africa is one of the three major private healthcare providers in the region with a relentless focus on offering value to all its partners and clients www.mediclinic.co.za
THE UAE Mediclinic Middle East has established a trusted brand and strong reputation in this developing region by offering clinical care of internationally recognised standards www.mediclinic.ae
THE UK Mediclinic has a 29.9% stake in Spire www.spirehealthcare.com South Africa & Namibia
MEDICLINIC INTERNATIONAL PLC 6 2020 CLINICAL SERVICES REPORT 76 8 11 623 Hospitals2 Sub-acute3 and Beds specialised hospitals4 453 14 21 Theatres Day case clinics5 Outpatient clinics6 33 140 Permanent and fixed-term employees
EXPANDING ACROSS THE CONTINUUM OF CARE Mediclinic is focused on providing specialist-orientated, multidisciplinary services across the continuum of care in such a way that the Group will be regarded as the most respected and trusted provider of healthcare services by clients, medical practitioners, healthcare insurers and regulators of healthcare in each of its markets.
N I O PREVENT A PARTNERSHIPS T N A A S I HANC L EN E Y L T A I T ECOVER C I R S G Telemedicine GROWTH I CARE RECENTLY LAUNCHED D
Day case clinics Specialised hospitals IVF TO ENHANCE Sub-acute THE QUALITY hospitals OF LIFE
V
A Diagnostics Outpatient clinics L
U Acute-care Genetic services EXPANSION COMING SOON N E hospitals O I T E A Q V Health awareness IOR U O INSTITUTE OF WINELANDS ORTHOPAEDICS AND A and education N RHEUMATOLOGY ORTHOPAEDIC HOSPITAL T N I O I N
SPRINGS Notes 1 Figures disclosed at 31 March 2020. 2 Provides patient treatment with specialised medical and nursing staff, and medical equipment. 3 Provides comprehensive goal-orientated inpatient care designed for a patient who has had an acute illness, injury or exacerbation of a disease process. 4 Provides specialised in-hospital care, catering for single specialities such as a cardiac hospital, paediatric hospital, etc. 5 Provides elective procedures, surgical procedures and planned medical procedures, but admits and discharges patients on the same day. 6 Provides consultations (by general practitioner, specialist or allied healthcare professional) with no theatre facilities.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 7 INTRODUCTION CONTINUED
BUSINESS MODEL Mediclinic’s business model enables it to quickly respond to opportunities and risks, while safeguarding clients, employees and the interests of stakeholders. The Group is expanding the horizon of what care can be.
THE 83.9% 3 OUTCOME Group grand mean score Market-leading positions for Press Ganey® patient in three geographies experience survey1
2% 83% compounded growth in admissions Participation in Gallup® employee in the past five years engagement survey
THE CARE PUTTING PATIENTS FIRST MAINTAINING CLINICAL By taking a holistic view of clients’ needs, EXCELLENCE Mediclinic is focused on improving all With more than 115 healthcare facilities aspects of the healthcare value equation across four countries, Mediclinic applies – clinical outcomes, client experience stringent quality standards regardless and cost. The Group is ensuring that of location. The Group provides clients are able to receive quality care care and facilities of international in the right care setting at a cost that standard with more than 10 different is fair, predictable and transparent. It accreditations and certifications and also maintains dialogue with clients various international benchmarking and communities through public health initiatives to meet local requirements. awareness campaigns aimed at improving lifestyle choices and overall health.
THE EXPERTISE EMPLOYEES With experience and insight gained Mediclinic’s employees play a pivotal FOUNDATION over more than three decades of part in achieving its strategic goals. To maintaining market-leading positions empower every employee, the Group in diverse geographies, the Group has continuously builds on a culture that is created expertise that spans across client centred; trusting and respectful; all aspects of the business – from patient safety focused; performance client care, patient safety, nursing driven; and team orientated. Through and specialised medicine to facility its strategies dedicated to diversity and management, procurement and inclusion, and attracting and retaining finance, and acquisitions. top talent, Mediclinic secures its future.
MEDICLINIC INTERNATIONAL PLC 8 2020 CLINICAL SERVICES REPORT We exist to care for our clients when they are at their most vulnerable. Herein lies our true value: harnessing the exceptional talent, compassion and energy of Mediclinic employees and partners to ensure our clients receive cost-effective, quality care and outstanding client experiences. Dr Ronnie van der Merwe, Group Chief Executive Officer
ENABLED BY THE MEDICLINIC 8 GROUP STRATEGY: Trusted by eight tertiary institutions Constituent of across all three divisions to help FTSE4Good train the healthcare workers of PURPOSE tomorrow To enhance the quality of life
Signatory of the VISION ±£114m CDP (originally the To be the partner of choice Economic contribution to Carbon Disclosure that people trust for all their healthcare needs monthly salaries Project) ORGANISATIONAL VALUES Client centred
FINDING BETTER WAYS TO CARE LEVERAGING KNOWLEDGE Trusting and respectful In order to align its service offering AND SCALE Patient safety focused with the needs of clients, Mediclinic The power of Mediclinic is that is expanding its core operations it operates as a Group, not three Performance driven to position itself as an integrated separate divisions. Close working Team orientated healthcare provider across the relationships enable learning to be continuum of care. Through innovation, shared across geographies. Highly STRATEGIC GOALS acquisition, partnerships and specialised medicine and cancer expansion, the Group is expanding to care, procurement synergies and Goal 1: To become an integrated provide a seamless suite of healthcare enterprise resource management healthcare provider across services that prevent, treat and recover, have been established as a direct the continuum of care; all under the umbrella of a single, result – all enhancing Mediclinic’s Goal 2: To improve our value connected system. services and efficiency. proposition significantly; Goal 3: To transform our healthcare services and client engagement through digitalisation; Goal 4: To evolve as an analytics-driven organisation; STAKEHOLDERS FUTURE VISION Mediclinic listens carefully to how The Group provides care in a world Goal 5: To strengthen our position as the employer stakeholders feel and what they want. that is being reshaped by evolving of choice; Strong relationships lie at the heart client needs, regulatory frameworks of its ability to enhance the quality and climate forces. This calls for a Goal 6: To grow in existing markets and expand into new of life. By engaging on key issues, it sustainable approach in everything it markets; and not only ensures close cooperation does, from the way it utilises natural and coordination with government resources and engages with employees Goal 7: To achieve superior long-term financial returns. and regulatory role players, it’s to the type of investments it makes also able to realise public-private and how it conducts business. TRANSFORMATION DRIVERS partnerships (‘PPPs’) and seize business opportunities which expand Innovation its services, help it achieve its strategic Sustainable development goals, and diversify revenue streams. FINANCE Mediclinic has a strong financial Read more in the 2020 Annual Report profile, supported by an extensive at annualreport.mediclinic.com. property portfolio. The Group has good access to capital and a EXPERTISE YOU CAN TRUST disciplined capital allocation approach. Note 1 Score negatively impacted by Hirslanden experiencing an interruption in surveying.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 9 INTRODUCTION CONTINUED
SWITZERLAND HIRSLANDEN
17 7 7 Hospitals Secondary care Tertiary care community hospitals city hospitals 10 000+ 2 3 Full-time employees Day case clinics1 Outpatient clinics
OUTPATIENT CARE ROUTINE PROCEDURES SPECIALISED TREATMENTS
ADVANCED TECHNOLOGY RESEARCH AND TRAINING
Speciality split
Cardiology 11% Care settings General medicine 2% Inpatient 82% General surgery 30% Day cases 4% Internal medicine 17% Outpatient 14% Laboratory 1%
Obstetrics & gynaecology 7% AVERAGE AGE OF PATIENT: Oncology 2% Orthopaedics 22% 56 YEARS Radiology 8% AVERAGE LENGTH OF STAY: 4.80 DAYS
Length of stay and case mix index2 NON-SURGERY ELECTIVE EMERGENCY3 35% 40% 25% 19 4.80
18 4.77
19 1.47 ISO 9001:2015
18 1.45 certification for all facilities
Inpatient length of stay CCRG case mix Inpatient length of stay CCRG case mix
Notes 1 At 1 April 2020, Hirslanden’s day case clinics increased to three with the acquisition of Operationszentrum Zumikon. 2 Case mix indices of the divisions were calculated by using the internally developed clinical and cost-related grouping (‘CCRG’). Case mix refers to the characteristics of patients served, where some have more complex medical conditions which may influence outcomes. For more information on the importance of case mix, refer to page 36. High case mix index for Hirslanden mainly due to high load of complex and technologically advanced cases in an older population; low case mix index for Mediclinic Middle East due to its younger patient population. 3 Reflecting inpatient and day case admissions only for all divisions. At Hirslanden, major trauma, neonatal intensive care and advanced critical care handled by cantonal and university teaching facilities.
MEDICLINIC INTERNATIONAL PLC 10 2020 CLINICAL SERVICES REPORT GERMANY
3
3 Zurich 2 1 12 16 17 2 3 FRANCE
15 AUSTRIA 7
Bern 10 11 1 5 1 4 6
2 SWITZERLAND
13 14
Geneva
8 9
ITALY
Hospitals Day case clinics
Canton of Aarau Canton of Lucerne Canton of Lucerne 1 Hirslanden Klinik Aarau1 10 Klinik St. Anna1 1 St. Anna im Bahnhof
Canton of Appenzell Ausserrhoden 11 St. Anna in Meggen Canton of Zurich 2 Klinik Am Rosenberg 2 Operationszentrum Bellaria Canton of St. Gallen
1 2 Canton of Basel-Land 12 Klinik Stephanshorn 3 Operationszentrum Zumikon 3 Klinik Birshof Canton of Vaud
1 Outpatient clinics Canton of Bern 13 Clinique Cecil
4 Klinik Beau-Site 14 Clinique Bois-Cerf Canton of Bern
5 Klinik Linde1 1 Praxiszentrum am Bahnhof Bern Canton of Zug 6 Klinik Permanence 15 AndreasKlinik Cham Zug1 2 Praxiszentrum am Bahnhof Düdingen
7 Salem-Spital1 Canton of Zurich Canton of Schaffhausen
Canton of Geneva 16 Klinik Hirslanden1 3 Praxiszentrum am Bahnhof Schaffhausen
8 Clinique La Colline 17 Klinik Im Park1
9 Clinique des Grangettes1
Notes 1 Hospital with obstetrics department. 2 Acquisition of Operationszentrum Zumikon effective 1 April 2020.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 11 INTRODUCTION CONTINUED
SOUTH AFRICA & NAMIBIA MEDICLINIC SOUTHERN AFRICA
52 46 8 Hospitals Trauma units Sub-acute and specialised hospitals 15 900+ 59 10 Full-time employees Emergency transport Day case clinics bases in South Africa
ROUTINE PROCEDURES SPECIALISED TREATMENTS TRANSPLANT MEDICINE
ADVANCED TECHNOLOGY RESEARCH AND TRAINING
Speciality split Care settings
Cardiology 9% Inpatient 89%
General medicine 7% Day cases 9.0%
General surgery 23% Outpatient 2%
Internal medicine 23%
Obstetrics & gynaecology 11% AVERAGE AGE OF PATIENT: Oncology 1% 39 YEARS Orthopaedics 17% AVERAGE LENGTH OF STAY: Paediatrics 9% 3.88 DAYS
NON-SURGERY ELECTIVE EMERGENCY
Length of stay and case mix index 42% 36% 22%
19 3.88
18 3.76 COHSASA 19 1.22 accreditation 18 1.20 37 for 37 hospitals Inpatient length of stay Inpatient length of stay CCRG case mix ISO 14001:2015 CCRG case mix certification for 44 hospitals
MEDICLINIC INTERNATIONAL PLC 12 2020 CLINICAL SERVICES REPORT 8
34 Pretoria 12 9 6 2 2 5 7 1 10 3 3 28 4 13 5 11 4 15 Johannesburg NAMIBIA Windhoek 35 30 4 29 14
20 23 22 21 6
26 7 Pretoria Johannesburg 27 25 24
3 17 8 8 10 2 8 33 31 32 Sub-acute and 1 16 specialised hospitals 46 Bloemfontein 19 39 5 18 45 47 44 Cape 1 6 Town 36 7 SOUTH AFRICA 49 9 37 51 38 10 50 Day case clinics
52 43 42 40 41 48 Cape Town
Hospitals Limpopo Western Cape 3 Intercare Sub-Acute 20 Mediclinic Lephalale 36 Mediclinic Cape Gate Hospital Irene Free State 21 Mediclinic Limpopo 37 Mediclinic Cape Town 4 Intercare Medfem Hospital 1 Mediclinic Bloemfontein 22 Mediclinic Thabazimbi 38 Mediclinic Constantiaberg 5 Intercare Sub-Acute 2 Mediclinic Hoogland Hospital Sandton 23 Mediclinic Tzaneen 39 Mediclinic Durbanville 3 Mediclinic Welkom 6 Intercare Sub-Acute Hospital 40 Mediclinic Geneva Tyger Valley Gauteng Mpumalanga 24 Mediclinic Ermelo 41 Mediclinic George 7 Mediclinic Winelands 4 Mediclinic Emfuleni Orthopaedic Hospital 25 Mediclinic Highveld 42 Mediclinic Hermanus 5 Mediclinic Gynaecological 8 Welkom Medical Centre Hospital 43 Mediclinic Klein Karoo 26 Mediclinic Nelspruit Sub-Acute Hospital
6 Mediclinic Heart Hospital 27 Mediclinic Secunda 44 Mediclinic Louis Leipoldt
7 Mediclinic Kloof 45 Mediclinic Milnerton Day case clinics Namibia 8 Mediclinic Legae 46 Mediclinic Paarl 1 Intercare Day Hospital 28 Mediclinic Otjiwarongo Century City 9 Mediclinic Medforum 47 Mediclinic Panorama 29 Mediclinic Swakopmund 2 Intercare Day Hospital 10 Mediclinic Midstream 48 Mediclinic Plettenberg Bay 30 Mediclinic Windhoek Hazeldean 11 Mediclinic Morningside 49 Mediclinic Stellenbosch Northern Cape 3 Intercare Day Hospital Irene 12 Mediclinic Muelmed 50 Mediclinic Strand 31 Mediclinic Gariep (part 4 Intercare Day 13 Mediclinic Sandton of Mediclinic Kimberley) 51 Mediclinic Vergelegen Hospital Sandton
14 Mediclinic Vereeniging 32 Mediclinic Kimberley 52 Mediclinic Worcester 5 Mediclinic Durbanville Day Clinic 15 Wits Donald Gordon 33 Mediclinic Upington Medical Centre1 Sub-acute and 6 Mediclinic Limpopo Day Clinic North West specialised hospitals 7 Mediclinic Nelspruit Day Clinic KwaZulu-Natal 34 Mediclinic Brits 1 Denmar Specialist 8 Mediclinic Newcastle 16 Mediclinic Howick 35 Mediclinic Potchefstroom Psychiatric Hospital Day Clinic 17 Mediclinic Newcastle 2 Intercare Sub-Acute Hospital 9 Mediclinic Stellenbosch 18 Mediclinic Pietermaritzburg Hazeldean Day Clinic
19 Mediclinic Victoria 10 Welkom Medical Centre Day Clinic
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 13 INTRODUCTION CONTINUED
THE UAE MEDICLINIC MIDDLE EAST
7 2 Hospitals Day case clinics 18 6 700+ Outpatient clinics Full-time employees
OUTPATIENT CARE ROUTINE PROCEDURES SPECIALISED TREATMENTS
ADVANCED TECHNOLOGY RESEARCH AND TRAINING
Speciality split Care settings Cardiology 5% Inpatient 24% General medicine 13% Day cases 11% General surgery 8% Outpatient 65% Internal medicine 26%
Laboratory 11% AVERAGE AGE OF PATIENT: Nursing and allied health professions 4% 33 YEARS Obstetrics & gynaecology 7% AVERAGE LENGTH OF STAY: Oncology 4% 2.90 DAYS Orthopaedics 5%
Paediatrics 8% NON-SURGERY ELECTIVE EMERGENCY
Radiology 9% 58% 21% 21%
accreditation Length of stay and case mix index 1 JCI for all facilities 19 2.90 accreditation for 18 2.90 2 Mediclinic City CAP Hospital laboratory 19 1.08 18 1.08 ISO 15189:2009 Inpatient length of stay Inpatient length of stay certification for all laboratories Notes CCRG case mix 1 Joint Commission International (‘JCI’). CCRG case mix 2 College of American Pathologists (‘CAP’).
MEDICLINIC INTERNATIONAL PLC 14 2020 CLINICAL SERVICES REPORT 6 Dubai 1 7 5 2 15
7 2 10 6 13 17 14
ARABIAN GULF Dubai
Abu Dhabi 9 11 4 4 3 1 3 1 16 2 8 18 Al Ain
5
UNITED ARAB
12 EMIRATES
SAUDI ARABIA
Hospitals Outpatient clinics
1 Mediclinic Airport Road Hospital 1 Mediclinic Al Bawadi 11 Mediclinic Khalifa City
2 Mediclinic Al Ain Hospital 2 Mediclinic Arabian Ranches 12 Mediclinic Madinat Zayed
3 Mediclinic Al Jowhara Hospital 3 Mediclinic Al Madar 13 Mediclinic Meadows
4 Mediclinic Al Noor Hospital 4 Mediclinic Al Mamora 14 Mediclinic Me‘aisem
5 Mediclinic City Hospital 5 ENEC 15 Mediclinic Mirdif
6 Mediclinic Parkview Hospital 6 Mediclinic Al Qusais 16 Mediclinic Mussafah
7 Mediclinic Welcare Hospital 7 Mediclinic Al Sufouh 17 Mediclinic Springs
8 Mediclinic Al Yahar 18 Mediclinic Zakher Day case clinics 9 Mediclinic Baniyas 1 Mediclinic Deira 10 Mediclinic Ibn Battuta 2 Mediclinic Dubai Mall
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 15 INTRODUCTION CONTINUED
THE HEALTHCARE LANDSCAPE Mediclinic provides a wide range of clinical services throughout its divisions. Each division operates in a different context, dealing with distinct burdens of disease and working within different governmental frameworks.
HIRSLANDEN MEDICLINIC MEDICLINIC SOUTHERN AFRICA MIDDLE EAST Main medical issues Communicable (infectious) diseases/trauma
• Burden of communicable • Burden of disease consists • Burden of disease mainly (infectious) diseases and mainly of communicable consists of chronic lifestyle trauma is very small (infectious) diseases diseases and communicable (infectious) diseases
Chronic diseases
• Burden of disease consists • Chronic diseases more • Chronic underlying medical mainly of chronic diseases prevalent in medical conditions may significantly commonly associated with scheme-covered impact the level of care lifestyle and old age population, followed by received and/or length of • Chronic underlying medical communicable diseases stay conditions may significantly and trauma impact the level of care • In 2019, 43.6% of patients received and/or length of admitted had chronic stay underlying medical conditions; 60% of adult patients admitted were overweight or obese
Most common chronic diseases
• Hypertension, ischaemic • Hypertension, diabetes • In 2019, the chronic diseases heart disease and mellitus and most prevalent in admissions hyperlipidaemia most hyperlipidaemia most were diabetes, hypertension common chronic diseases common underlying and hyperlipidaemia chronic conditions
Medical • Most admitting medical • Admitting medical • Employs most of the practitioner practitioners self-employed, practitioners, excluding medical practitioners who employment while medical practitioners emergency medicine work in the hospitals and working in the fields of practitioners within certain clinics hospital-based specialities, emergency centres, • Owns and operates the such as anaesthetics, internal self-employed and practise laboratory and radiology medicine and emergency independently services medicine, employed at • Radiology, laboratory and certain hospitals oncology services provided • In most instances, radiology, by independent practices nuclear medicine and radiation oncology services owned and operated by hospitals
MEDICLINIC INTERNATIONAL PLC 16 2020 CLINICAL SERVICES REPORT HIRSLANDEN MEDICLINIC MEDICLINIC SOUTHERN AFRICA MIDDLE EAST
Governance • Quality Manager, Infection • Each hospital’s Patient • Medical Directors at all Control Specialist and Critical Safety Manager, Infection hospitals and lead physicians Incident Manager, as well as Control Specialist and at clinics coordinate and subcommittees for quality, several subcommittees oversee the clinical activities IPC and critical incident tasked with overseeing in the facility reporting at every hospital patient safety, IPC and • Clinical hospital committees • Corporate Office Clinical antimicrobial stewardship at each hospital Services department (‘AMS’) initiatives and • Multidisciplinary medical coordinates subcommittee reviewing patient safety affairs board provides activities, monitored by events clinical oversight in hospitals clinical key performance • Hospital Clinical Managers by providing feedback to indicators (‘KPIs’), and enable more integrated senior management team performs audits on various approach by acting as • Six subcommittees of the clinical policies conduit between clinical hospital committees • Affiliated medical management and medical including IPC, clinical risk practitioners integrated into practitioners management, credentialing this structure by established • Regional Clinical Manager and privileging, research and boards in several specialities supports the hospital ethics, quality and patient clinical teams safety, and pharmacy and therapeutic committees
Clinical quality • All treating and admitting • All treating and admitting • All physicians licensed with medical practitioners medical practitioners the relevant authority in registered with the registry registered with the Health the UAE (Dubai Health for medical professions of Professions Council of Authority, Dubai Healthcare the Swiss government South Africa (‘HPCSA’) or City Authority, Department • Affiliation follows strict entry Health Professions Council of Health) criteria and comprehensive of Namibia (‘HPCNA’) • Standardised physician credentialing process, • Medical practitioners work performance appraisal assisted by clinical within scope of defined process includes reviewing committee clinical disciplines as feedback from peers and • Medical practitioners determined by HPCSA/ patients, clinical KPIs and evaluated at least annually HPCNA registration any incidents and quality- on case numbers, infections, • Performance and clinical related complaints re-operations and liability outcomes monitored by • Clinical privileges reviewed cases CPCs composed of annually and depend on • Abnormalities investigated medical practitioners physician’s activity during by hospital management working at hospital, the past year and additional • Anonymous means to report supported by hospital skills obtained performance problems, general managers and • Comprehensive incident which hospital management regional and Corporate reporting and concerns teams and medical Office teams addressed by Medical practitioner committees Director and Clinical Quality address Patient Safety Committee • Insufficient performance • All patient complaints improvements lead to investigated de-accreditation • Immediate action taken if problem arises, including counselling, remedial action, review of privileges or, if appropriate, termination of privileges
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 17 THE VALUE EQUATION VALUE =
CLINICAL CLIENT OUTCOMES EXPERIENCE
COST
SUMMARY Three critical areas define the value respectful; and patient safety equation in healthcare – clinical focused. Mediclinic’s value outcomes, client experience and proposition is a key factor in pursuit cost. of its purpose and realisation of its vision. It directly addresses a key At the heart of Mediclinic lies its industry challenge: the affordability Patients First philosophy, supported of healthcare. In this regard by the organisational values of Mediclinic sees itself very much as being client centred; trusting and part of the solution.
IMPORTANCE Mediclinic employees and associated stakeholders and pursue its vision to As the partner, the Group is medical practitioners form the be the partner of choice that people positioned to have long-term foundation from which the Group is trust for all their healthcare needs. relationships that extend beyond able to offer its services to patients isolated interactions and trusted to and communities, which in turn In this, the Group is dedicated to deliver measurable, quality outcomes allows it to unlock value for all partnering with all its stakeholders. and transparent reporting.
LINK TO MEDICLINIC GROUP STRATEGY
GOAL STAKEHOLDER GROUPS SUB-GOALS
Goal 2 Clients, employees and potential • Significantly improve the patient To improve our applicants, governments and experience value proposition authorities, healthcare insurers, • Improve clinical outcomes significantly industry partners and medical • Significantly reduce the ‘cost of practitioners us’ (the ‘cost’ aspect of the value equation is reported on in the 2020 Sustainable Development Report on page 39)
MEDICLINIC INTERNATIONAL PLC 18 2020 CLINICAL SERVICES REPORT ANALYTICS
SUMMARY One of the Group’s strategic goals is During the year, the Analytics and One of the Group’s to evolve as an analytics-driven Reporting, Enterprise Information organisation. Critical success factors Management and Health Information strategic goals is in achieving this goal are the Management departments to evolve as an availability and processing of integrated to form the Data Science high-quality data, and the unlocking and Information Management analytics-driven of valuable insights from data by function in order to unlock greater organisation. leveraging the next generation of efficiencies and to formulate and analytical technologies such as implement a holistic data machine learning. management and analytics strategy in 2020.
IMPORTANCE Analytics draws on the wealth of data to improve the business. Over many years, Mediclinic has built the tools and capabilities to translate healthcare and client data into decision enablers.
LINK TO MEDICLINIC GROUP STRATEGY
GOAL STAKEHOLDER GROUPS SUB-GOALS
Goal 5 Clients, employees and potential • Enable fact-based strategic and To evolve as an applicants, medical practitioners, operational decisions across the analytics-driven healthcare insurers, industry Group organisation partners • Improve and manage data assets • Implement data-driven innovation
The newly formed department was established only in December 2019. As such, detailed reporting on the data management strategy and the sub-goals mentioned above will be reported on only in the 2021 Clinical Services Report.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 19 PERFORMANCE SUMMARY A summary of the key focus areas and progress against established sub-goals during the reporting period.
PROGRESS Group-wide Hirslanden Mediclinic Southern Africa Mediclinic Middle East CLINICAL GOVERNANCE
• Refined and optimised • Commenced • Appointed additional • Implemented Ward-to- the clinical governance implementation of Hospital Clinical Board accountability structure to enforce Ward-to-Board Managers framework the Ward-to-Board accountability • Continued with • Implemented quality accountability framework implementation of new management framework framework • Introduced doctors’ clinical performance, • Defined and aligned committee at divisional oversight and clinical risk management level governance model in strategy to the Group collaboration with • Developed clinical model supporting medical for cost per event practitioners (‘CPE’) and diagnostic- related grouping (‘DRG’) use
CLINICAL PERFORMANCE
• Roll-out of new clinical • Assessed adherence to • Developed action plans • All facilities successfully indicators, including the the safe surgery in collaboration with accredited/re-accredited standardised infection checklist through medical practitioners to by the JCI ratio (‘SIR’) model for 16 unannounced audits prevent adverse events • Refined hospital-level surgical site infections with an average score • Developed hospital- clinical structures (‘SSIs’) and refinement of 92% specific action plans • Refined clinical strategy of existing indicator • Identified patient aimed at improving for Abu Dhabi and definitions and pathways that qualify clinical performance Al Ain expansion of categories for standardisation, • Enhanced the national • Further developed and • Supported the divisions especially in terms of hand hygiene strategy expanded coordinated in eradicating never fast-track orthopaedics to further improve hand care initiatives events and decreasing • Indications board policy hygiene compliance • Defined clear strategy the number of serious prepared and applied to • Implemented additional for establishing Centres adverse events (‘SAEs’) surgery of the vertebral components of the of Excellence (‘CoEs’) • Enhanced collaboration column and vessel AMS strategy • Established trauma and between divisions with surgery at pilot hospitals • Reviewed and refined urgent care centres working groups on • Defined criteria of the comprehensive • Established 24-hour obstetric safety and system provider model IPC strategy paediatric service at surgical safety and determined level of • Implemented clinical Mediclinic Welcare adherence at hospital initiatives aimed at Hospital and Mediclinic level significantly improving Parkview Hospital obstetric care • Completed final phase of the national stroke management implementation plan • Publicly published subset of hospital- specific clinical performance results
MEDICLINIC INTERNATIONAL PLC 20 2020 CLINICAL SERVICES REPORT PROGRESS Group-wide Hirslanden Mediclinic Southern Africa Mediclinic Middle East DIGITALISATION AND ANALYTICS
• Supported Hirslanden • Radiology information • Dedicated taskforce • Continued EHR roll-out and Mediclinic Middle system pilot at Klinik Im appointed to manage • Ensured compliance East with EHR Park completed and EHR process and with health information implementation rolled out to Klinik continued action plans exchange (‘HIE’) • Supported Mediclinic Stephanshorn aimed at improving requirements in Southern Africa in the • Roll-out of patient data implementation Abu Dhabi evaluation of EHR management system readiness systems (‘PDMS’) for intensive • Established a machine care and anaesthesia at learning capability Klinik Hirslanden • Introduced standardised documentation approach for medical practitioners in the EHR and commenced pilot project at Klinik Stephanshorn
INDUSTRY EVENTS n/a • Hosted Hirslanden n/a • Hosted second Doctors’ Summit Mediclinic Middle East Annual Research Day
MEDICATION SAFETY, IMPLANTS AND DISPOSABLES, AND DIAGNOSTICS
• Refined and optimised • Commenced with • Developed additional • Improved the utilisation the medication specialist group action plans to improve of generic medication management process meetings for cardiology medication safety • Investigated robotic and orthopaedics in pharmacy system order to standardise • Continued the implants and centralisation and disposables consolidation strategy for laboratories
NURSING AND MEDICAL PRACTITIONERS
• Enhanced collaboration • Developed a model • Improved nursing skills • Continued on nursing to validate doctors’ mix and repositioned implementation of performance Nursing Unit Managers standardised appraisal to improve clinical process for medical outcomes practitioners and commenced roll-out for nursing staff
PATIENT SAFETY
• Patient safety workshop • Continued roll-out of • Hosted three • Completed Agency for in October 2019 patient-related outcome multidisciplinary patient Healthcare Research and attended by 130 leaders measurement safety workshops across Quality Hospital Survey across the Group • Completed Patient the division on patient safety culture Safety Policy compliance audit
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 21 The 2019 programme was multifaceted, addressing topics from current developments in Swiss health policy to the revolutionary role of quantum computing in healthcare.
HIRSLANDEN DOCTORS’ SUMMIT 2019 As part of the commitment to professional development, Hirslanden organises an annual congress for its medical practitioners. This year the focus fell on the partnership between doctors and hospitals.
The annual Hirslanden Doctors’ Among the highlights of the event During the 2019 event, the general Summit took place on were the presentations on the Group’s public could get an insight into the 29 November 2019 and was attended strategy by Dr Ronnie van der Merwe, key issues through live tweets and by around 300 of Hirslanden’s Group Chief Executive Officer of Instagram stories posted throughout medical practitioners. The event Mediclinic, and Dr Daniel Liedtke, the day. Several speaker interviews looked at the role doctors play in the Chief Executive Officer of Hirslanden. were uploaded to Hirslanden’s evolving healthcare environment and While Dr Van der Merwe reported on YouTube account. gave insight into the Group’s newly the new Group strategy, Dr Liedtke formulated strategy. elucidated the new Hirslanden Another highlight of the Hirslanden strategy, ‘Together We Care’, derived Doctors’ Summit was the The 2019 programme was from the strategy of the parent presentation of a cheque to the aid multifaceted, addressing topics company. Both underscored the organisation, Mercy Ships. Rather from current developments in Swiss importance of a close relationship than giving doctors a token for their health policy to the revolutionary with doctors to Mediclinic and participation in the summit, role of quantum computing in Hirslanden’s future success – a fact Hirslanden decided to widen the healthcare. Dr Jack Silversin, an that was brought home once again in impact by donating those funds to experienced consultant from the Dr Silversin’s presentation. Mercy Ships instead. United States, discussed the importance of a common vision for At the Hirslanden Doctors’ Summit, Read more about Hirslanden’s doctors and hospitals in his keynote particular attention is paid to partnership with Mercy Ships in the address. He emphasised the networking: during lunch and breaks, 2020 Sustainable Development fundamental importance of a doctors had the opportunity to Report. functioning relationship between exchange ideas with colleagues from doctors and hospital management other Hirslanden hospitals and and provided insights into how this departments, thus gathering relationship can be improved. valuable input.
MEDICLINIC INTERNATIONAL PLC 22 2020 CLINICAL SERVICES REPORT CONNECT CONNECT
BETTER WAYS TO CONNECT
The wellbeing of the Group’s clients forms the foundation of the business with Mediclinic’s core purpose being to enhance the quality of life.
What matters most to these stakeholders is the delivery of quality, safe and cost-effective healthcare by means of world-class facilities and technology while ensuring the best possible client experience and protecting personal data.
HOW MEDICLINIC MEDICLINIC’S I carefully considered the ENGAGES RESPONSE nature of the relationship • Press Ganey® patient experience • The client is entrenched in three of between Mediclinic and index surveys Mediclinic’s organisational values: those who make use of • Public publishing of clinical being client centred, trusting and our services within an performance results respectful, and patient safety evolving healthcare focused. • Systematic patient rounds during landscape. A patient is a hospital stay • Continuous feedback is encouraged by way of patient person receiving medical • 24-hour helplines experience surveys administered care; a client is a person • Health awareness days by Press Ganey®. who receives advice. The • Brochures and magazines • Putting Patients First remains a latter implies a level of • Websites and blogs offering key strategic objective for the trust and a long-term health-related information Group. Mediclinic continues to relationship that extends • Social media invest in its people, clinical facilities and technology. beyond mere treatment. • Client alliance programmes • Patient experience programmes We want our patients to focus on improved caregiver interact with Mediclinic empathy and communication, beyond the conventional intentional rounding, food service processes that enhance patient treatment process, rather experience and safety, and as a client who turns to effective management of us to enhance their complaints. quality of life. • Public-facing awareness and education campaigns run Dr Ronnie van der Merwe, throughout the year. Group Chief Executive Officer
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 23 PATIENT EXPERIENCE
PATIENT EXPERIENCE
PRESS GANEY® Mediclinic benchmarks and publicly The patient experience survey reports on patient experience on a collects feedback on the following divisional level through Press Ganey®, categories: an internationally recognised leading • Admissions process provider of patient experience • Condition of room measurement for healthcare • Meals organisations across the continuum • Nurses of care. Patients are surveyed after • Physicians discharge and this valuable feedback • Tests and treatments helps Mediclinic better understand • Experience of visitors patients’ needs and adapt care • Personal issues (i.e. privacy, safety, services accordingly (Table 1). hygiene, respect) • Discharge process • Overall experience
Table 1: Press Ganey® results for the 2019 calendar year
Hirslanden1 Mediclinic Southern Africa Mediclinic Middle East1 October 2014 Participating since February 2017 October 2014 Total participating facilities 17 50 6 Total surveys collected 12 191 52 958 2 939 Likelihood of recommending 92.1% 85.0% 88.6% the hospital/clinic2
Overall 88.3 (2019: 87.4) 82.7 (2019: 82.0) 86.0 (2019: 85.6)
Admissions3 92.5 85.7 86.4
Nurses 89.7 (2019: 88.7) 82.3 (2019: 81.4) 88.9 (2019: 89.0)
Mean score Physicians 91.4 (2019: 91.2) 86.6 (2019: 86.2) 88.8 (2019: 88.6) out of 100 Tests and 89.4 83.6 86.1 treatments3
Personal issues3 88.1 80.3 86.2
Discharge3 86.5 81.9 82.7
Notes 1 Caution must be exercised when interpreting the 2019 patient experience results for Hirslanden and Mediclinic Middle East. No feedback was collected for Hirslanden by Press Ganey® for several months and the Al Ain region in Mediclinic Middle East had a low response rate. 2 Incomparable with prior year data due to new measurement categories. 3 No prior year data stated as this is a new disclosure.
SPOTLIGHT ON PATIENT SURVEYS 68 000 No fewer than 68 000 patient surveys were collected in 2019. A medical practice survey is currently conducted at Mediclinic Middle East outpatient PATIENT SURVEYS clinics while ambulatory and emergency centre surveys will be added for all divisions in 2020. In addition, Hirslanden must comply with the survey of the Swiss National Association for Quality Development, ANQ.
MEDICLINIC INTERNATIONAL PLC 24 2020 CLINICAL SERVICES REPORT CONNECT CURRENT INITIATIVES The various initiatives listed below are in line with the Press Ganey® priority index per division, and as such are not comparable across the Group.
DIVISIONAL INITIATIVES
HIRSLANDEN MEDICLINIC SOUTHERN AFRICA MEDICLINIC MIDDLE EAST • Relaunch of working group • Nursing Odyssey project to improve • Dedicated doctor engagement on discharge management nursing quality moving into next sessions in Abu Dhabi with planned for March 2020 phase after extensive work done on Al Ain scheduled for • Discharge checklist introduced the empowerment of nurses who run February 2020 • Interruption in service resulted the units (Unit Managers) • Centralised contact centre in no feedback collected for • Rolling out an enhanced prescription • Hourly rounding policy for several months booklet which encompasses more Mediclinic City Hospital • Service challenge rectified by content and retains both normal • Improvement of discharge selecting and appointing new and antimicrobial charts process at Mediclinic City fieldwork provider • Recording of pharmacy interventions Hospital and shared learnings of potential • Focus on registration process errors prevented at Mediclinic Ibn Battuta • Enhancing medicine labels to • Quarterly meetings between improve information on medicines clinical, operational and available to the patient marketing teams • Value-based care provision within the • In-person input from Press following focus areas: medication Ganey® patient experience safety & AMS, safe surgery, safe advisor critical care, safe mother & baby care, safe emergency care • Embedment of initiatives on Patient Safety and Quality Improvement skills • IPC principle embedment
STREAMLINING EMERGENCY ADMISSIONS At Mediclinic City Hospital in the UAE, a technological solution has not only made emergency admissions more efficient, but also lowered risks associated with the process.
In hospitals around the world, the readers for automatic patient Dr Rolf Hartung and Head of sight of patients completing registration in the Emergency Emergency Department admission forms is a familiar one Department. This works by inserting Dr Jacques Malan. – even in emergency departments, the patient’s Emirates ID in the card where time is of the essence. Up reader, which then captures the After a rigorous process redesign until the first quarter of 2019, person’s information and copies it and by formulating action plans to patient registrations in the to the Health Information System. mitigate identified risks, a dramatic Emergency Department of improvement from the original Mediclinic City Hospital were To mitigate any potential risks manual process was implemented. also done manually. Patient associated with the new admission administrators would type system, Mediclinic City Hospital No identification error had occured in the information collected on proactively implemented a failure four months into the new card admission forms, but this came modes and effects analysis. The aim reader system. The new process with various risks. The manual was to identify where and how the furthermore made employees more encoding caused bottlenecks process might fail and assess the efficient and streamlined the and exposed the hospital to relative impact of various failures. emergency admission process. identification errors. Over the course of three months, Operations Manager Virginia It’s one of several initiatives at In late April 2019 the hospital Chapman led the project, under Mediclinic Middle East which put launched a project to use card the sponsorship of Medical Director patient safety and satisfaction first.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 25 PATIENT EXPERIENCE CONTINUED
INTENTIONAL ROUNDING Through regular, structured patient checks, Mediclinic Southern Africa is improving patients’ experience of care.
There is no denying that being in One such patient round is the clinical A year into its implementation and hospital is stressful. Even more so bedside handover, where the current there is evidence of intentional when you feel unsure about aspects of nursing shift informs the next shift of rounding’s positive impact at the treatment and your confinement the patient’s specific care needs. By Mediclinic Southern Africa. Feedback to bed keeps you out of the loop. doing this in the presence of the from 2019 patient experience surveys Nurses have a crucial role to play in client, nurses can ensure the patient show improvements in two key keeping patients informed, ensuring is kept informed. indicators: the perceived skill of their safety and comfort, and nurses and whether they kept enhancing their overall experience. To For the implementation of intentional patients informed. For the former, the make the most of these opportunities, rounding at Mediclinic Southern median of 82.4% increased to 83.4%; Mediclinic Southern Africa has placed Africa, Walsh and Nursing Operations for the latter it increased from 77.6% a focus on intentional rounding over Manager Louise Aylward studied to 78.4%. Walsh notes that in both the past year. international guidelines, pored over cases the improvement was evidence-based articles and analysed statistically significant and The practice was recommended by best practices within the division. The accompanied by reduced variance. Press Ganey®, the independent result was a thorough implementation provider of Mediclinic’s patient guide with structured steps so As part of Mediclinic’s Patients First experience surveys, to improve patient individual hospitals could measure, commitment, the project is making a satisfaction. Where patients felt they analyse and tailor their implementa- real difference to how patients were not kept adequately informed tion. In January 2019, the project got experience care. or included in treatment decisions, underway in all of the division’s intentional rounding would involve hospitals. them and ensure regular touch points.
‘What intentional rounding isn’t, is Figure 1: Effect of intentional rounding on patient experience merely the implementation of hourly Nurses kept you informed rounds,’ clarifies Yolanda Walsh, Nursing Odyssey Programme 79.5 Manager. Within Mediclinic, intentional rounding is defined as a meaningful interaction. For the patient, it should 79 feel as if nurses are anticipating their individual needs and that they have insight into their treatment. 78.5
By making use of a structured routine, intentional rounding aims to deliver 78 essential nursing care reliably and proactively. The reported benefits of the practice are myriad: results 77.5 published in the American Journal of Nursing1 show intentional rounding reduces patient falls by 52%, 77 decreases nurse calls by 37% and increases patient satisfaction by 12%. Project start 76.5 Intentional rounding typically involves Jan – 2018 Mar May Jul Sep Nov Jan – 2019 Mar May Jul Sep Nov – 2019 set phrases and scheduled tasks, as well as asking about the four Ps: Positioning, Personal needs, Pain and Placement. However, in Mediclinic Response to Press Ganey® patient experience survey Southern Africa, the approach was Median to optimise the various patient rounds in the existing ward routines, Note making sure every interaction was 1 Meade, Christine et al. ‘Effect of Nursing Rounds on Patients’ Call Light Use, Satisfaction, and Safety’. meaningful. American Journal of Nursing (September 2006).
MEDICLINIC INTERNATIONAL PLC 26 2020 CLINICAL SERVICES REPORT Through a variety of
KNOWLEDGE educational campaigns, CONNECT IS POWER all three divisions empowered the public to prevent health problems and handle emergency situations.
EVENTS/ Global Hand Hygiene Day INTERACTIONS (5 May), International Nurses Day (12 May) International Nurses Day (12 May) International Nurses Day (12 May), World Heart Day (29 September)
Breast cancer, men’s health, lung cancer, bowel cancer HEALTH: Heart health & stroke identification, diabetes, SOCIAL pregnancy MEDIA PATIENT EMPOWERMENT: Private fixed fees, online pre-admission Healthy fasting during Ramadan, heart health, back to school, breastfeeding
Heart emergency, lung WEBSITE emergency, winter emergency Back to school, healthy fasting
Mediclinic Prime (monthly), NEWSLETTERS Mediclinic Baby (weekly)
Heart emergency, lung VIDEO emergency, winter emergency Healthy school lunches
Heart emergency, lung emergency, winter emergency INFOGRAPHICS Back to school
How much do you know about QUIZ the heart?
POLL Breastfeeding
Hirslanden Mediclinic Southern Africa Mediclinic Middle East
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 27
PATIENT EXPERIENCE CONTINUED
SAFETY TOP OF MIND Patient safety campaigns within the Group ensure that employees keep clients at the heart of all Mediclinic does.
FLU JABS FOR WHERE CLEAN HANDS EXPLORING THE A BETTER DINING EMPLOYEES COUNT ‘ROOM OF HORRORS’ EXPERIENCE Vaccination enables With 5 May declared Not a fairground Because nutrition is such employees to protect Global Hand Hygiene Day attraction, but just as an important aspect of those they encounter, by the World Health terrifying as any haunted health and recovery, making the annual flu Organization (‘WHO’), house: in the ‘Room Mediclinic Southern Africa vaccine an integral Hirslanden marked of Horrors’ clinical set out to optimise the measure in patient safety. the day with several employees must identify experience. Meal times This is a universal focus initiatives: an explainer threats to patient safety were changed to match area across the Group and video, information stand, in a specially arranged home routine more closely internal campaigns are hand cream and even hospital room. This and patients can now aimed at increasing the cookies. Employees were interactive campaign by choose between full, employee participation challenged to submit the Swiss Patient Safety healthy and light meals. rate. At Hirslanden, the videos on the topic of Foundation ran from Separate menus were annual campaign was keeping hands clean. 16–20 September 2019 introduced for paediatric, expanded to include an in seven Hirslanden rehabilitation and long- expert talk, employee facilities. Hirslanden stay patients and extra video statements and employees were so alert snacks for breastfeeding an award for the clinic to potential hazards, they mothers. To improve with the highest uptake. even picked up some nutrition, a diet nurse is The result? Division-wide risks not identified by the allocated to every unit, the vaccination rate campaign organisers. ensuring that patients increased by almost 8% receive the correct meals. from 18.6% to 26.3%. The Incorrect serving poses increase year-on-year is a risk to patient safety; encouraging, with more for example, a meal with activities planned to known allergens or food boost the overall rate Did you know? before a procedure. considerably in the The flu vaccine Nurses also monitor intake medium term. prevents influenza in and assist patients to eat. Following the project 70–90% implementation, the Press of healthy adults. Ganey® patient experience surveys recorded improved scores for meals.
MEDICLINIC INTERNATIONAL PLC 28 2020 CLINICAL SERVICES REPORT PATIENTS FIRST CONNECT HOW MEDICLINIC PUT PATIENTS FIRST IN 2019
Patient safety workshop Indicators for clinical Press Ganey® inpatient held for leadership across performance expanded experience index grand mean score out of 100 the Group
Surgical safety checklist More day case clinics rolled out in all facilities 88.3% health technology CPCs for all three assessments divisions 12 (‘HTAs’) conducted
Hirslanden Public website with Survey of patient hospital-specific clinical experience streamlined performance indicators for to increase participation Mediclinic Southern Africa
FOCUS ON PATIENT SAFETY tumour boards for breast and Held as part of the Mediclinic Group prostate cancer were joined by 82.7% Conference in October 2019, multidisciplinary medical boards in a patient safety workshop was oncology, urology and lung cancer attended by 130 senior managers at the hospitals in Aarau, Bern and from the three divisions. Biel. The Hirslanden breast cancer Furthermore, Mediclinic Middle East centres collaborated with University conducted a survey on safety culture Basel and the Swiss Group for Mediclinic by the Agency for Healthcare Clinical Cancer Research. An Southern Africa Research and Quality; the survey is information technology tool for planned for 2020 in the other two benchmarking clinical outcomes divisions, in conjunction with the between the centres is in introduction of a safety pledge. development. Extensive training has been done on the criteria for never events to A PIPELINE FOR NURSING TALENT standardise reporting between Two Mediclinic Southern Africa 86.0% divisions. learning centres have been accredited to present the three-year GREATER CONVENIENCE Diploma in Nursing. The division All three divisions have day case signed an agreement with the South clinics to meet client needs: African Nursing Council to conduct 1 Hirslanden has two , Mediclinic their exams in India, which will Mediclinic Middle East Southern Africa has six, with a facilitate the recruitment of nurses. further four operated by Intercare, and Mediclinic Middle East two. OPPORTUNITIES • Implementing standardised EXCELLENCE IN CANCER CARE measures for clinical performance At Hirslanden and Mediclinic Middle in outpatient clinics East, Comprehensive Cancer • Developing performance Centres deliver world-class cancer indicators for ambulatory surgery care. At Hirslanden, the designated units
Note 1 At 1 April 2020, Hirslanden’s day case clinics increased to three with the acquisition of Operationszentrum Zumikon.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 29 MEDICLINIC CITY HOSPITAL BETTER WAYS TO UNLOCK VALUE MORE VALUE FOR CLIENTS Across the divisions, projects focus on improving the quality of care, reducing costs for patients and providing innovative services.
HIRSLANDEN EXPANDING ACROSS THE Hirslanden facilities will act as BREAST CANCER CENTRES CONTINUUM OF CARE supervisors. In support of the Swiss FORM NETWORK Swiss clients can look forward to an strategy to transform healthcare Hirslanden breast cancer centres integrated healthcare ecosystem models, the qualification enables are collaborating with the thanks to a collaboration between nurses to support and supplement University of Basel and the Swiss Hirslanden and Medbase. Already doctors by performing basic clinical Group for Clinical Cancer Research the biggest provider of primary care examinations and making simple to form a study network. Activities with more than 50 medical care clinical diagnoses. within the network include the centres in Switzerland, Medbase has development of a digital tool for its sights on reaching 200 centres. THE RIGHT CARE AT THE benchmarking clinical outcomes The collaboration envisions an RIGHT LEVEL between the Hirslanden breast interdisciplinary, cross-sector network Within Hirslanden, a pilot cancer centres. that will look after every aspect of the investigation evaluated the frequency healthcare journey, from prevention of various procedures according to ONWARDS WITH ONCOLOGY and primary care to outpatient insurance class to evaluate possible Besides the designated tumour procedures and specialised surgery. medical over-servicing. Based on boards for breast and prostate a Klinik Hirslanden model, services cancer, other multidisciplinary GROWING THE ROLE OF NURSES are allocated to different levels of medical boards (lung, urology, In cooperation with the Bern insurance class according to oncology) were successfully University of Applied Sciences, outcomes. Treatment must be implemented at the hospitals in Hirslanden is providing internships for effective, appropriate and efficient Aarau, Bern and Biel. This is to students of the master’s degree for to qualify as standard medicine. ensure treatment quality and Nurse Practitioner. For the pilot The investigation found no adherence to international medical programme, physicians at three over-servicing. guidelines and national regulations.
MEDICLINIC INTERNATIONAL PLC 30 2020 CLINICAL SERVICES REPORT MEDICLINIC SOUTHERN AFRICA A JOURNEY TO BETTER NURSING SHARING CLINICAL PERFORMANCE online foetal heart rate monitors were Through the Nursing Odyssey WITH THE PUBLIC implemented in 23 obstetric units project, Mediclinic Southern Africa In a move to empower patients and and head-cooling equipment in
embarked on a quest to address drive improvement, Mediclinic 20 neonatal critical care units (‘CCUs’). UNLOCK VALUE issues that impact the quality of Southern Africa on 25 November nursing. The initiative focused on 2019 launched a public website that MORE PATIENTS CHOSE intentional rounding (see page 26), reports patient safety indicators. CARE EXPERT timely recognition and rescue Clients can select any hospital in Care Expert is an innovative, of deteriorating patients, and the division to view the incidence integrated hip and knee arthroplasty empowering unit managers. Phase 1 of falls, medication errors, near product co-developed by Mediclinic of the Nursing Odyssey has already misses and pressure ulcers as well as Southern Africa and its associated shown improvements in patient the extended length of stay index. orthopaedic surgeons. The experience metrics. By June 2020, 3 051 users had made product optimises the efficiency, use of the site. effectiveness and quality of CLEARING THE WAY FOR STROKE treatment and is based on value of TREATMENT FOCUS ON MOTHER AND BABY care, rather than fee-for-service. In With stroke training days conducted To improve obstetrics outcomes, 2019, Mediclinic Southern Africa at 49 Mediclinic Southern Africa Mediclinic Southern Africa facilities completed 2 453 Care hospitals, a standardised clinical implemented a range of initiatives. Expert cases, an increase of 46% on pathway has been set in place for These include clinical guidelines the previous year. This means nearly dealing with this medical emergency. published on the Doctors’ Portal, 41% of all hip and knee arthroplasties Closer collaboration within clinical collaborative performance reports were Care Expert procedures. teams at and between hospitals is for hospitals and obstetricians, Effective pain management and evidenced by success stories of morbidity and mortality meetings, and information sharing with clinicians improved patient care. In 2020, a Mediclinic midwifery skills resulted in a more efficient care stroke database will be developed. enhancement training. Intellispace process.
MEDICLINIC MIDDLE EAST GENOME SEQUENCING FOR THE PURSUIT OF EXCELLENCE (‘MBRU’) for the training of medical PRECISE TREATMENT To facilitate the establishment students. A four-year postgraduate Mediclinic Middle East is at the of CoE, Mediclinic Middle East paediatric residency programme is forefront of healthcare with the has created a framework of run with Al Jalila Children’s Hospital use of genetics for personalised requirements. Hospital Directors and a memorandum of medicine. To enable the opening of presented their initiatives for understanding has been signed for the UAE’s first precision medicine lab the foundation of CoE, clinical a range of subjects. The division also in 2020, the division has added a programmes and specialised units. places students from the Higher genetics service and acquired These include a Comprehensive Colleges of Technology, Al Ain equipment for genome sequencing. Cancer Centre, Breast Centre, Neuro University and Fatima College of Further preparations include Centre and Cardiovascular Centre, Health Sciences. registration with the Ministry of with various facilities working Health, appointment of two together in a hub-and-spoke model. REASON TO SMILE molecular geneticists and finalisation A further five centres have project Mediclinic Middle East has appointed of the test menu. status and are working towards a director for dental services to accreditation. Offering clients the implement strategy, oversight and FERTILITY CENTRE FOR very best care are the specialised support, as well as advise on new ABU DHABI units for Robotic Surgery, technology. The division aims to The construction of an in vitro Endometriosis and Bariatrics as well introduce oral scanners in busy fertilisation (‘IVF’) centre at as the Diabetes Programme. practices for quicker turnaround Mediclinic Al Bateen has been times in preparing crowns. completed. Bourn Hall International COMMITTED TO EDUCATION Standardisation of dental MENA Ltd, subsidiary of the IVF Academic affiliations exist between consumables across the division pioneers Bourn Hall, is in the process Mediclinic Middle East and will create significant efficiencies of obtaining Department of Health Mohammed Bin Rashid University and cost savings. clearance for the centre. of Medicine and Health Sciences
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 31 BETTER WAYS TO CARE
CLINICAL PERFORMANCE Mediclinic’s purpose is to enhance the quality of life. To achieve that, superior clinical performance is essential. Clinical governance lays the foundation for the structures and processes that ensure the best possible outcomes for patients.
CLINICAL PERFORMANCE FRAMEWORK: WARD-TO-BOARD FOLLOWING THE CLINICAL MANAGEMENT MODEL ACCOUNTABILITY: Mediclinic uses a simple, yet powerful clinical performance framework STRENGTHENING THE built on a sound clinical governance foundation – collectively, the clinical ACCOUNTABILITY management model (Figure 2). FRAMEWORK
The model supports a structured approach to clinical management To improve efficiency and through a clinical governance foundation layer that provides the enable seamless integration of structures and processes required for clinical performance. information flow, Mediclinic pursues Ward-to-Board accountability. To this end, the Clinical Figure 2: Performance and Sustainability Clinical Committee has been replicated SUPERIOR management CLINICAL at divisional and hospital level. model PERFORMANCE Aligning the committees and reviewing divisional differences provide valuable information on organisational accountability pathways and structure. In addition, clinical services and governance VALUE-BASED committees where possible call CARE on independent experts to act as ‘positive dissenters’. Divisional CPCs CLINICAL were established for three divisions COST-EFFICIENCY during the year.
CLINICAL EFFECTIVENESS
PATIENT SAFETY (including IPC)
CLINICAL GOVERNANCE
MEDICLINIC INTERNATIONAL PLC 32 2020 CLINICAL SERVICES REPORT Clinical services and governance committees where possible call on independent experts to act as ‘positive dissenters’.
Table 2: Divisional CPC summary
Hirslanden Mediclinic Southern Africa Mediclinic Middle East
Meetings held 1 4 3 CARE Summary Quality boards established Subcommittees active at Hospitals and clinics at each facility 38 hospitals divided into clusters – each cluster has a clinical quality and patient safety committee which meets regularly
HTAs: IDENTIFYING THE BEST-VALUE TECHNOLOGY To ensure capital is allocated strategically and investments in equipment and interventions are sound, the Group makes use of HTAs. These measure clinical and cost effectiveness and the broader impact of healthcare treatment and tests on those who plan, provide or receive care. Research focuses on evidence of a technology’s effectiveness by comparing it to the current standard intervention.
Having established a competency in HTAs, the Company is in the process of looking to strengthen the function so that in time it becomes a core, centrally shared service which will enable better clinical decision-making and aid clinical standardisation.
EHRs: STREAMLINING PATIENT DATA EHRs not only transform both clinical being implemented, as well as a and business processes, these also: radiology information system. These • improve quality, safety and projects form part of HIT2020, efficiency; a larger back-office centralisation • reduce health disparities; project at this division. EXCHANGE AND • improve care coordination; RECORD • enable client engagement; Mediclinic Southern Africa has • improve population and public appointed a taskforce which will The integration of health; evaluate and manage the process of Mediclinic’s EHR with • protect privacy and personal selecting and implementing an EHR the UAE government’s health information; solution that will suit the local HIE enables physicians • enable expansion into previously operating and fiscal environment. to review patient untapped markets by laying medications, allergies, the foundation for artificial Mediclinic Middle East commenced laboratory tests and intelligence-enhanced diagnostics, with the roll-out of its EHR at radiology reports telemedicine and remote-sensing, Mediclinic Parkview cluster clinics, across both systems. thereby future-proofing the Mediclinic Khalifa city clinic and Mediclinic Middle East organisation. Mediclinic Al Noor Hospital during is also represented on the year, with Mediclinic Airport the clinical advisory Establishing a comprehensive digital Road planned for 2020. The roll- and technical backbone is a priority across all the out schedule was impacted by committees of the divisions, in line with the Group’s introduction of the Department HIE project. strategic goal to transform its of Health Abu Dhabi’s new HIE healthcare services and client project. The EHR was successfully engagement through digitalisation integrated with the HIE in (goal 3). Abu Dhabi, making Mediclinic Middle East the first At Hirslanden, an EHR and PDMS are private provider to achieve this.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 33 CLINICAL PERFORMANCE CONTINUED
WHO IS DOING THE RESEARCH AT MEDICLINIC MIDDLE EAST? RESEARCH: GAINING GREATER MEDICAL INSIGHT Research is conducted across the divisions, making Mediclinic an attractive partner for multinational, multisite studies. During the year, divisional and Group research committees were established which will monitor the ongoing research in each division.
HIRSLANDEN MEDICLINIC MEDICLINIC SOUTHERN AFRICA MIDDLE EAST 27 31 68 38% MBRU student research approved medical approved medical approved medical 34% investigator-initiated research studies research studies research studies 19% pharmaceutical industry sponsored
6% grants 3% consortium studies SETTING THE STANDARD FOR THE UAE
RESEARCH DAY Recognised with the Best Researcher Award at the 2019 Research Day, Dr Shaheenah Dawood, senior oncologist 11 at Mediclinic City Hospital, gives insight into her work. February 2019 What does your research At Mediclinic City Hospital, we project involve? have all the standard operating I’m looking at the use of procedures in place, we actively CPD immunotherapy (pemrolizumab and collaborate with the medical school tamoxifen) in the treatment of and, most importantly, we have the points hormone receptor positive breast support of the whole Mediclinic to cancer. This is the first investigator- ensure that we strive for academic initiated phase II clinical trial in the brilliance and ultimately help the UAE to do so. Immunotherapy has patients in our community. 19 largely been focused on more presentations immunogenic malignancies such as What is the study’s lung cancer and patients with triple significance for the clinical negative breast cancer. If the results research community in of this two-year study are positive, the UAE? 45 it could open up a larger cohort of In the past we have shied away posters patients with breast cancer who from doing phase II clinical trials could benefit from immunotherapy. and have focused more on phase III and IV trials. This study will allow What makes Mediclinic City us to gain more experience in this 221 Hospital a good facility for this realm. Furthermore, the trial has research? a huge translational component attendees The hospital has grown to be a that will allow us to look at unique comprehensive oncology CoE in signatures to better define cohorts the region, attracting both national that will benefit from therapy. and international patients. This also I believe this trial will set the involved developing a dedicated example of how we conduct future clinical trials programme to enhance investigator-initiated trials in the academic credibility, enable UAE. It is an opportunity to leave international collaborations and a lasting footprint in the oncology facilitate access to novel agents. community.
MEDICLINIC INTERNATIONAL PLC 34 2020 CLINICAL SERVICES REPORT CLINICAL OUTCOMES
CLINICAL INDICATORS BENCHMARKING Each aspect of the clinical when reviewing the clinical Benchmarking is used to measure performance framework – patient performance results reported performance over time. Facilities safety, clinical effectiveness, clinical on pages 37–49: and divisions are benchmarked cost efficiency and value-based • all indicators are reported for the against each other where sufficient
care – builds on the previous one. calendar year to ensure complete information is available to control CARE and comparable results; for those variables facilities do More than 75 clinical indicators • figures in the2020 Clinical Services not have control over, such as the are measured monthly in line with Report may differ from the previous mix of patients and/or differences a standardised set of definitions report where additional data in regulatory requirements. and classifications. Many of these became available after publication Otherwise, facility performance is outcome indicators are self- or where criteria changed (refer to benchmarked over time. As access reported and others are derived page 36); to clinical data from the divisions from administrative data. These • for comparative purposes, the case improves, more benchmarking will indicators are monitored for trends mix indices of the divisions were be possible with risk adjustment. and used to identify opportunities calculated by using the internally for improvement. The hospitals developed CCRG system (refer to Where available, external closely monitor their results and page 36); benchmarking is used. This will compare themselves with other • statistical significance is determined be expanded over time. hospitals in the same division. for a subset of the indicators and calculated by determining whether Clinical indicator improvements there is a statistical difference when during the year include the roll-out values from prior periods are of the SIR model for SSIs; the compared (refer to page 36); and refinement of existing indicator • not all indicators are directly definitions; and the expansion of comparable due to regulatory categories. requirements, e.g. Simplified Acute Physiological Score (‘SAPS’) II is The scope of services and delivery measured at Hirslanden while SAPS 3 model of each division differ is measured at Mediclinic Southern significantly. Note the following Africa and Mediclinic Middle East.
Table 3: Comparable benchmarks of international clinical quality
Mediclinic Mediclinic Indicator Hirslanden Southern Africa Middle East
Vermont Oxford Network (‘VON’) n/a • •
SAPS II • n/a n/a
SAPS 3 n/a • •
The Initiative on Quality Medicine (‘IQM’) • n/a n/a
Catheter-associated urinary tract infections (‘CAUTI’), Selected central line-associated blood stream infections (‘CLABSI’) patient groups • • and ventilator-associated pneumonia (‘VAP’), as per only Centres for Disease Control and Prevention definitions
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 35 CLINICAL OUTCOMES CONTINUED
DISCREPANCIES The ‘Clinical outcomes’ section that follows, provides a summary of the events that have occurred in the divisions during the year. As the effect of actions become prevalent over time, so too the data changes resulting in indicators which fluctuate slightly after the reporting period. These changes can be contributed to one or more of the following reasons: • reclassification of an event after investigation; • delay in receiving infection test results (e.g. microbiology culture results); • delay in capturing of data; • delay in billing days and patient counts; • finalisation of accounts (e.g. accounts for complex cases); and/or • discharge of patients to palliative care facilities.
KEY TERMS Case mix IPC bundles Case mix refers to the IPC bundles are groups characteristics of patients of evidence-based served, where some have more practices which, when performed complex medical conditions which consistently, significantly improve may influence outcomes. Healthcare patient outcomes and prevent providers have no control over device-related and procedure- these characteristics and therefore related healthcare-associated the need exists to keep them fixed infection (‘HAI’). in comparative analysis. The ability to measure the heterogeneous Statistical significance case mix of hospitals has been Statistical significance is recognised for some time as critical determined to identify to improving hospitals and health areas of improvement that create system management through knowledge leveraging and sharing planning and quality assurance, as opportunities to the benefit of all well as achieving equity in hospital divisions. By also identifying areas reimbursement. Without the of concern, it allows the Group to capability to measure case mix determine key focus areas for future differences, the comparative initiatives. analysis of hospital outcomes and attempts to establish the Statistical significance is determined reasonableness of those outcomes by performing a hypothesis test. often reflects in oversimplification of A difference is deemed to be the issues involved and may result in statistically significant if the p-value invalid and misleading findings. exceeds a 5% critical limit. The indicators reported represent Clinical and cost-related the means of their respective groupings distributions and the hypothesis The CCRG is a test examines if the means for classification system of the type successive years are different of illness and clinical severity in from the same distribution (null a hierarchical system of clinical and hypothesis) or not (alternative statistical homogenous groups used hypothesis). This result allows to assign a risk score to each Mediclinic to conclude if a change is patient. A higher score reflects significant or not. The test statistic higher complexity and case load. for the hypothesis test and the These risk scores in turn are used to distribution of the test statistic are group patients in risk stratums to dependent on the type of data enable risk-adjusted benchmarking. being reported on.
MEDICLINIC INTERNATIONAL PLC 36 2020 CLINICAL SERVICES REPORT Statistical significance EXAMPLE OF STATISTICAL SIGNIFICANCE continued Where variation in the current Figure 3: Adverse events – Mediclinic Middle East year’s data is found to be Rate per 1 000 patient days statistically significant as Statistically significant compared to prior reporting periods, the applicable data in the Hospital-associated pressure ulcers graph is marked with an orange 19 0.23 dot and an explanation is provided, 18 0.18 if available (see example right). In these instances it is unlikely that 17 0.40 the changes in the numbers are Falls due to chance. 19 0.52
18 0.42
17 0.51 CARE
Medication errors
19 2.94
18 3.55
17 3.51
PATIENT SAFETY Achieving patient safety requires Never events a collective commitment to building Across the divisions, the WHO surgical a patient safety culture. This means safety checklist is followed to decrease that each employee focuses on errors and adverse events, and increase reporting and learning from near teamwork and communication during misses and adverse events that may surgery. cause patient harm. An open culture where teams are comfortable The implementation of the safe surgical discussing patient safety incidents checklist remains a key focus area, with and concerns is fostered through good progress made across all divisions the inclusive completion of systems during the year. Mediclinic reports only analysis of SAEs in hospitals. These on a subset of surgical and procedural processes lead to an informed never events at present, focusing on: culture because teams learn from the correct identification of patients, the adverse events to mitigate procedures and sites, and the future incidents. Fundamental to prevention of retained foreign objects. this is the ‘just culture’ (Frankl framework) wherein employees Figure 4: Never events1 involved in adverse events are Rate per 1 000 patient days treated fairly. (Number of events in brackets)
Hirslanden
19 0.002 (1)
18 0.006 (3)
17 0.004 (2)
Mediclinic Southern Africa
19 0.014 (27)
18 0.009 (17)
17 0.009 (17)
Note Mediclinic Middle East 1 The measurement and reporting of never events have been refined during the year to 19 0.007 (1) ensure comparable rates across the Group. The never event rate is reported to the third 18 0.022 (3) decimal to negate the obscuring effect of 17 0.00 (0) rounding.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 37 CLINICAL OUTCOMES CONTINUED
Adverse events HIRSLANDEN Figure 6: Falls breakdown An important aspect of improving Rate per 1 000 patient days the quality and safety of patient care Figure 5: Adverse events is preventing adverse events that Rate per 1 000 patient days Falls without Injury could harm patients, including Falls with Injury hospital-associated pressure ulcers, Statistically significant falls and medication errors. 19 0.80 1.66 Hospital-associated pressure ulcers 18 0.75 1.71 19 0.87 The 8.42% decrease in the hospital- 18 0.95 associated pressure ulcer rate from 17 0.73 0.95 in 2018 to 0.87 in 2019 is not statistically significant. Falls The fall rate remained stable at 2.46. 19 2.46
18 2.46 Hirslanden commenced reporting on
17 2.52 medication errors in 2018. The 17.02% decrease in the medication error rate from 1.41 in 2018 to 1.17 in 2019 is Medication errors statistically significant. Analysis of 19 1.17 the fluctuation is difficult as the
18 1.41 current reporting system is restrictive with limited classification and system factor analysis abilities.
MEDICLINIC SOUTHERN AFRICA
Figure 7: Adverse events Medication errors per 1 000 patient Rate per 1 000 patient days days reduced by 17.65% from 1.19 in 2018 to 0.98 in 2019, a statistically Statistically significant significant decrease, mainly due to a reduction in administration errors. Hospital-associated pressure ulcers The involvement of pharmacists in identifying incorrect medication 19 0.23 error reporting has resulted in 18 0.23 additional reporting mechanisms for potential medication errors. 17 0.22 Near-miss medication errors related Falls to prescription and dispensing are recorded to show where pharmacists 19 1.07 intervene with regard to appropriate 18 1.03 prescription of antibiotics and other medication, and where own 17 1.02 dispensing errors are corrected
Medication errors before medication is given to the patient. Pharmacists are also 19 0.98 well placed to identify certain 18 1.19 administration errors which may not have been identified by the nursing 17 1.58 employees in the wards. This reporting is supplementary to the The rate of hospital-associated hospital events management system pressure ulcers remained stable at and is quantitative, voluntary and 0.23. dependent on time availability of pharmacists. The data collection The 3.88% increase in fall rate from to date has been used to guide 1.03 in 2018 to 1.07 in 2019 is not hospitals to identify specific areas for statistically significant. Preventing falls quality improvement and prevention remains a key focus area and the Falls of medication errors, and to provide Policy was reviewed during the period a measurement tool to track and aligned to the Group policy. progress.
MEDICLINIC INTERNATIONAL PLC 38 2020 CLINICAL SERVICES REPORT MEDICLINIC MIDDLE EAST
Figure 8: Adverse events Rate per 1 000 patient days
Statistically significant
Hospital-associated pressure ulcers
19 0.23
18 0.18
17 0.40
Falls CARE
19 0.52
18 0.42
17 0.51
Medication errors
19 2.94
18 3.55
17 3.51
The increase in the hospital- educational videos for employees, associated pressure ulcer rate by fall prevention posters in patient 27.78% from 0.18 in 2018 to 0.23 in rooms and creating a fall prevention 2019 is not statistically significant. booklet for patients and visitors. A pressure injury prevention project Training for clinical employees in team was reactivated in response to the division continued. the increase to address this across the entire division. Progress made The medication error rate decreased against the listed standards and by 17.18% from 3.55 in 2018 to 2.94 in objectives as part of the prevention 2019, a statistically significant change. initiatives was measured and major There is a continued focus on compliance improvements were medication management. Both noted since August. outpatient and inpatient medication errors are reported and are classified The 23.81% increase in the fall rate as prescription, dispensing and from 0.42 in 2018 to 0.52 in 2019 is administration errors. Focused not statistically significant, and is medication audits and physician mainly due to patient and parent education and training are ongoing in non-compliance to fall prevention all facilities. Medication errors directly instructions. Fall awareness and related to the newly implemented prevention remain a focus area for EHR in Mediclinic Parkview reduced Mediclinic Middle East, with renewed significantly as the doctors, nurses emphasis on patient education and and pharmacists adjusted to the awareness of calling nurse assistance. system and important stock The fall awareness campaign includes management issues were resolved.
Fall awareness and prevention remain a focus area for Mediclinic Middle East, with renewed emphasis on patient education and awareness of calling nurse assistance.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 39 CLINICAL OUTCOMES CONTINUED
Infection prevention and control Hand hygiene Preventing infection is paramount to patient safety. Activities include Hirslanden Mediclinic Mediclinic Southern Africa Middle East standardising processes around infection control based on Adherence to hand Hand hygiene Hand hygiene data is international best practices; hygiene procedures compliance results collected at all implementing care bundles around is essential to showed a 4.96% facilities using a the prevention of SSI, VAP, CLABSI prevent HAI and improvement from standardised tool. and CAUTI; and running surveillance compliance is 75.92% in 2018 to Data is reported to projects with multilayer methodology. evaluated through 79.68%. Hospitals Infection Control direct observation continue to focus Committees of each Each division has central IPC by IPC specialists. on interventions to cluster to address specialists who standardise infection improve hand hygiene non-compliance. control policies and procedures for compliance. There is the respective geography. Each a direct correlation facility has IPC team members who between the improved receive regular training and monitor compliance to the IPC bundles and hand hygiene any infections. compliance and the reduction in HAI rates.
MEDICLINIC SOUTHERN AFRICA
Figure 9: Hand hygiene compliance rate (%) vs HAI rate
Compliance rate 82% 2.4 HAI rate 80% 2.2
78% 2.0
76% 1.8
74% 1.6
72% 1.4 Jan 2018 Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan 2019 Feb Mar Apr May June July Aug Sep Oct Nov Dec 2019
MEDICLINIC MIDDLE EAST
Figure 10: Hand hygiene compliance rate1
2019 Dec
2018 Nov
Oct
Sep
Aug
July
June
May
Apr
Note Mar 1 Average for 2018 calculated without Mediclinic Parkview Feb Hospital data, as the hospital only opened in September 2018. Jan
78% 80% 82% 84% 86% 88% 90%
MEDICLINIC INTERNATIONAL PLC 40 2020 CLINICAL SERVICES REPORT Healthcare-associated infections Device-associated infections
Hand hygiene HIRSLANDEN HIRSLANDEN The HAI rate remained stable in 2019. As these conditions are rare, the Figure 13: Device-associated infections calculated rates can be sensitive to Rate per 1 000 device days single events. VAP
MEDICLINIC SOUTHERN AFRICA 19 2.18 18 1.60 Figure 11: HAIs Rate per 1 000 patient days 17 4.17
CLABSI 19 1.81 19 0.32 18 1.91 CARE 18 0.23 17 1.98 17 0.38
Southern Africa has a high burden of CAUTI infectious diseases, unlike Switzerland and the UAE, necessitating a 19 0.91
continued focus on the identification 18 0.40 of infectious diseases and community- acquired infections upon admission 17 0.91 and the prevention of HAI. The rates of all device-associated infections increased during the period. The 5.23% decrease in the HAI rate The VAP rate increased by 36.25% from 1.60 in 2018 to 2.18 in 2019; the from 1.91 in 2018 to 1.81 in 2019 is not CLABSI rate increased by 39.13% from 0.23 in 2018 to 0.32 in 2019; and statistically significant and is mainly the CAUTI rate increased by 127.50% from 0.40 in 2018 to 0.91 in 2019. due to an increase in the hand None of these increases are statistically significant. Behind the relative hygiene compliance and continuous values there are seven incidences of VAP, four of CLABSI and 13 of focus on device-associated infection CAUTI in different hospitals in the Hirslanden network. control bundles. Hospitals continue to focus on interventions to improve MEDICLINIC SOUTHERN AFRICA compliance and on the five moments of hand hygiene as outlined by Figure 14: Device-associated infections the WHO. Rate per 1 000 device days
Statistically significant
MEDICLINIC MIDDLE EAST VAP
Figure 12: HAIs 19 3.57 Rate per 1 000 patient days 18 3.84
17 4.90 19 0.94
18 1.11 CLABSI
17 1.19 19 2.98
18 2.52 The 15.32% decrease in the HAI rate 17 2.43 from 1.11 in 2018 to 0.94 in 2019 is not statistically significant. There is a CAUTI continued focus on current IPC practices in the division, with a 19 1.89
specific focus on the implementation 18 2.26 of care bundles in the CCUs and compliance with antibiotic 17 2.54 prophylaxis guidelines. The VAP and CAUTI rates decreased by 7.03% from 3.84 in 2018 to 3.57 in 2019 and by 16.37% from 2.26 in 2018 to 1.89 in 2019 respectively, mainly due to continued improvement of IPC bundle compliance. The 18.25% increase in the rate of CLABSI from 2.52 in 2018 to 2.98 is statistically significant. Each CLABSI case is analysed to understand the underlying contributing factors and to implement targeted interventions.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 41 CLINICAL OUTCOMES CONTINUED
MEDICLINIC SOUTHERN AFRICA The 4.49% decrease in the rate of SSIs from 2.67 in 2018 to 2.55 in 2019 is Figure 15: SSIs not statistically significant. The main Rate per 1 000 theatre cases contributing surgeries to the SSI rate are caesarean sections 19 2.55 (14.61% increase) and abdominal hysterectomies. Specific patient factors 18 2.67 impacting the SSI rate include obesity, 17 2.77 non-conforming to hair removal requirements prior to surgery, age and co-morbidities such as diabetes mellitus.
MEDICLINIC MIDDLE EAST
Figure 16: Device-associated Figure 17: SSIs infections Rate per 1 000 theatre cases Rate per 1 000 device days 19 2.57 Statistically significant 18 2.98
VAP 17 3.14
19 0.30
18 0.33 The majority of the reported HAIs in Mediclinic Middle East are SSI cases. 17 0.54 The 13.76% decrease in the SSI rate from 2.98 in 2018 to 2.57 in 2019 is CLABSI not statistically significant. Surgical 19 1.19 practices, theatre process flow, scrubbing processes, theatre attire, 18 1.79 antibiotic prophylaxis and 17 1.27 environment care were reviewed and addressed. The SSI cases after CAUTI caesarean sections (elective and emergency) decreased significantly 19 0.97 for the period under review after 18 0.34 reinforcing antibiotic guidelines, 17 0.37 monitoring compliance and standardising preoperative skin preparation and cleaning, as well The VAP and CLABSI rates educating patients on post-discharge decreased by 9.09% from 0.33 in wound management. 2018 to 0.30 in 2019 and by 33.52% from 1.79 in 2018 to 1.19 in 2019 respectively, mainly due to the reinforcement and strict adherence to care bundles in the intensive care units. Neither of these decreases is statistically significant. The rate of CAUTI increased by 185.29% from 0.34 in 2018 to 0.97 in 2019, a statistically significant change.
IPC care bundle practices were reinforced and staff competencies on catheter insertion added to the intensive care unit competencies. A taskforce was also identified to review the current audit process, compliance to the CAUTI bundles and validation of such cases.
MEDICLINIC INTERNATIONAL PLC 42 2020 CLINICAL SERVICES REPORT Antimicrobial stewardship Antimicrobial resistance increases with growing utilisation of antimicrobials, therefore Mediclinic Southern Africa and Mediclinic Middle East monitor total antimicrobial utilisation in defined daily doses (‘DDD’).
HIRSLANDEN The burden of resistant germs in Switzerland is low. Colonisation of patients with multidrug-resistant organisms is monitored on a monthly basis. Antibiotic consumption is reported to the Society of Pharmacists and benchmarked against other Swiss hospitals.
MEDICLINIC SOUTHERN AFRICA CARE Considering the high burden of infectious diseases in Southern Africa, effectively managing antimicrobial resources and preventing multidrug resistance are critical.
Figure 18: Antimicrobial utlisation indicators
DDD Rate per 100 patient days
19 73.27
18 74.99
17 83.60
Undesired agents utilised for surgical prophylaxis Percentage of undesired prophylaxis (%)
19 3.22
18 3.50
17 3.83
Prolonged treatment Rate per 1 000 exposures
19 8.67
18 8.10
17 8.02
The total antimicrobial usage decreased by 2.29% in 2019. The undesired surgical prophylaxis rate decreased by 8.00% from 3.50% in 2018 to 3.22% in 2019, due to improved use of the surgical prophylaxis guidelines. The 7.04% increase in the prolonged treatment exposure At Mediclinic Southern rate from 8.10 in 2018 to 8.67 in 2019 is not statistically significant. Africa the total These indicators are based on administrative and billing data and are continuously updated and refined. antimicrobial usage decreased by 2.29% Improvement in the utilisation of antimicrobials is driven by retrospective audits and feedback interventions by the clinical and in 2019. ward pharmacists in each hospital. Their interventions include discussions with the prescribing medical practitioner to improve appropriate dose, duration and frequency of antimicrobials, and to stop or change antimicrobials as soon as investigations demonstrate the causative organism’s resistance profile.
MEDICLINIC MIDDLE EAST Adult and paediatric antibiotic guidelines and the antibiotic stewardship programme were revised and implemented during the period. Compliance to the guidelines is continuously monitored.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 43 CLINICAL OUTCOMES CONTINUED
CLINICAL EFFECTIVENESS Adult critical care mortality – SAPS II Hirslanden participates in the mandatory dataset for CCUs in Clinical effectiveness measures whether Switzerland. SAPS II is a physiological mortality prediction model that the indication for the treatment was utilises patient attributes to calculate an expected mortality value. correct and whether the care was The expected mortality rate is compared to the actual mortality rate rendered timeously. The divisions calculating a mortality index. participate in various international comparable outcomes databases, and Table 4: SAPS II mortality index also continuously measure and refine 2017 2018 2019 a set of internal indicators. Cases 7 805 7 364 6 707 Mortality Average age of patients (years) 68.0 68.0 68.3
HIRSLANDEN SAPS II expected mortality rate (%) 8.00 13.44 13.42 Actual mortality rate (%) 2.50 2.81 2.65 Figure 19: Inpatient mortality rate (%) Percentage of admissions SAPS II mortality index 0.31 0.21 0.20 Average length of stay in CCU (days) 2.0 2.2 2.2 19 0.95 Percentage of ventilated patients (%) 34.08 31.95 31.59 18 0.96
17 0.95
The 1.04% decrease in the inpatient mortality rate from 0.96% in 2018 to 0.95% in 2019 is not statistically significant and remains in line with the 2017 and 2018 rates.
MEDICLINIC SOUTHERN AFRICA
Figure 20: Inpatient mortality Adult critical care mortality – SAPS 3
Crude mortality rate Table 5: SAPS 3 mortality index Expected mortality rate Mortality index 2017 2018 2019 Cases 21 163 22 688 23 303 1.52% 19 0.86 Average age of patients (years) 62.0 62.3 62.6 1.76% SAPS 3 expected mortalities (cases) 3 779 4 088 4 245 1.54% 18 0.92 1.67% Actual mortalities (cases) 3 779 3 650 3 567 SAPS 3 expected mortality rate (%) 17.86 18.02 18.22 1.61% 17 0.94 1.72% Actual mortality rate (%) 16.96 16.09 15.31 SAPS 3 mortality index 0.95 0.89 0.84 The division’s mortality index remained Average SAPS 3 score 51.06 50.77 51.04 below one over the last 15 months, with a reduction of 6.52% year-on-year and The SAPS 3 mortality index decreased by 5.62% in 2019, mainly as an average rate of 0.86 in 2019. A new a result of continuously monitoring the data integrity and ensuring mortality systems analysis guideline will the early identification of patients at risk of complications. Lessons be implemented to help hospitals track learned are shared between units and hospitals on a regular basis, and identify key contributing factors in which drives continuous improvement. Improving clinical outcomes order to identify opportunities for and nursing expertise in CCUs remain focus areas. further quality improvement.
MEDICLINIC INTERNATIONAL PLC 44 2020 CLINICAL SERVICES REPORT Neonatal mortality and Vermont Oxford Network Mediclinic Southern Africa has contributed to the VON since 2001 and currently has 30 hospitals registered on the network. The VON is an international initiative aimed at improving the quality of care of infants through the collection and benchmarking of outcome data across the globe. There are currently over 1 300 participating centres around the world.
Although Mediclinic Southern Africa captures data on all infants admitted to participating neonatal CCUs, CARE included in this Report are the very low birth weight (‘VLBW’) newborns, which include neonates who weigh 401–1 500g at birth or fall into a gestational age range of 22–29 weeks. Most cases in 2019 were at 29 weeks’ gestation and weighed more than 1 000g.
Figure 21: Average birth weight, gestational age and admissions for VLBW infants in 2019
Given for gestational age in weeks
Average birth weight Number of admissions
23 3 540
24 13 690
25 21 735
26 59 793
27 64 922
28 87 1 028
29 101 1 166
30 91 1 235
31 69 1 296
32 67 1 326
33 32 1 348
34 17 1 333
35 5 1 364
36 3 1 393
37 1 2 1 388
38
39
40
41 1 1175
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 45 CLINICAL OUTCOMES CONTINUED
MEDICLINIC SOUTHERN AFRICA
Figure 22: Neonatal key performance measures (%)
VON Median 2018 Mediclinic Southern Africa 2019
Mortality 19 17.2
18 17.6
17 20.4
Mortality excluding 19 15.8 early deaths 18 14.5
17 19.1
Death or morbidity 19 34.6
18 36.7
17 41.7
Any late infection 19 8.6
18 4.8
17 15.8 There was improvement seen with Necrotising 19 5.4 regards to chronic lung disease, enterocolitis which results as a complication of 18 4.9 ventilation in preterm infants. 17 7.5 An increase was seen in late Chronic 19 15.4 infections which can be due, among lung disease, many other influencing factors, to infants < 33 weeks 18 25.0 central line use and invasive 17 15.5 ventilation. Increases were also seen in necrotising enterocolitis, which is a condition that typically occurs Pneumothorax 19 1.0 in the second to third week of life 18 0.9 in premature infants, and is
17 1.3 characterised by variable damage to the intestinal tract ranging from injury to the internal lining of the Severe 19 2.2 intraventricular gut to perforation of the bowel. haemorrhage 18 3.7 A neonatal central line care bundle has been compiled and implemented 17 5.3 to address this.
Cystic 19 1.2 Severe retinopathy of prematurity, periventricular a disease caused by abnormal leukomalacia 18 1.6 development of retinal blood vessels 17 2.8 in premature infants, is mainly caused by excessive oxygen use. All areas Severe retinopathy 19 2.4 where small preterm babies are of prematurity delivered or nursed now have oxygen 18 1.2 blenders, and oxygen saturation 17 1.6 targets are prescribed daily.
MEDICLINIC INTERNATIONAL PLC 46 2020 CLINICAL SERVICES REPORT MEDICLINIC MIDDLE EAST
The mortality rate in the UAE is still low when Neonatal mortality and compared to the other divisions due to the Vermont Oxford Network demographics and age profile of the patients. The VON database participation is well entrenched in The overall acuity level of inpatient admissions the facilities. This is an important initiative to measure and complexity of procedures are also much lower performance and improve the quality of care delivered in the UAE compared to other divisions. to patients.
Figure 23: Inpatient mortality rate (%) Although all infants admitted to neonatal CCUs are Percentage of admissions included in the programme, reporting focuses on all infants eligible for the VLBW database. When 19 0.29 interpreting data, it must be considered that as the CARE 18 0.30 information is expressed as a percentage, a small sample size of VLBW can skew results when compared 17 0.23 to the larger number of babies in the network The 3.33% decrease in the mortality rate from database. 0.30% in 2018 to 0.29% in 2019 was not statistically significant. The majority of the mortalities occurred at The division used data from the VON as a the Comprehensive Cancer Centre at Mediclinic City benchmarking tool for its neonatal units in 2019. Hospital where the higher acuity patients are treated. Legislative changes were also made to allow natural Figure 24: Average birth weight, death in the UAE. gestational age and admissions for VLBW infants 2017–2019 Adult critical care mortality – SAPS 3 Given for gestational age in weeks Table 6: SAPS 3 mortality index Average birth weight 2017 2018 2019 Number of admissions Cases 2 056 2 771 2 118 23 3 510 Average age of patients 41.0 56.7 56.9 (years) 24 5 582 SAPS 3 expected 16 54 40 25 6 807 mortalities (cases) 26 13 880 Number of mortality cases 46 51 37 SAPS 3 expected mortality 27 8 924 0.77 0.91 1.9 rate (%) 28 14 1 155 Mortality rate (%) 2.24 1.8 1.7 29 24 1 183 SAPS 3 mortality index 2.90 0.95 0.93 30 22 1 288 Average SAPS 3 score 40.72 40.81 40.74 31 21 1 329
The SAPS 3 mortality index decreased by 2.11% in 2019, 32 22 1 291 mainly as a result of continued and improved monitoring to identify high-risk cases, and early detection of 33 11 1 417 complications to initiate the appropriate interventions 34 3 1 231 and treatment. 35 2 1 268
The number of VLBW cases admitted to neonatal CCUs are low and the outcomes are in line with the KPIs of VON.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 47 CLINICAL OUTCOMES CONTINUED
MEDICLINIC MIDDLE EAST
Figure 25: Neonatal key performance measures (%)
VON Median 2018 Mediclinic Middle East 2019
Mortality 19 6.3
18 10.4
17 14.9
Mortality excluding 19 6.3 early deaths 18 6.5
17 12.5
Death or morbidity 19 20.3
18 39.6
17 35.1
Any late infection 19 7.5
18 6.1
17 2.9
Necrotising 19 4.4 enterocolitis 18
17
Chronic 19 9.1 lung disease, infants < 33 weeks 18 33.3
17 22.0
Pneumothorax 19 1.5
18 4.0
17 4.0
Severe 19 5.5 Intraventricular haemorrhage 18 2.4
17 5.5
Cystic 19 periventricular leukomalacia 18
17 3.4
Severe retinopathy 19 2.0 of prematurity 18
17 5.3
MEDICLINIC INTERNATIONAL PLC 48 2020 CLINICAL SERVICES REPORT Re-admission, re-operation and extended stay The extended stay index is calculated using the average length of stay of patients in hospital divided by an HIRSLANDEN average expected length of stay of the same patient group. The expected length of stay is calculated based Figure 26: Re-admission and re-operation rates (%) on the diagnoses and procedures for which patients are admitted. Re-admission rate (%)
19 1.50 Figure 28: Extended stay index
18 1.63 19 1.19 17 1.51 18 1.15 CARE
Re-operation rate (%) 17 1.12
19 1.23 The 3.41% increase in the extended stay index from 1.15 in 18 1.54 2018 to 1.19 in 2019 is not statistically significant.
17 1.62 MEDICLINIC MIDDLE EAST Re-admission rate is reported as a 15-day unscheduled Figure 29: Re-admission and re-admission rate as defined by the International Quality re-operation rates (%) Indicator Project. The 15-day interval was chosen according to the 18-day re-admission criteria of the Swiss Statistically significant DRG system to provide input to the case management process. The 7.98% decrease in the re-admission rate Re-admission rate (%) from 1.63% in 2018 to 1.50% in 2019 is not statistically 19 1.51 significant. 18 1.32
The re-operation rate decreased by 20.13% from 1.54% in 17 1.10 2018 to 1.23% in 2019. Every single re-admission case is reviewed at hospital level by a member of the quality Re-operation rate (%) management team to ensure continuous improvement. 19 0.25
MEDICLINIC SOUTHERN AFRICA 18 0.26
17 0.25 Mediclinic Southern Africa reports on a 30-day all-cause re-admission rate which refers to patients re-admitted within 30 days of the first admission, whether the second The division reports on unplanned re-admissions. admission is related to the first admission or not; and The 14.39% increase in the 30-day re-admission rate from whether it is planned or unplanned. 1.32% in 2018 to 1.51% in 2019 is statistically significant. Chemotherapy administration, wound care, false labours, Figure 27: Re-admission rate (%) maternity-related conditions, lithotripsies, dialysis and removal of an implant are excluded in the calculations. Statistically significant The most common reasons for re-admissions were non-infectious surgical complications, same/worsening 19 12.52 symptoms, medical complications and postoperative 18 12.68 infections.
17 12.50 The continued increase in the unplanned re-admission rate has been identified as one of the top clinical risks for The 3.48% decrease in the re-admission rate from 12.68% this division. To effectively manage this risk, a revised in 2018 to 12.52% in 2019 is statistically significant. reporting framework was implemented to categorise all the re-admission cases in a standardised format per clinical department, per diagnosis and per individual medical practitioner to identify potential trends and implement improvement initiatives where appropriate.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 49 NOT JUST COLLEAGUES, BUT FAMILY
When Mediclinic Southern Africa employee Tania Palvie was diagnosed with placenta praevia late in a much longed-for pregnancy, she had the comfort of knowing trusted colleagues would look after her.
PHOTO: ILSE’S PHOTOGRAPHY
Our fertility journey started six Mediclinic Welkom in the Human It was the personal touches that years ago. Like one in seven couples, Resources department. Now I was kept me sane. Sr Van Niekerk made we couldn’t fall pregnant and after experiencing the inner workings of the it possible for me to have my hair trying for three years, decided to opt hospital as a patient. coloured and my nails done in for IVF treatment. The first round my room. The highlight was the didn’t work, but a second round in I quickly got used to my new maternity shoot we did one Sunday 2018 resulted in a twin pregnancy. routine. Every four hours or so, afternoon, four weeks after I was the nurses would take my blood admitted. I’d originally planned an I heard their perfect little pressure and three times a day, they outside shoot, but with the hospital’s heartbeats during a scan at would bring the cardiotocography help, we could realise the most seven weeks. We were so excited. machine to monitor the baby’s beautiful pictures. I will cherish those Then, three weeks later, I had heartbeat. Throughout, the nurses photos forever, because they show a miscarriage. Our hearts were did their best to reassure me and an important part of our journey. shattered. It started to feel like it was when I had questions, the Unit never going to happen for us. Manager, Sr Corné van Niekerk, I had a caesarean at 35 weeks. would take the time to explain what At the weekly sonar Dr Kotze had We decided to try one last time in was happening. picked up that the placenta was March 2019. For us, it was third time starting to calcify and she didn’t lucky. With a whole lot of love and Over the next 47 days, I really got want to risk an abruption. prayer and a bit of science, our little to know the nurses in the maternity miracle was on her way. The due ward. From Sr Dikgang, the baby On 4 December 2019 we took our date of 1 January 2020 was etched whisperer, to Sr Aggie, the hand little girl home. It was a moment into our hearts. hygiene queen. Sr Ketso, who we’d been dreaming about for smiled day and night, and enrolled six years and it was thanks to our Except for the morning sickness, nurse Martie, who lit up the ward amazing doctor and the dedicated it was a very healthy pregnancy. with her energy. Always friendly nurses of Mediclinic Welkom. I am But during the 21-week ultrasound, and professional, all the nurses proud to work for Mediclinic and my gynaecologist, Dr Neltjie Kotze, worked to keep me positive as we count them as my colleagues. But picked up that the placenta was counted down the weeks. Working then again, they are no longer just lying low in the uterus. The doctor for Mediclinic I knew what their jobs my colleagues, they are family. raised her concerns with us and entailed but it was an eye-opener suggested bedrest if it didn’t move seeing them in action. up. We started preparing ourselves mentally in case I had to go to I saw them work in very challenging hospital. situations, from emergency C-sections to dealing with five At 29 weeks I was admitted to admissions on a Saturday. Through hospital with major placenta teamwork they managed to handle praevia. When the placenta blocks the challenges and still look after the cervix there is a high risk of all the other patients in their care. bleeding and preterm delivery, Being on the other side for once, so I needed to be monitored. I developed new respect for my For 15 years, I’d been working at colleagues.
MEDICLINIC INTERNATIONAL PLC 50 2020 CLINICAL SERVICES REPORT A FRESH LOOK AT PAIN RELIEF
In virtual reality (‘VR’), Clinique Cecil has found an innovative way to help patients manage the pain and anxiety associated with medical treatment and procedures.
A brightly painted rowing boat drifts is capable of modifying the and sedatives needed when lazily on placid water just metres perception of pain. While initial inserting catheters. VR has also from a golden beach. Wispy white studies were done on healthy been used with success to reduce clouds float above a lighthouse in subjects exposed to various pain- postoperative pain. candy cane colours. Bathed in warm inducing stimuli, in recent years sunlight, it’s an idyllic scene – and therapeutic VR has been put to the Researchers explain the efficacy of a world removed from Clinique Cecil test in the clinical environment. VR in its ability to distract the user. in Lausanne, Switzerland, where a In a study by doctors at Cedars- Because it is so highly immersive, it patient is viewing the landscape Sinai Medical Centre, VR was shown diverts attention from the source of through VR goggles. to significantly reduce pain in pain. And since the feeling of pain hospitalised patients. can be intensified by anxiety, VR The use of VR in the healthcare works by having a relaxing effect setting is a promising new solution and boosting positive emotions. for pain management. Using 3D visuals, this innovative At Clinique Cecil, there are six technology transports the patient Because it is so VR headsets in use: in cardiology, into an immersive virtual world. The anaesthesiology, dialysis, surgery, cutting-edge graphics are so vivid highly immersive, maternity and the outpatient surgery that the user has an overwhelming it diverts attention centre. One dialysis patient who feeling of ‘presence’, of being in tried the VR headset typically had a different environment to the one from the source very high blood pressure during in which the physical body finds of pain. treatment. But after 10 minutes of itself. The effect is enhanced by the using the device, his levels were use of headphones, which lets the within normal parameters. Ziegler patient listen to calming sounds Thus far the technology has been recounts how another patient, who and carefully scripted hypnotic tested in a variety of settings. For suffered from chronic pain, initially meditations. burn patients, dressing changes refused to use VR, disbelieving are known to be extremely painful. it would help. The Clinique Cecil ‘When Clinique Cecil decided But the use of VR in combination personnel persuaded her to give to revise their approach to pain with painkillers noticeably lowered it a try. ‘Once she’d been using the management, the hospital went the pain patients experienced. headset for a while, she started to cry in search of innovative solutions,’ The power of perception goes – it actually relieved her pain.’ says Anna Ziegler, Specialist: even further: VR can reduce use Nursing Policies and Development of pharmaceuticals. According to While VR headsets may sound at Hirslanden. They came across Healthy Mind, a French company futuristic, the approach to several studies that described the that creates therapeutic VR prioritising patient experience is positive effect of VR. programs, a preliminary small-scale true throughout the Group. In every study suggests the technology way possible, Mediclinic seeks to Research has shown VR immersion reduces the doses of analgesics enhance clients’ quality of life.
Source ‘Virtual reality for management of pain in hospitalised patients: A randomised comparative effectiveness trial’ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219115
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 51 SECTION HEADING
ST. ANNA IM BAHNHOF FACILITY FOCUS BUILDING A BETTER SERVICE Through its expansion across the continuum of care, Mediclinic can accompany clients throughout their healthcare journey.
DAY CASE CLINIC Conveniently located at the train surgeries of the same type are station in the centre of Lucerne, this scheduled consecutively, waiting WHERE day case clinic addresses the times between procedures are Lucerne, increasing demand for same-day eliminated and patients are ready for Switzerland surgeries. Hirslanden strategically discharge within two hours. The developed it in response to changes in surgery at St. Anna im Bahnhof is WHEN Opened in late 2018, Swiss healthcare policy that saw complemented by a medical centre several procedures reclassified from that offers an array of services, fully operational in 2019 inpatient to outpatient. To offer clients ranging from specialist consultations a true in-and-out experience, the and a radiology institute to entire approach has been streamlined: physiotherapy and nutritional advice.
MEDICLINIC INTERNATIONAL PLC 52 2020 CLINICAL SERVICES REPORT MEDICLINIC SPRINGS CHILD AND BABY CLINIC PAEDIATRIC With increasing demand for paediatric occupational and speech therapy. OUTPATIENT CLINIC services at nearby facility Mediclinic Having a multidisciplinary team in one Meadows, but no option to enlarge the setting is not only convenient for WHERE premises, the case for opening families, but less traumatic for children. Dubai, the UAE Mediclinic Springs Child and Baby Clinic The design and layout of the clinic was WHEN was clear. The location is in a high- specially conceived to create a October 2019 footfall shopping centre, close to welcoming environment, with child- several schools and within a residential friendly decor and play areas for area favoured by families. The facility distraction. The establishment of this brings together general paediatrics and dedicated facility has simultaneously family medicine, along with paediatric enabled Mediclinic Meadows to expand physiotherapy, psychology, and its non-paediatric services.
ORTHOPAEDIC AND In a pioneering partnership with the outcomes and more efficient pathways RHEUMATOLOGY Institute of Orthopaedics and – a critical aspect of value-based care. Rheumatology, Mediclinic Winelands It is also a training facility that offers HOSPITAL Orthopaedic Hospital brings accredited fellowship programmes and WHERE together orthopaedic surgeons, registrar training in partnership with Stellenbosch, rheumatologists, rehabilitation Stellenbosch University. Developed at South Africa personnel and case managers. For the former Mediclinic Stellenbosch South Africans who mistakenly believe premises, the upgraded facility already WHEN they have to travel abroad for high- offers four theatres, 34 beds and August 2019 level musculoskeletal expertise, the 16 consultation rooms, but is undergoing facility is a one-stop solution on local further redevelopment. A dedicated soil. The hospital’s multidisciplinary orthopaedic day case clinic with 10 beds approach enables better clinical and one theatre will be added in 2021.
HIRSLANDEN: Eight hospitals ranked in the top 25 for Switzerland according AWARDS to Newsweek’s list of the World’s Best Hospitals 2019
MEDICLINIC SOUTHERN AFRICA: Six hospitals included in Discovery Health’s Top 20 Private Hospitals in South Africa 2019, based on the results of patient surveys.
MEDICLINIC MIDDLE EAST: Awards at the UAE’s Mother, Baby & Child Awards 2019 for Mediclinic City Hospital (women’s health services – gold, maternity services – silver, paediatrics– gold) and Mediclinic Parkview Hospital (Hospital of the Year – silver).
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 53 ASSURANCE ACCREDITATIONS, CERTIFICATIONS, INITIATIVES AND PARTNERSHIPS To provide the necessary independent assurance over the quality and reliability of its healthcare services, processes and facilities, the Group follows a combined assurance model with assurance between management, internal audit and external accreditation and certification. It also partners with leading organisations and educational institutions to expand its services and invest in the future healthcare workforce.
Detail Website
ACCREDITATION
COHSASA COHSASA has accredited all of www.cohsasa.co.za Mediclinic Southern Africa’s participating hospitals1. The accreditation assessments are based on detailed hospital standards and are validated by the International Society for Quality Assurance in Healthcare. COLLEGE OF AMERICAN The laboratory at Mediclinic City www.cap.org PATHOLOGISTS Hospital in Dubai is accredited by the CAP, which evaluates the entire spectrum of laboratory test disciplines against the most scientifically rigorous customised requirements. EUROPEAN FOUNDATION The EFQM was formed to recognise www.efqm.org FOR QUALITY and promote sustainable success and MANAGEMENT (‘EFQM’) to provide guidance to those seeking to achieve it. Hirslanden applies the EFQM Business Excellence Model throughout its quality management process. Three of its hospitals received three-star excellence ratings. JOINT ACCREDITATION The JACIE is Europe’s only official n/a COMMITTEE ISCT-EUROPE accreditation body in the field & EBMT of haematopoietic stem cell transplantation and cellular therapy. Klinik Hirslanden is the only private hospital in Switzerland to earn JACIE accreditation. JOINT COMMISSION The JCI is a leader in healthcare www.jointcommissioninternational.org INTERNATIONAL accreditation and the author and evaluator of rigorous international standards in quality and patient safety. All Mediclinic Middle East facilities were accredited or re-accredited in 2019. SWISS FEDERATION OF The Swiss Federation of Clinical www.sfcns.ch/portrait.html CLINICAL NEURO- Neuro-societies promotes SOCIETIES collaborations and interactions between clinical neuro-societies in Switzerland to enhance interdisciplinary knowledge and overall impact of all its disciplines. The Stroke Centre at Klinik Hirslanden is accredited by the Swiss Federation of Clinical Neuro-societies.
= Hirslanden = Mediclinic Southern Africa = Mediclinic Middle East
Note 1 COHSASA accreditation is limited to the largest hospitals caring for the more complex cases. These hospitals undergo regular re-accreditation surveys on a rotational basis, the findings of which are shared with the hospitals and with the Mediclinic Southern Africa Corporate Office. Learning points emerging from findings are used to inform focus areas for improvement initiatives which also benefit smaller non-participating hospitals. In addition, the smaller facilities adhere to all the required regulatory requirements and industry standards.
MEDICLINIC INTERNATIONAL PLC 54 2020 CLINICAL SERVICES REPORT Detail Website
CERTIFICATION
GERMAN CANCER Certification by the German Cancer n/a SOCIETY Society reassures patients that treatment is based on high-quality standards. The Cancer Centre at Klinik Hirslanden has held this certification since 2017. Its certification extends to breast and prostate cancer (including uro-oncology), gynaecological tumours, colon cancer, and haematological and lymphological oncology. The hospital is the first, and only, private institution in Switzerland to obtain this certification. ISO 9001:2015 This independent international n/a certification shows that the organisation meets world-class specifications for quality, safety and efficiency. All Hirslanden hospitals are ISO 9001:2015 certified. SWISS CANCER LEAGUE The Swiss Cancer League is a national, www.krebsliga.ch charitable, private non-profit organisation that attends to all aspects of cancer with the aim of ensuring that more people can be treated successfully. A cancer centre must meet about 100 criteria in order to pass external certification. Hirslanden has five certified Cancer Centres.
= Hirslanden
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 55 ASSURANCE CONTINUED
Detail Website
INITIATIVES
IQM The IQM promotes further www.initiative-qualitaetsmedizin.de improvements in medicine through innovative and efficient procedures and thereby setting new standards in quality. In Switzerland, quality measurements using routine data are based on the Swiss Inpatient Quality Indicators (CH-IQI). Hirslanden has been applying these quality management criteria since 2012. PRESS GANEY® Press Ganey® strengthens patient- www.pressganey.com provider relationships through real-time feedback and performance benchmarks, leveraging state-of-the- art survey methodology. All three divisions use the Press Ganey® platform to measure and report on patient experience. VERMONT OXFORD VON is a non-profit collaboration of public.vtoxford.org NETWORK more than 1 300 hospitals to improve neonatal care globally with data-driven quality improvement and research. Currently, 30 Mediclinic Southern Africa facilities and six Mediclinic Middle East facilities participate.
PARTNERSHIPS
BERN UNIVERSITY OF Hirslanden partnered with the www.bfh.ch APPLIED SCIENCES Bern University of Applied Sciences to provide internships for the master modules ‘Clinical Assessment’ and ‘Advanced Nursing Practice in Primary Care’ in the Nurse Practitioner Programme. This is a pilot implementation during which certain physicians will act as supervisors. The project commenced in December 2019. BOURN HALL Mediclinic Middle East holds a minority www.bournhall-clinic.ae INTERNATIONAL stake in Bourn Hall International MENA LTD MENA Ltd, the holding company for the Bourn Hall Fertility Centre in the UAE, a pioneering and JCI quality- accredited fertility centre. FATIMA COLLEGE OF A memorandum of understanding www.fchs.ac.ae HEALTH SCIENCES between Mediclinic Middle East and Fatima College of Health Sciences (established in 2006) facilitates academic collaboration and creates learning and development opportunities for Emiratis. The memorandum of understanding paves the way for students enrolled in Nursing, Health Emergency (paramedics), Pharmacy, Radiography and Physiotherapy to experience on-the-job training in various Mediclinic facilities across the UAE.
= Hirslanden = Mediclinic Southern Africa = Mediclinic Middle East
MEDICLINIC INTERNATIONAL PLC 56 2020 CLINICAL SERVICES REPORT Detail Website
INITIATIVES
KANTONSPITAL Hirslanden and Kantonspital Baselland www.ksbl.ch BASELLAND have signed a cooperation agreement for a joint venture in the treatment of musculoskeletal disorders. The joint venture will be established in 2020. MOHAMMED BIN RASHID In line with Mediclinic Middle East’s www.mbruniversity.ac.ae UNIVERSITY OF MEDICINE partnership with MBRU, Mediclinic City AND HEALTH SCIENCES Hospital is approved as a training site for medical students. STELLENBOSCH In partnership with Stellenbosch www.sun.ac.za UNIVERSITY University, Mediclinic Southern Africa offers medical students the opportunity to complete their training in Internal Medicine under the supervision of accredited full-time specialists working at Mediclinic hospitals. In 2019, the partnership assisted 160 students. UNIVERSITY OF A memorandum of agreement www.uj.ac.za JOHANNESBURG between Mediclinic Private Higher Education Institution and University of Johannesburg makes provision for collaboration on research, the sharing of intellectual property and opportunity for students to receive practical training in Emergency Medical Care. In 2019, the partnership assisted two students. UNIVERSITY HOSPITALS A PPP has been concluded to create www.hug-ge.ch/en OF GENEVA a day case clinic. UNIVERSITY OF LUCERNE In partnership with the University of www.unilu.ch Lucerne, Hirslanden Klinik St. Anna trains medical students from the Joint Medical Master Programme. In 2019, the partnership assisted 133 students. UNIVERSITY OF ZURICH In partnership with the University of www.uzh.ch Zurich, Klinik Hirslanden offers medical students the opportunity to complete their training in several perioperative medicine modules. In 2019, the partnership assisted 118 students. WITS UNIVERSITY Mediclinic Southern Africa has a www.dgmc.co.za DONALD GORDON partnership with Wits University and MEDICAL CENTRE also manages Wits University Donald Gordon Medical Centre, the only private specialist training facility in South Africa and the largest and most successful solid organ transplant centre in the country.
= Hirslanden = Mediclinic Southern Africa = Mediclinic Middle East
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 57 ASSURANCE CONTINUED
INITIATIVE ON QUALITY MEDICINE IQM is another quality measurement The peer review procedure is an Principles to be applied are, among scheme applied by Hirslanden. The essential part of the IQM. Clinically others, the clarification of statistical initiative has three principles: (a) to active medical practitioners (the peculiarities, clear process rules and measure quality based on routine peer team) analyse processes and interdisciplinary teams. data; (b) to publish the results to structures systematically in the promote transparency; and (c) to original medical procedure. A peer There are 300 indicators available, of improve quality with a peer review review procedure is initialised if the which 44 have already defined quality procedure. The IQM comprises results are significantly above or targets and 23 are related to patient performance indicators for results, below the relevant benchmarks. safety issues. The results are provided on data sets and processes, as well as The core of the procedure is the a half-year basis and publicly reported clinical pictures and treatment cooperative case discussion. Some annually in May. The performance of all forms. More than 380 hospitals benefits of the peer review are hospitals was measured against a subset participate in Germany and the opportunity to uncover local of 44 indicators. The performance of the Switzerland; Hirslanden has been specialities, identify weaknesses and hospitals largely exceeds the benchmark a member since 2012. establish an open error culture. of the initiative.
Table 7: IQM results (January–December 2019) – Hirslanden
Number of Number of Proportion of indicators with indicators cases in IQM target without target Achievement Participating hospitals indicators (%) achievement achievement level (%)
AndreasKlinik Cham Zug 70.5 22 3 88.0
Clinique Bois-Cerf, Lausanne 49.1 10 2 83.3
Clinique Cecil, Lausanne 89.2 37 4 90.2
Clinique des Grangettes, 73.4 36 1 97.3 Chêne-Bougeries
Clinique La Colline, Geneva 54.1 26 0 100.0
Hirslanden Klinik Aarau 83.5 30 9 76.9
Hirslanden Klinik Meggen, 38.5 9 1 90.0 Klinik St. Anna AG
Klinik Am Rosenberg, Heiden 49.6 7 0 100.0
Klinik Beau-Site, Bern 85.9 31 7 81.6
Klinik Birshof, Basel 54.7 11 0 100.0
Klinik Hirslanden, Zurich 79.6 33 11 75.0
Klinik Im Park, Zurich 83.8 40 5 88.9
Klinik Linde, Biel 75.4 24 5 82.8
Klinik Permanence, Bern 49.9 16 1 94.1
Klinik St. Anna, Lucerne 81.9 34 7 82.9
Klinik Stephanshorn, St. Gallen 75.0 30 5 85.7
Salem-Spital, Bern 79.4 21 8 72.4
MEDICLINIC INTERNATIONAL PLC 58 2020 CLINICAL SERVICES REPORT TRAINING THE NEXT GENERATION In 2019, Mediclinic Middle East welcomed its first intake of medical students.
It takes years of dedicated studying own knowledge and expertise,’ says appointments, with close to to become a medical practitioner. David Hadley, the divisional Chief 200 doctors appointed. While But book knowledge can take Executive Officer. many of them have a teaching a doctor only so far – practical background, MBRU conducted experience is essential. To help the The medical students training under workshops in teacher training prior to doctors of the future gain empirical Mediclinic’s clinicians complete the clerkships getting underway. ‘The knowledge, Mediclinic Middle East is a 40-week rotation in the programme for faculty development making clinical clerkships available. departments of Family Medicine, is ongoing and will soon involve Surgery, Paediatrics and General online courses. The intention is to In May 2016, the division signed an Medicine. In their fifth year, medical apply for JCI accreditation as affiliation agreement with MBRU and students will do subspecialities as an Academic Medical Centre network in September 2019 the first cohort of well as Obstetrics and Gynaecology. in due course,’ says Dr Du Preez. fourth-year medical students joined Once students have completed their various Mediclinic Middle East full six-year course, including their All clinical placements of students hospitals in Dubai. This makes clerkships at Mediclinic, they will were put on hold in March due to Mediclinic the first private hospital have attained an MBBS degree. The COVID-19. The MBRU medical group in the UAE to work with clinical clerkships allow them to hone students are continuing with academic institutions in a formal their skills in real-life situations under their studies by way of an active capacity. ‘As an organisation, the guidance of professionals. online programme in which some Mediclinic is committed to the Mediclinic faculty are participating. advancement of medicine through ‘Mediclinic Middle East is particularly Telemedicine will be another the development and training of well placed for the role as almost all opportunity for the students to gain the next generation of doctors. It is specialities are represented,’ explains practical experience and this will be a great privilege and honour to be Dr Leon du Preez, Senior Corporate considered in due course. able to help these talented individuals Medical Director. The physicians progress with the assistance of our involved all have adjunct faculty
WHAT THE STUDENTS HAVE TO SAY
Undertaking my clinical Having the opportunity to My favourite part about the clerkship has been an learn more from well-versed experience is witnessing how incredibly transformative doctors and cooperative qualified doctors provide experience that has allowed patients has made me humbler patients with emotional me to observe and and a more curious medical security and high-quality care. participate in the application student. The staff at Mediclinic My clinical knowledge as well of theoretical concepts to couldn’t have been more as my interactions with clinical practice. Every team helpful and supportive than patients have progressed that I have been part of thus they were, and I thank them to a level of confidence and far has demonstrated their for that. professionalism inspired by dedication to education and Rashed Rowaiee our doctors and medical optimal patient care. educators from Mediclinic. Iman Fawad Anan Alaa Mahmoud
PRACTICE IN EMERGENCY CARE South Africa’s Mediclinic Midstream has hosted University of Johannesburg students who are studying Emergency Medical Care. Students are required to see 100 patients and execute a number of skills such as administering oxygen. Mediclinic Midstream is a state-of-the-art hospital with a fully equipped emergency department featuring a procedure room, two resuscitation beds and a hazardous materials shower.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 59 CLINICAL ETHICS SUMMARY
ADVANCED CARE PLANNING, DOCTOR QUALIFICATIONS EMPLOYEE AND PATIENT 1 END-OF-LIFE AND TERMINAL 5 AND PERFORMANCE, AND 7 PROTECTION CARE ILLEGAL PRACTICE The safety of Mediclinic employees Clinical governance structures are in Credentialing and privileging of and patients is of paramount place to report, audit and address doctors follows a combined importance and across the Group any concerns in line with local approach – a formal process verifies it is managed through established regulations and legislation. registration, qualifications and IPC measures. Occupational health credentials while an informal process specialists provide a service at ASSISTED REPRODUCTIVE solicits performance-related each hospital. On acceptance of 2 TECHNOLOGY AND IVF information from peers. employment, all healthcare Centres providing this service are employees are screened for governed by the local regulatory and Prevention policies are established pulmonary tuberculosis, and legal framework, e.g. in the UAE, and doctors are monitored through screened and vaccinated against Bourne Hall Fertility Centre complies annual validation of registration; Hepatitis B if they do not have with Federal Law No. (11) of 2008 on investigations of deteriorating sufficient antibodies. licensing fertilisation centres in the hospital clinical quality indicators; country. In addition, compliance is mortality audits; serious incident Proper management of sharps monitored by the licensing investigations; complaints from injuries and safety procedures authorities during inspections. patients, doctors and staff; medico- are applied at all three divisions. legal investigations; ethics line Depending on the geography, COMPETENCE AND SCOPE reports; clinical performance HIV/Aids diagnosis and support are 3 OF PRACTICE committee meetings; direct offered to affected employees in Established clinical governance reporting by doctors; and informal accordance with local regulations. structures monitor and address feedback from staff regarding any concerns. Recruiting the correct recurrent concerns. Mediclinic’s recruitment policies skills and continuously assessing the are in accordance with the local skill-set of employees remain key DRUG TRIALS AND MEDICAL legislation of its divisions. At focus areas. Many strategies are 6 RESEARCH Hirslanden and Mediclinic Southern implemented to ensure competency Drug trials and medical research are Africa, the HIV/Aids status of new of staff (e.g. formal training, short aligned with the Declaration of recruits is not considered during courses and clinical facilitators). Helsinki and local legislation. appointment, whereas at Mediclinic Middle East, foreigners planning to DOCTOR COVER, All requests for clinical drug trials work in the UAE must be tested for 4 AVAILABILITY AND and medical research are approved HIV upon arrival (and thereafter RESPONSE by an independent, accredited ethics every two years). On-call rosters are compiled and committee before being accepted available at emergency centres. for evaluation and approval by the In the event of an increase in the An established management process respective divisional committees. incidence or an outbreak of and reporting system address All approved trials are recorded on Methicillin-resistant Staphylococcus non-compliant independent medical a registry and no unofficial drug aureus, healthcare employees are practitioners; an established human testing is allowed. Medical research screened and decolonised, if resources process addresses and experiments are managed by necessary. employed doctors. a clinical research approval committee and related policies. Flu vaccines are offered annually to employees. Other vaccines, e.g. The Group deals with medical ethical diphtheria and measles, are offered issues on a daily basis. Most of these when there is an indication; when are covered by formal policies, but there is an increase in cases in some are still elusive and quite a specific area; or as post-exposure. complex to deal with by way of At Hirslanden, radiation exposure policy. In all instances, response and and compliance with prevailing reaction are governed by local acceptable exposure limits are legislation and regulations. monitored centrally.
MEDICLINIC INTERNATIONAL PLC 60 2020 CLINICAL SERVICES REPORT ETHICAL BEHAVIOUR INAPPROPRIATE CARE TECHNOLOGY (INCLUDING 8 AND BILLING, AND 12 Appropriate care is a Group- 17 ROBOTICS) FALSIFICATION wide focus area. It is managed by Equipment must be CE certified OF DIAGNOSIS AND indication boards at Hirslanden, and and approved by the local regulator DOCUMENTATION CPE at Mediclinic Southern Africa and/or certified by the Food and Operational and clinical and Mediclinic Middle East. Cost Drug Administration of the United management at each hospital is reporting and management States. CE marking is a certification responsible for ensuring the ethical processes and structures are in mark that indicates conformity with conduct of healthcare practitioners place. Complex cases are discussed health, safety and environmental and staff. Human resources policies with treating doctors. protection standards for products are in place to address issues of sold within the European Economic misconduct and criminal behaviour. ORGAN TRADE Area (‘EEA’); it is also found on Regular documentation and clinical 13 The organ donation and products sold outside the EEA that coding audits ensure compliance receipt process is carefully are manufactured in, or designed to with legal, ethical and operational documented and is in line with be sold in, the EEA. requirements. Across all divisions, applicable legislation. fraudulent behaviour of medical Equipment may only be used for the practitioners and staff can be PHARMACY approved indications and as dictated reported via independent ethics 14 Pharmacy policies, by local or international guidelines. lines. procedures and audits ensure Clinical safety must be proven compliance with legislation, ethical before any new technology is EUTHANASIA and operational requirements. implemented at a division or in 9 Euthanasia is neither practised a facility. nor condoned in any Mediclinic REMUNERATION, facility. All hospitals have control 15 KICKBACKS TERMINATION OF measures in place to ensure Perverse incentives are prohibited. 18 PREGNANCY compliance with local legislation. Corporate Office and hospital Strict control measures exist to management ensure strict ensure legal compliance. In addition, FORCED FEMALE compliance with established rules. the Group allows employees 10 CIRCUMCISION freedom of choice as to whether Control measures ensure compliance REPORTING AND they wish to refrain from with respective legislation. Informed 16 DISCLOSURE OF participating in any terminations consent for any medical or surgical ADVERSE EVENTS of pregnancy for moral, religious, intervention or procedure is upheld Each hospital has a formal adverse ethical or related reasons. by the profession and is entrenched event reporting system. A ‘just in local laws. culture’ (Frankl framework) is promoted. The reporting system GENETICS is non-punitive and the recorded 11 Genetic testing and counselling adverse events are discussed at are offered in each division the hospitals’ clinical hospital according to local regulations and committees. To prevent similar legislation, and in adherence to incidents, learning from incidents the relevant ethical framework. is a key focus area. The results of genetic testing are governed by the same data privacy principles and rules which apply to other personal information.
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 61 GLOSSARY OF TERMS
TERM MEANING AMS antimicrobial stewardship CAP College of American Pathologists CAUTI catheter-associated urinary tract infection CCRG clinical and cost-related grouping CCU critical care unit CLABSI central line-associated blood stream infection CoE Centre of Excellence Company Mediclinic International plc CPE cost per event DDD defined daily dose of antimicrobial use DRG diagnostic-related grouping EEA European Economic Area EHR electronic health record Group Mediclinic International plc and its subsidiaries, including its divisions in Switzerland, Southern Africa and the United Arab Emirates HAI healthcare-associated infection HIE health information exchange in Abu Dhabi Hirslanden the Group’s operations in Switzerland, trading under the Hirslanden brand, with Hirslanden AG as the intermediary holding company of the Group’s operations in Switzerland HPCNA Health Professions Council of Namibia HPCSA Health Professions Council of South Africa HTA health technology assessment IPC infection prevention and control IQM Initiative on Quality Medicine IVF in vitro fertilisation JACIE Joint Accreditation Committee ISCT-Europe & EBMT, accreditation body for stem cell transplantation JCI Joint Commission International, an international quality measurement accreditation organisation, aimed at improving quality of care KPIs key performance indicators LSE London Stock Exchange
MEDICLINIC INTERNATIONAL PLC 62 2020 CLINICAL SERVICES REPORT TERM MEANING MBRU Mohammed Bin Rashid University of Medicine and Health Sciences Mediclinic Mediclinic International plc Mediclinic Middle East the Group’s operations in the UAE, trading under the Mediclinic brand, with Mediclinic Middle East Holdings (registered in Jersey) as the intermediate holding company of the Group’s operations in Dubai and Abu Dhabi Mediclinic Southern Africa the Group’s operations in South Africa and Namibia, trading under the Mediclinic brand, with Mediclinic Southern Africa (Pty) Ltd as the intermediary holding company of the Group’s operations in South Africa and Namibia PDMS patient data management system Period under review/reporting period 1 January 2019–31 December 2019 PPP public-private partnership SAE serious adverse event SAPS Simplified Acute Physiological Score SIR standardised infection ratio SSI surgical site infection UAE the United Arab Emirates VAP ventilator-associated pneumonia VLBW very low birth weight, as describing newborns who weigh 401–1 500g at birth VON Vermont Oxford Network VR virtual reality WHO World Health Organization
MEDICLINIC INTERNATIONAL PLC 2020 CLINICAL SERVICES REPORT 63 COMPANY INFORMATION
Mediclinic International plc INVESTOR RELATIONS (incorporated and registered in England and Wales) Company number: 08338604 James Arnold Head of Investor Relations REGISTERED OFFICE 14 Curzon Street, London W1J 5HN, United Kingdom Mediclinic International plc Tel: +44 20 3786 8180/1 6th Floor, 65 Gresham Street Email: [email protected] London, EC2V 7NQ, United Kingdom Tel: +44 20 7954 9548 REGISTRAR/TRANSFER SECRETARIES Email: [email protected] Website: www.mediclinic.com UK United Kingdom Computershare Investor Services PLC ETHICS LINES The Pavilions, Bridgwater Road, Bristol, BS99 6ZZ Tel: +44 370 703 6022 SWITZERLAND AND SOUTH AFRICA Email: [email protected] Tel: 0800 005 316 UAE SOUTH AFRICA Tel: 800 1 55000 Computershare Investor Services (Pty) Ltd Rosebank Towers, 15 Biermann Avenue, Rosebank 2196 LISTING Private Bag X9000, Saxonwold, 2132 Tel: +27 11 370 5000 FTSE sector: Healthcare Providers ISIN code: GB00B8HX8Z88 NAMIBIA SEDOL number: B8HX8Z8 Transfer Secretaries (Pty) Ltd EPIC number: MDC 4 Robert Mugabe Avenue, Windhoek LEI: 2138002S5BSBIZTD5I60 PO Box 2401, Windhoek Primary listing: LSE (share code: MDC) Tel: +264 61 227 647 Secondary listing: JSE (share code: MEI) Secondary listing: NSX (share code: MEP) CORPORATE ADVISORS
DIRECTORS Auditor PricewaterhouseCoopers LLP, London Dr Edwin Hertzog (ne) (Chair) (South African), Inga Beale DBE (ind ne) (Chair Designate) (British), Corporate broker and sponsors Dr Ronnie van der Merwe (Group Chief Executive Officer) UK (South African), Jurgens Myburgh (Group Chief Financial Joint corporate brokers: Morgan Stanley & Co Officer) (South African), Alan Grieve (Senior Independent International plc and UBS Investment Bank Director) (British and Swiss), Dr Muhadditha Al Hashimi SOUTH AFRICA (ind ne) (Emirati), Jannie Durand (ne) (South African), JSE sponsor: Rand Merchant Bank (a division of Dr Felicity Harvey CBE (ind ne) (British), Danie Meintjes FirstRand Bank Limited) (ne) (South African), Dr Anja Oswald (ind ne) (Swiss), NAMIBIA Trevor Petersen (ind ne) (South African), Tom Singer NSX sponsor: Simonis Storm Securities (Pty) Ltd (ind ne) (British), Pieter Uys (alternate to Jannie Durand) (South African) Legal advisors UK COMPANY SECRETARY Slaughter and May SOUTH AFRICA Link Company Matters Limited (previously named Capita Cliffe Dekker Hofmeyr Inc. Company Secretarial Services Limited) Caroline Emmet Remuneratoon consultant 6th Floor, 65 Gresham Street Deloitte LLP London, EC2V 7NQ, United Kingdom Tel: +44 20 7954 9548 Communication agancy Email: [email protected] FTI Consulting Tel: +44 20 3727 1000 Email: [email protected]
MEDICLINIC INTERNATIONAL PLC 64 2020 CLINICAL SERVICES REPORT DESIGNPORTFOLIO / TIP AFRICA PUBLISHING