Annual integrated report 2011

Clinical governance report: SA

At Netcare, quality leadership is more than a goal. It is a way of being that enables us to improve the lives of the people we serve and to optimise the health and wellbeing of our communities.


As the pressure to transform our health systems intensifies, Netcare has resolved to play a leading role in developing new and better ways of delivering high standards of care.

Increased emphasis has been placed on clinical and quality measurement and benchmarking across the organisation. Netcare has also adopted leading-edge improvement methodologies and has emphasised active and integrated engagement with management, frontline staff and doctors in quality leadership across our business.

Learning from patient experience

Measure Oct 2010
– Sept 2011
  Oct 2009
– Sept 2010
Acute healthcare/hospitals      
Patient Satisfaction Index (PSI) including general wards and emergency department 88.4%   88.2%
Customer feedback: Compliments rate per 1 000 inpatient days 5.36   3.16
Customer feedback: Complaints rate per 1 000 inpatient days 0.80   0.81
Medicross centres/Prime Cure clinics      
Centres and clinics: Customer satisfaction* 90.8%   90.0%
Pharmacies: Customer satisfaction* 87.2%   86.5%
National Renal Care      
Customer satisfaction 84.0%   83.0%
* Measured by Customer Feedback System.

To remain the healthcare provider of choice, we must constantly request and respond to input from patients about how our nurses, staff and doctors can deliver the best possible service. With the increase in consumer education, we are intensifying our efforts to create patient and family-centred care informed by patients’ expectations. Patient satisfaction measures remain consistently high and compliment rates have increased relative to last year.

The Hospital division undertook a comparison against the United States (US) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which reviews patients’ perspectives of hospital care across over 3 800 US hospitals. The results are shown on the graph below.

Benchmarking Netcare patient satisfaction against US ratings

HCAHPS data retrieved from www.hospitalcompare.hhs.gov

The report compares Netcare hospitals to the latest available HCAHPS data (January 2010 to December 2010) in response to the question “Overall, how satisfied were you with the service you received at our hospital?

Building on this research in 2012, Netcare is looking to adjust its patient surveys to include all the HCAHPS questions. This will allow for direct comparisons, including questions on communication around medicines.

Promoting a patient safety culture

High quality, safe healthcare requires individual excellence supported by well designed systems and processes. We constantly review our healthcare processes and adjust systems to support safe practice.

Our programme includes a detailed system for internal reporting of adverse events and near misses that occur during treatment. Specific improvement initiatives are being implemented in three focus areas, namely falls, pressure sores and medication errors.

Adverse events Oct 2010
– Sept 2011
  Oct 2009
– Sept 2010
Overall incident rate per 1 000 inpatient days 9.66   9.54
Pressure sores 0.52   0.60
Falls 0.77   0.73
Medication errors 0.91   0.92

A pilot survey on patient safety culture was conducted in August 2011 with staff across 14 Netcare hospitals. Using the US Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture, the survey compared Netcare performance to 1 032 hospitals included in the 2011 AHRQ Comparative Database Report.

The Netcare pilot showed a positive score for a culture of organisational learning and continuous improvement as well as good management support for patient safety. The survey also confirmed that frequency of reporting remains a challenge and that a nonpunitive response to errors, although higher than the comparative database, requires further development.

A commitment to clinical quality improvement

We continue to adapt best practice strategies from across the world to streamline our processes and improve outcomes. Improvement strategies seek to close the implementation gap between known best practices and what we do, and have focused on creating learning networks and strengthening communication and teamwork. We have also piloted improvement strategies using verified systems from other industries such as Lean Kaizen and the Institute of Healthcare Improvement Breakthrough Series.

We elected to focus on a suite of high-impact clinical improvement areas across the organisation, while encouraging small-scale innovation in individual hospitals and units as prototypes for future spread. The table below highlights key focus areas and the improvement in outcomes achieved.

We report on the following high-impact clinical improvement areas:

  • Prevention of infections and antibiotic stewardship;
  • Optimising care in acute myocardial infarction;
  • Preventing venous thrombo-embolism (VTE), including deep vein thrombosis;
  • Benchmarking outcomes in neonatal intensive care – Vermont Oxford Network (VON);
  • Elevating cardiopulmonary resuscitation competency and early warning systems;
  • Monitoring our helicopter emergency service and fixed-wing mortality (Netcare 911); and
  • Benchmarking haemodialysis and peritoneal dialysis outcomes (National Renal Care).

Netcare clinical quality improvement focus areas

  Prevention of healthcare-associated infections:
Ventilator-associated pneumonia (VAP)
Surgical site infection (SSI)
Central line-associated blood stream infection (CLABSI)
Catheter-associated urinary tract infections (CAUTI)
Antibiotic stewardship: Spread of programme across units
Optimising care in acute myocardial infarction (AMI): AMI in-hospital mortality
Venous thrombo-embolism: Prevention of deep vein thrombosis (DVT): documented risk assessment
Benchmarking outcomes in neonatal intensive care: VON
Elevating cardiopulmonary resuscitation competency
Netcare 911: Monitoring of helicopter emergency service mortality
Netcare 911: Monitoring fixed-wing mortality
National Renal Care haemodialysis and peritoneal dialysis outcomes compared to international benchmarks

Better than expected   On target   Less than expected

Clinical quality initiatives

  Oct 2010 – Sept 2011   Oct 2009 – Sept 2010
HAI rate per 1 000 inpatient days 1.94   2.14
Active antibiotic stewardship programme initiated 17 hospitals   six hospitals
VAP bundle compliance: Overall May 11 – Sept 11: 85.05%
Oct 10 – Sept 2011: 83.86%
  May 10 – Sept 10: 80.90%
VAP per 1 000 ventilator days 8.43   9.60
SSI bundle compliance May 11 – Sept 11: 68.95%
Oct 10 – Sept 2011: 66.05%
  May 10 – Sept 10: 72.26%
SSI per 1 000 theatre cases 2.44   2.51
CLABSI bundle compliance May 11 – Sept 11: 81.38%
Oct 10–Sept 2011: 78.52%
  May 10 – Sept 10: 67.10%
CLABSI per 1 000 central line days 2.25   3.91
CAUTI bundle compliance May 11 – Sept 11: 66.01%
Oct 10 – Sept 2011: 62.68%
  May 10 – Sept 10: 53.80%
CAUTI per 1 000 catheter days 3.35   5.15
HAI rate for the four above-listed bundles (VAP, CLABSI, CAUTI, SSI) per 1 000 device days or theatre cases 3.14   3.97

Prevention of healthcare associated infections and antibiotic stewardship

Healthcare-associated infections (HAI) are among the most common and serious adverse events in hospitals across the world, occurring in an estimated one in 10 hospital admissions overall. In SA, the burden of infectious diseases is exacerbated by the concomitant epidemics of HIV and tuberculosis that present a major public health problem for the country.

The threat posed by infectious diseases and increasing resistance to antibiotics is growing on a global scale. In addition, the devastating effect of international outbreaks, such as the Severe Acute Respiratory Syndrome (SARS) and more recently H1N1, has emphasised the importance of efficient and effective management and prevention of infectious diseases.

Ongoing infection prevention and control measures, including protocols and procedures regarding infection and transmission, are in place. In addition, Netcare has progressed frontline staff engagement in the “Best Care … Always!” campaign that emphasises strict adherence to specific measures that are shown to reduce transmission. We have also adopted the well-proven tool – “the checklist” – and driven compliance to process improvement initiatives by repeating these initiatives many times. Improvements met or exceeded our targets in all areas except in compliance to surgical site infection steps. Here, monitoring has been increased and plans are in place to address gaps through intensified testing of potential solutions.

Further antibiotic stewardship programmes have been implemented through multidisciplinary teams, and we have put strong emphasis on escalating clinical and ward pharmacy services across multiple hospitals in Netcare. We will extend this work to more Netcare hospitals in 2012 and measure the impact on antibiotic utilisation over time.

Optimising care in acute myocardial infarction

In SA, about 33 people die every day due to acute myocardial infarction (AMI), commonly known as a heart attack1. Across the world, leading cardiology and healthcare organisations have worked with clinicians to develop guidelines for optimal care based on evidence, and called for increased education of the general public and emergency responders about the symptoms of AMI and the need for immediate treatment. Although the type of care received by patients varies based on clinical condition and other co-morbidities, studies have shown that patients with AMI who receive specific care have reduced morbidity and mortality.

1 Medical Research Council, South Africa, The Heart and Stroke Foundation South Africa, Heart Disease in South Africa, Media Data Document. Compiled by Krisela Steyn, Department of Medicine, University of Cape Town & Chronic Diseases of Lifestyle Unit, at the Medical Research Council. http://www. heartfoundation.co.za/docs/heartmonth/ HeartDiseaseinSA.pdf

Netcare has over the past 18 months implemented a comprehensive reporting system to measure process compliance to seven recommended components of AMI care across the 17 cardiac units. Within these units, AMI in-hospital mortality has been measured to assess the impact of improvement efforts. The hospitals involved have demonstrated improvement in process compliance over 2010 and Netcare is on target to reduce AMI in-hospital mortality.

The AMI in-hospital mortality for the year ended 30 September 2011 was 7.34% (Apr 2010 – Sept 2010: 7.52%).

Preventing venous thrombo-embolism including deep vein thrombosis

Venous thrombosis, known as VTE, is one of the most common preventable causes of death in hospitalised patients and pregnant women worldwide. A VTE occurs when a blood clot forms in a vein and includes both DVT and pulmonary embolism (PE). DVT occurs when a blood clot blocks a deep vein, usually in the leg. PE is a potentially life-threatening complication and occurs when the blood clot escapes into the circulation and becomes lodged in the lungs. VTE is often a silent disease, and the first appearance can be fatal.

Netcare has aligned with leading hospitals across the world in following recommendations that all patients be assessed for the risk of developing blood clots on admission to hospital, and be given preventative treatment according to their individual needs. Options include blood-thinning drugs such as heparin, anti-embolism stockings and foot impulse or pneumatic devices. Importantly, this advice covers all patients admitted to hospital – including those admitted for day-case procedures – and not only those patients undergoing surgery.

A comprehensive risk assessment process has been developed and implemented across all hospitals along with compliance measures to monitor improvement. Despite substantive improvement in administration of VTE risk assessments, our efforts have not yet resulted in a decrease in hospital DVT diagnosis. Next steps include follow-up analysis of the problem and the implementation of appropriate actions.

Benchmarking outcomes in neonatal intensive care – VON

The VON comprises over 850 neonatal intensive care units around the world. It is a non-profit voluntary collaboration of healthcare professionals, dedicated to improving the quality and safety of medical care for newborn infants and their families. Netcare has 21 hospitals that participate in this network, benchmarking their individual data against network participants and engaging in the VON web seminars held every six weeks.

In addition to the elements indicated in the table above, Netcare hospitals have performed favourably in relation to the VON with respect to pneumothorax, intra-ventricular haemorrhages, retinopathy of prematurity, cystic periventricular leuckomalacia and extreme length of stay.

Neonatal intensive care units – VON (all infants)

% Netcare
Neonatal survival 95.60   96.10   95.80
Neonatal death and morbidity 15.20   20.70   15.20
Neonatal healthcare-associated infections 4.40   3.10   4.30
Chronic lung disease 9.50   15.70   9.60
* For the calendar year.

Cardiopulmonary resuscitation competency and early warning systems for cardiac or respiratory arrest

Despite advances in cardiopulmonary resuscitation (CPR) and the fact that CPR has been performed on patients suffering sudden in-hospital cardiac arrest for almost 50 years, several international studies have shown that survival from in-hospital cardiac arrest remains low. There are no data available from any SA setting on survival of patients who suffered cardiac arrest in an in-hospital or out-of-hospital setting.

During the past year, Netcare has implemented a standardised in-hospital resuscitation programme aimed at enhancing access to quality CPR and improving the outcomes of patients who suffer cardiac arrest. A national Resuscitation Programme Manager was appointed for the Hospital division. This is a common appointment in many international hospitals, but a first for SA.

Mock resuscitations are performed regularly in all hospitals and compliance has been formally assessed with a national average of 73% measured against best practice CPR standards. Respiratory arrest was found to be the primary cause of collapse in Netcare facilities, accounting for just over 60% of in-hospital arrests. The next step is to seek further improvement in the speed of response through the implementation of a modified early warning system.

Netcare 911: monitoring of helicopter emergency service and fixed-wing mortality

Netcare 911 has steadily implemented clinical governance and quality systems over the years to ensure the highest standards of pre-hospital and aeromedical emergency care. In the past year, further measures were implemented and refined. These include the monitoring of outcomes of patients transported by the helicopter emergency service (HEMS) and fixed-wing air ambulance services. Internationally benchmarked criteria are used to determine whether a helicopter authorisation is appropriate and beneficial to patient outcome or not, and clinical outcomes data are used to assess the accuracy of air ambulance dispatch.

Meetings on HEMS and fixed-wing morbidity and mortality are held on a monthly basis. Case reviews are undertaken and external specialists are invited to present on relevant topics and lead case discussions to ensure staff remain at the forefront of best practice.

Emergency care practitioner rapid sequence induction was a focus area in the year. A range of research projects on pre-hospital rapid sequence induction (RSI) protocols and outcomes is currently underway. The first study, in collaboration with the University of KwaZulu-Natal, is a retrospective study on the safety of pre-hospital RSI.

National Renal Care: haemodialysis and peritoneal dialysis outcomes compared to international benchmarks

The National Renal Care (NRC) division has introduced systems to monitor clinical indicators and benchmark all facilities. These have focused on identifying best practice opportunities and changes that may improve patient outcomes in both haemodialysis and peritoneal dialysis.

Data indicate that while some measures (such as albumin >35g/l) were lower than international benchmarks due to the prevalence of malnutrition in SA, almost all other indicators such as calcium (2.1 – 2.55 mmol/l), phosphate (0.8 – 1.8mmol/l) and parathyroid hormone (<150pg/ml) were above the benchmarks.

Developments include continuous improvement in relation to benchmarks and a best practice report for the individual units. Funders and doctors receive a quarterly update from NRC detailing the latest clinical trends and evidence-based practice.

Developing platforms for quality leadership

Netcare Quality Leadership Committee: This committee, comprising external Board members, management and clinical staff, oversees the quality leadership strategic priorities, and monitors clinical governance and the achievement of quality measures and goals.
Netcare National Quality Leadership Council: An executive committee that includes the heads of all divisions within Netcare (Hospitals, Netcare 911, Primary Care and NRC) together with the Director – Quality Leadership and key functional clinical leaders. The Council is responsible for setting annual quality leadership priorities and targets, and reviews performance across all improvement initiatives including patient safety, service quality improvement, clinical quality improvement and regulatory compliance. Each division is committed to biannual reviews of quality measures and goals.
Leadership “focused attention to detail” rounds: On their regular quality and safety rounds, executive and senior leaders do a focused walk through facilities with frontline staff and managers to engage on their healthcare improvement efforts and the hurdles they face. Top-level support is offered when needed.
Netcare Clinical Ethics Committee: A multidisciplinary committee comprising external experts as well as representatives of health professionals from various divisions. The Committee provides expertise and input on clinical ethical issues for the organisation, its patients, staff and individual facilities.
Clinical Advisory Panel: Active doctor engagement in quality improvement is a key focus for Netcare. Specific doctor engagement forums are being established to bring relevant medical expertise and clinical leadership into our quality initiatives.
Netcare localised medical forums: Localised medical forums are established within individual business units and hospitals, including physician advisory boards and morbidity and mortality committees to ensure frontline doctor engagement and interdisciplinary team interaction and input in relation to patient care.
Adverse Event Learning Committee: The focus of this committee is to identify and transfer learnings from incidents across Netcare, and to build a repository of corrective and prevention strategies that our staff can access to support their improvement efforts.
Strengthened Netcare Quality Leadership department: Netcare has bolstered the Quality Leadership department with further medical skills, project management capacity and the integration of our previous clinical audit department. The development of quality improvement capability to lead and support quality initiatives across Netcare is a key focus. This includes key staff completing the IHI quality improvement advisors programme, building an internal management improvement capability and transferring of knowledge in regular group sessions.
Netcare quality improvement learning collaboratives: These teams combine frontline experience and relevant expertise in a collaborative team that explores better implementation of improvement plans.
Quality leadership and information systems development team: This partnership between the quality leadership and the information systems departments was established to facilitate and fast-track the use of technology in quality improvement and measurement.

Clinical governance achievements 2011

First accredited level one trauma centres

In June 2011, two Netcare emergency and trauma centres, namely Netcare Milpark Hospital and Netcare Union Hospital, applied for and were accredited by the Trauma Society of SA as the first two level one trauma centres in SA. Accreditation sets these two centres apart from other emergency units, having met the highest standards for trauma victims.

National Department of Health Core Standards

Netcare Hospital Division conducted two pilot assessments of the National Department of Health Core Standards in 2011 as a baseline for a full-scale assessment across all divisions. A full review of all hospitals will be completed by January 2012 with a report on outcomes by February 2012.

Looking ahead

  • Further integration of improvement efforts and increased improvement capacity will accelerate our quality leadership achievements.
  • Build on our learning platforms to further empower staff and leaders through increased use of enabling technologies and information networks.
  • Continue to engage with our doctors on quality standards and improvement focus areas.
  • Increase engagement with stakeholders on key topics in quality healthcare.
  • Continue to play a leading role in supporting initiatives that enhance the healthcare system in SA.