Quality leadership and improvement

Netcare Group quality management framework

The Netcare quality management system is designed to provide assurance of the highest quality of care in all Netcare facilities by adopting a multi-dimensional quality framework that includes over 300 measures for quality, a comprehensive quality improvement learning system, and a collective commitment by leaders and frontline employees to the Netcare Way behaviours.

We embrace the concept of the strategic Triple Aim (best patient experience, best outcomes and most cost-effective care) as the foundational principle and philosophy of our work in quality leadership. We have further strengthened our system by adding a fourth dimension of healthcare value creation, which is a commitment to building a dynamic system of engagement between healthcare leaders, staff, healthcare professionals and the patients and their families in the communities we serve, so that we continue to identify opportunities for learning and improvement.

Building a dynamic system of engagement between healthcare leaders, staff, healthcare professionals and the patients and families

Netcare Group quality leadership management framework

The Netcare Group quality leadership management framework is aligned to our pillars of excellence and guides our efforts to coordinate and align quality leadership programmes across all divisions and throughout all levels of the organisation.

Quality governance committees

Patient experience

How Netcare monitors patient feedback to ensure patients and families have a positive experience. Patient-centred care is central to the Netcare quality leadership programme. We are guided by international best practice and the guidelines set out by the Department of Health, including the Batho Pele principles ¹ and the Patients’ Rights Charter ² as summarised below.

Netcare patient feedback system

The leadership teams at our facilities also make personal rounds to ask patients and families about their experiences. This gives the leadership direct feedback of what is going well and also enables them to identify areas for immediate action or general improvement.

The Netcare hospital patient feedback systems reporting suite includes trends, summary dashboards and ward-level reporting. Using iPads, web-based and mobile surveys to engage with patients, the system provides reliable feedback on a daily basis, to help us improve our responsiveness, understand required changes to meet patient needs and improve patient-centred care.

Our patient feedback questions for hospitals are based on the United States’ (US) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which allows us to benchmark ourselves against 4 000 US hospitals and health facilities that make use of this methodology. The survey asks patients questions about the clarity of communication, medication information, discharge planning, the hospital environment and the patient’s overall experience.

The table below shows ‘top-box’ (best possible) responses for the five specific areas that we have focused on in our quality leadership goals.

The HCAHPS survey measures ’top box’ performance and reflects the percentage of patients that score the most positive response. For example:

• The ‘Yes, definitely’ score excludes ‘Probably yes’, ‘Probably’ and ‘Definitely no’ responses.
• The ‘Always’ score excludes ‘Usually’, ‘Sometimes’ and ‘Never’ responses.
• For ratings out of 10, only the 9 and 10 responses are included.
• For ‘Yes’ and ‘No’ responses, only the ‘Yes’ responses are included.

Responding to patient feedback

We have achieved improvements in patient satisfaction on discharge information received, pain management while in hospital and medication information received when at home. A collaborative team of pharmacists working with nursing colleagues at each hospital have made great strides in developing a medication information process for patients while in hospital and after discharge. These efforts have improved our patient feedback scores from a 66% ’top box’ score in 2014 to 74% in 2015.

Patient feedback indicates that we need to improve the information provided to them on symptoms and health problems that they should be aware of once discharged from hospital. In addition to over 50 procedure-specific discharge information leaflets, we have worked with nursing and doctor groups to develop and test general patient information leaflets for four major categories: emergency, maternity, surgical and medical. We are tracking the impact of this initiative at six pilot hospitals, with early indications showing positive results. Pilot findings will inform the next stages of the project.

Patient safety and clinical outcomes

In line with international best practice, Netcare hospitals measure a set of key indicators for patient safety as well as specific clinical processes and outcomes recognised globally as important for patient care. These include infection prevention, antibiotic stewardship, preventing blood clots and best practice after a myocardial infarction (heart attack).

In 2015, Medicross completed a health promotion drive for hypertension screening and compliance to medication and National Renal Care continued to track the international clinical outcome measures for dialysis patients. Netcare 911’s clinical quality assurance programme was further strengthened through the implementation of a national morbidity and mortality programme, which reviews selected cases and ensures that learnings are rapidly disseminated to teams on the ground.

Infection prevention and control

Netcare’s infection prevention programme is designed to prevent the risk of spread of infections. This is done through active monitoring and surveillance by dedicated staff as well as the implementation of standard operating practices, education and specific infection improvement programmes at the frontline of care.

All Netcare divisions have implemented a risk-based approach to infection prevention and control that focuses on sustained improvement of outcomes and compliance to best practice care for infection risk areas. Sharing ideas for improvement and measurement of outcomes across divisions and facilities has enabled faster learning and optimised our risk management strategies.

The roll-out of the electronic laboratory system in our hospitals has been an important milestone in advancing our management of infection prevention and control, particularly in terms of the four most common infection risks in hospitals. We use strict tracking measures and definitions stipulated by the Centre for Disease Control.

We are proud to have achieved year-on-year improvement in all four infection risks, namely central line bloodstream infections, ventilator associated pneumonia, catheter associate urinary tract infections and surgical site infections. A total of 32 hospitals reached zero infections for central line bloodstream infections and 18 hospitals reached a zero rate for ventilator associated pneumonia in 2015. We are committed to driving a ’Going for zero’ campaign to continue to address the growing risk of healthcare associated infections around the world. 

Hand hygiene

Hand hygiene (including washing with soap and water or using alcohol hand gel or spray), is recognised internationally as a critical factor for preventing the spread of infection. 

Staff and leaders use every opportunity to reiterate our commitment to hand hygiene and drive awareness programmes on a regular basis and we have outstanding participation by all staff in World Hand Hygiene Day, which is held annually in May.

All Netcare facilities are monitoring their hand hygiene programmes by using the World Health Organization (WHO) hand hygiene assessment criteria. We also actively monitor the five moments of hand hygiene and compliance across our wards and units, and results are shared with frontline teams and healthcare professionals.

We have furthermore increased communication on the importance of hand hygiene through high visibility signage throughout our facilities.

Reminders and information for patients and families are also displayed prominently and alcohol hand sanitisers are placed in public areas throughout the hospital including entrance areas, coffee shops and hallways so they are readily accessible to staff, patients, families and other visitors.

Multidrug-resistant infections

Infections due to multidrug-resistant bacteria, commonly known as “superbugs”, are a leading cause of morbidity and mortality globally, both in the community and in hospitals. We collaborate closely with experts locally and internationally to inform our policies and standard operating procedures to manage the risks for these infections. Our preventative measures include patient pre-admission risk review, screening of long-stay intensive care unit (ICU) patients, enhanced cleaning programmes, hand hygiene compliance and our Group-wide antimicrobial stewardship programme.

Training on the standard operating procedures for risk management of infections has been undertaken for each region of operation in SA and all staff at facility level. Presentations have also been made at continuing medical education events, physician advisory boards, and infection prevention and control sub-committees attended by clinicians. Two audits on preventative measures were undertaken in 2015 covering all hospitals, with findings yielding a final rating of compliance to processes of over 90%.

Netcare antimicrobial stewardship programme

Resistance to antibiotics is rising to dangerously high levels in all parts of the world, with an increased potential to compromise our ability to treat infectious diseases. The WHO is leading a global campaign ‘Antibiotics: Handle with care’, which calls on individuals, governments, health and agriculture professionals to take action in addressing this threat by only using antibiotics when necessary and as prescribed.

Our antimicrobial stewardship programme, which was initiated in 2011, has continued to progress in 51 Netcare hospitals and has resulted in a significant decrease in antibiotic consumption and an improvement in how antibiotics are used. The programme is driven by pharmacists who collaborate with frontline nursing teams and are supported by a strong base of clinician leaders that provide crucial back-up and clinical input into the programme.

While each hospital’s programme is adapted to local risks, we monitor the implementation of high impact antimicrobial stewardship activities and benchmark these across all hospitals.

The table below shows the consistency and spread of antimicrobial stewardship activities across Netcare hospitals.

Three of Netcare’s papers on antibiotic stewardship were published in 2015; two in peer-reviewed SA journals and one in the international Infectious Diseases and Therapy journal.

More recently (June 2016), Netcare was honoured to have a paper on a five-year review of our programme published in Lancet ID – one of the most prestigious international infectious disease journals.  

Health and safety risk management

In addition to ensuring that healthcare is patient-centred, we have a commitment to manage health and safety risks to ensure that harm is prevented. Our Group-wide learning system for monitoring and reporting safety includes safety programmes in specific focus areas and the timely dissemination of learnings from reported adverse events and near misses that occur during treatment. In addition to facility-level responses and risk management, adverse events are reviewed monthly by the national quality leadership review committee. Our approach is driven through the concept of ‘a promise to learn, a commitment to act’.

In addition to sustained actions relating to the risks of pressure sores and falls, our focus in 2015 has been on the following aspects:

• Strengthening medication safety
  We have completed a detailed measurement process to monitor the effective implementation of the medication safety programme across all facilities and wards. This includes a comprehensive set of high alert medication safety guides, as well as tools to ensure safe dispensing and medication administration. The measurement process provides a baseline for further improvement and has identified best practice facilities for shared learning and replication. It is driven through our clinical pharmacy services in collaboration with nursing services.
• Advancing the prevention of blood clots
  Extended hospital stay, surgery and being immobile for long periods of time are among the highest risks for developing blood clots. We have adopted global best practices for the prevention thereof, including documented risk assessments, monitoring of appropriate preventative therapy to ensure timely administration and, where medication is used, monitoring the dosage according to the patient’s condition.

Leadership focus on quality

Our strategic plan for quality and safety is underpinned by a multi-dimensional Group-level quality scorecard that we use to track progress against the goals set at Group-level for each division and at each facility.

Management teams at each facility are responsible for the day-to-day management of quality and for driving improvement initiatives relevant to their facility’s trends and goals. Quality outcomes and process measures form a significant percentage of performance management measures for all senior and frontline managers. Progress reviews are done in monthly meetings and during leadership walkabouts and leadership communication sessions which take place daily or weekly.

Internal benchmarking takes place across similar type and sized facilities and our quality audits identify specific actions required to achieve quality goals. Our overall quality performance improved year-on-year for all divisions.   

Frontline staff engagement in quality improvement

Staff engagement in quality improvement is crucial to ensure we build on our firm foundations for quality and harvest the ideas and leadership skills of employees at the frontline of care to evolve and improve quality.

The Netcare Way of Improvement uses internationally recognised quality improvement methodology to train employees. It has a strong emphasis on measurement, innovation and improving systems and processes.

Changes are first piloted and tested in discrete areas and, if successful, is then replicated and adapted across multiple locations. Regular quality improvement learning events are held across all divisions, regions and facilities. A survey of frontline hospital leadership teams indicates that 77% of the respondents had received quality improvement training and 41% had led and documented an improvement project in 2015.

In 2015, we recorded a record level of employee participation in Netcare’s quality leadership improvement initiatives. A total of 261 (2014: 163) improvement projects were submitted as abstracts to international and national professional academic events. Of these, just over 150 projects were submitted to the Netcare Quality Leadership Awards which recognise individuals and teams who have positively impacted patients’ lives through quality initiatives.

Winners of the 2015 Quality Leadership Awards

Improve patient safety during hospital stay by reducing preventable fall rate

Project Lead: Susan Coetzee – unit manager: neuro-orthopaedic ward (Netcare N1 City Hospital)

Co-author: Yvonne Faber (Netcare N1 City Hospital)

Preventing falls and resultant injuries requires strong leadership and vigilance as well as the active

engagement of the multi-disciplinary team involved in caring for patients.

Under the leadership of Sr Susan Coetzee, the neuro-orthopaedic team at Netcare N1 City Hospital developed a comprehensive strategy for change to reduce falls by using existing tools diligently and adapting them as learnings emerged, as well as introducing new ideas through various cycles of brainstorming, testing and evaluating these ideas over a three year period.

The results of this collective work resulted in a decreased rate of falls in the unit which has been sustained and further improved 10 months after the initial project was submitted for the quality leadership awards. In addition, Netcare N1 City Hospital has shown a decrease in falls per

1 000 paid patient days from 2.37 in 2013 to 1,81 in the year to date to May 2016.

Learning is a gift - even when pain is your teacher

Project lead: Soekie Grant – Professional urse, Pain Management (Netcare Milpark Hospital)

Co-authors: Pamela Yako (Netcare Mulbarton Hospital); Esme Cross (Netcare Park Lane Hospital); Catherine Smith (Netcare Krugersdorp Hospital); Jenni Subeke (Netcare Rosebank Hospital); Charlotte Botha (Netcare Olivedale Hospital); Magda van Vuuren (Netcare Union and Netcare Clinton hospitals); Lillian Seiso (Netcare Rand Hospital); William Smith (Netcare Rehabilitation Hospital).

Inadequate pain control contributes to delayed wound healing, increased length of hospital stays and higher mortality rates. Pain impacts overall patient outcomes and may also affect psychosocial factors which can cause depression and anxiety.

Following a successful project to improve the level of patient feedback regarding pain control at Netcare Milpark Hospital, the project lead mobilised and led a multi-hospital team from 11 hospitals to share learnings and roll out a pain improvement initiative across the Gauteng South West Region.

The collaboration led to a systematic review of existing programmes for pain management, including

strengthening the pain management knowledge base for ward ‘pain-link nurses’, by working together with a committed team from nursing Education. In addition, there was active engagement with nurse leaders, hospital general managers, doctors and anaesthetists to support the pain improvement journey.

The collective actions from participating hospitals resulted in an improvement in the overall GSW region patient feedback scores on pain management from 77.9% to 83.6% for July 2014 to June 2015. These results have been sustained at 83.7% from June 2015 to June 2016.

BCA Quality Improvement Award category

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