Quality and clinical governance

Quality is one of Life Healthcare’s core values and a key business strategy. Life Healthcare is the only healthcare organisation in southern Africa to have achieved multisite ISO 9001:2008 certification. All hospitals have met the criteria based on ongoing internal audits as well as surveillance audits conducted by an independent ISO certification agent. This accreditation confirms Life Healthcare’s standing as a world class provider of quality healthcare.

The need to improve the overall healthcare delivery system in South Africa is well recognised and has called for a new approach to collaboration among all role players. With this in mind, Life Healthcare is participating in an industry quality initiative called Best Care … Always. This includes strategic and hands-on interaction with the Department of Health in addressing challenges in healthcare delivery.

Quality management system

The Life Healthcare quality management system is sustainable and consistent across all hospitals. It is based on a factual assessment through ongoing management and measurement. Hospitals are assessed on their overall quality management, leadership responsibilities, and quality aspects in the nursing, pharmacy, patient services and engineering departments. Results are benchmarked across the group and form part of the performance management of senior hospital leaders. Stringent criteria promote compliance with procedures.

We have established a balance between clinical excellence (health) and patient experience (care). Clinical excellence (iQ) ensures that patients receive world class clinical care. This is balanced against the patient experience (Qe) which addresses the needs of patients and their families including emotional support, communication, physical facilities, services rendered by outsourced service providers and billing accuracy.

›	Infection control		›	Patient satisfaction
›	Patient health and safety		›	Customer loyalty
›	Clinical governance		›	Staff at the heart of quality
›	International benchmarking
›	Clinical improvement focus areas

Quality scorecard

The five key aspects that the quality scorecard measures consistently across all hospitals and consolidates monthly include:

The scorecard reflecting the Group average (shown below) focuses attention and effort on continual improvement in a manner that is measurable and quantifiable.

Clinical excellence (iQ)

Life Healthcare’s clinical excellence focuses on the following areas:

Clinical outcomes improvement

Working with our doctors, we have identified proven interventions and we measure our compliance to international evidence based practices of the Institute for Healthcare Improvement 100K Lives campaign, Canadian Safer Healthcare Now work, the American Alliance for Cardiac Care Excellence and the World Health Organisation World Alliance for Patient Safety.

Prevention of healthcare associated infections (HAIs)

According to the WHO patient safety initiative, healthcare associated infections (HAIs) remain the most frequent, costly and life threatening adverse event in healthcare facilities. Life Healthcare’s infection prevention and risk management department is involved in all aspects of the business including nursing, education, procurement, hospital services, operating theatres, sterile services, clinical and general engineering, renovations and new construction as well as occupational health.

In the USA recent estimates suggest there are approximately 4.5 infections per 100 admissions. In reducing the incidence of HAIs, Life Healthcare has had excellent results in the following fields after having adopted a ‘bundled’ approach (see graphs for results):

A ‘bundle’ is an evidence based, well researched intervention implemented together for all patients, and has been proved to reduce infections.

Cardiac excellence project

Life Healthcare embarked on the process of identifying proven interventions which reduce morbidity and mortality in patients with acute myocardial infarction (AMI). Together with our supporting doctors, we started measuring our compliance to these evidence based practices. As with our infection related clinical outcomes improvement campaigns, our cardiac excellence initiative has as its foundation the work done by the Institute of Healthcare Improvement (IHI), Canadian Safer Healthcare Now AMI campaigns and the American Alliance for Cardiac Care Excellence (ACE). These are based on leading healthcare organisations partnering with international cardiologists to ensure that every hospitalised patient suffering from acute myocardial infarction receives the right care, at the right time, every time. We acknowledge the significant support and contribution of these organisations.

The following components of care form part of our cardiac excellence project:

Life Healthcare has implemented these specified components of care at our hospitals with dedicated cardiac units. We are measuring compliance on an ongoing basis. Results have been heartening, showing reduced mortality rates for our patients.

Q^e – Patient experience

Patient satisfaction

To obtain accurate and reliable feedback on patients’ perceptions of the quality of our hospital care, Life Healthcare measures patient satisfaction through a Q-evaluator, an interactive electronic patient monitoring and feedback system adopted from international customer loyalty measurement trends. This measures our patients’ perception of a number of service aspects specific to individual departments and units within our hospitals, and enables management to gauge service levels. On average the group receives more than 1.2 million responses per year on this system which means that each patient averages two opportunities to provide feedback during hospitalisation. The overall patient feedback score for 2010 was 98.03%.

This system is supported by a manual comment card process that patients utilise to provide qualitative feedback and comments. During the year over 185 000 cards were returned and 94.2% of these cards contained positive comments. Complaints are treated as a priority for quick resolution and the opportunity to ensure our patients’ ultimate satisfaction.

Net promoter score

Life Healthcare uses this as the overall measure of customer satisfaction. This loyalty measurement is based on a single question: “How likely is it that you would recommend this Company to a friend or colleague?” A customer response indicating a high likelihood of recommending the Company is indicative of a patient whose needs and requirements have been met and such a patient is known as a promoter. A patient who is undecided or unlikely to recommend Life Healthcare is a detractor, and the score is calculated by subtracting the detractors from the promoters.

Patient health and safety measures

All patient incidents are reported and fully investigated by responsible managers. Remedial action is implemented to avoid recurrence of similar incidents in other units. Incidents are recorded on an electronic reporting system and are categorised by type, business unit and department in which the incident occurred. Detailed statistics are recorded and analysed through the use of a sophisticated electronic tracking system implemented throughout the group’s hospitals. This allows for trending, a factual approach to decision making, and the implementation of preventive measures.

The overall patient incident rate is measured as a ratio of the number of incidents per 1 000 paid patient days (PPDs). Two internationally accepted high risk areas receive specific and ongoing management attention in all hospitals. These are medication incidents and slips and falls.

Patient incidents

The overall patient incident rate has decreased from 5.5 per 1 000 PPDs in 2008 to 4.27 in 2009. During the financial year under review the rate remained flat at 4.27. This unchanged rate is partly due to a continued effort in the group to encourage 100% reporting of incidents.

Medication incidents

The overall medication incident rate has decreased to 2.00 per 1 000 PPDs from 2.2 in 2008. Life Healthcare continues to review these incidents and involves nursing and pharmacy staff, quality specialists and doctors in training to mitigate this risk.

Managing slips and falls

Globally hospitals report that patient slips and falls are the most common and serious injuries in hospitals. Our nurses identify high risk patients during the admission process and include preventive measures in the care plans for these patients. This approach has contributed to the reduction in slips and falls from 1.2 per 1 000 PPDs in 2008 to 0.71 in 2010.

Safety, health and the environment

Employee health and safety

Employees identify and report potential hazardous conditions through an alert process which addresses potential hazards. Trends are monitored to highlight possible new risks requiring mitigation. Various risk assessments are completed on all pathogens that may cause disease and to which staff may be exposed. Risks are mitigated in various ways, for example by the use of personal protective equipment or isolation facilities, various infection control precautionary measures, vaccines or prophylactic treatment.

Trained incident investigators investigate and report all occupational health and safety incidents to determine their root causes. Corrective actions are implemented to address the cause and prevent the recurrence of similar incidents. Incident trends are monitored throughout the Group.

All new employees receive quality induction and training in safety awareness as well as infection prevention and control. Some employees also act as safety representatives and link nurses reporting to occupational health and safety and infection control committees each month.

Continued safety awareness training and campaigns at operational levels have resulted in a reduction of incidents since 2007. Employees are monitored for occupational exposures such as radiation and are screened for tuberculosis (TB) and for latex allergies. In 2010, measles, H1N1 and seasonal influenza vaccinations were offered to all frontline healthcare workers.

Employee health and safety

The year on year reduction in employee incidents has been attained by focusing on specific high risk areas which include employee slips and falls and needle stick injuries, as well as on continued safety awareness campaigns and training.

Clinical engineering

Life Healthcare’s clinical engineers are responsible for the maintenance of all clinical equipment. Employees who will operate the equipment are appropriately trained and their competency assessed to ensure safe handling. Annual audits ensure adherence to and compliance with safety standards. The group ascribes to the Engineering and Construction Risk Institute (ECRI) philosophy, unless the manufacturer’s recommendations are more stringent. Our clinical engineers are actively involved in the Clinical Engineering Association of South Africa (CEASA) and participate in the SA Federation of Hospital Engineers’ programmes.

Environment

Life Healthcare is classified as a low impact organisation in environmental terms. However, we acknowledge the impact of our activities on the environment and bear responsibility for the environmental, health and safety consequences of our medical services. Our environmental obligations are managed through regular safety, health, environment and quality audits and the reviewing of environmental registers in the Group’s hospitals.

We endorse the need to manage the consumption of our natural resources in a sustainable manner, to conserve energy and water, and we are recycling paper, glass and plastic – all in an effort to reduce our carbon footprint in line with best international practices.

Healthcare waste management

The Waste Act was enacted to protect health and the environment by providing reasonable measures for the prevention of pollution and ecological degradation. Facilities that generate medical waste may store this for short periods of time. Life Healthcare is sensitive to the potential impact that waste generated through our hospitals’ activities could pose to the environment and to health if not correctly handled, disposed of or destroyed, particularly as the healthcare waste industry in South Africa has a history of illegal dumping and insufficient incinerators. Waste includes infectious waste, drug waste resulting from cancer treatments, waste from the usage of X-rays, cleaning concentrates, diesel fuel or motor oil which represent a danger to the soil or groundwater, and chemicals such as those used in anaesthetics.

To mitigate the risks within our control, Life Healthcare ensures that we minimise toxicity through the correct handling of waste within our facilities and that our waste disposal contractors meet legislative requirements in transporting, disposing of or destroying healthcare waste. Waste is weighed on collection, and Life Healthcare facilities keep and reconcile documentation on a monthly basis to monitor that the waste collected by external service providers was disposed of or destroyed correctly. Our healthcare waste transporters have tracking systems so that any deviation in the planned route is reported. Waste disposal contractors are audited internally and shortcomings are addressed. In addition, an environmental auditing team has been contracted to conduct independent audits of service providers.

All Life Healthcare facilities have recycling initiatives and training is provided to enable staff to reduce the amount of waste through correct segregation.

Energy usage

Life Healthcare’s primary source of energy is electricity and we purchase 124 367 994 kWh annually for use in our hospitals and other facilities. We have embarked on an energy conservation programme and have identified various initiatives in this regard. Currently we are measuring and creating a baseline to substantiate actual savings after implementation of the conservation initiatives. These will be reported on in 2011.

As a result of frequent power outages in 2009, Life Healthcare spent R 45 million in acquiring secondary back‑up generators at our hospitals. The cost of diesel for the generators is four to six times higher than Eskom’s electricity, but uninterrupted power supply in the event of any one of our primary generators malfunctioning during a power cut, is an imperative in healthcare delivery. Electricity supply to our hospitals stabilised as Eskom reduced its load shedding programme. In 2010, our diesel consumption for the on-site generation of emergency power was 81 273 litres.

Water usage

Water is obtained from municipal or regional utilities. Life Healthcare’s total water usage for the year was 1 194 552 kilolitres. At present less than 0.5% or 6 400 kilolitres is recycled or reused, however we have identified initiatives that will reduce our water consumption and this will be reported on in 2011.