CLINICAL SERVICES OVERVIEW

MEDICLINIC ANNUAL REPORT 2017 37 CLINICAL SERVICES OVERVIEW INTRODUCTION Mediclinic provides a wide range of clinical services throughout its operating platforms. The services include acute care inpatient services, and highly specialised services, day case surgery, hospital-based emergency centres, pre-hospital emergency services and outpatient consultation services. Support services include laboratory, radiology and nuclear medicine. Mediclinic strives to ensure that the clinical services provided throughout the Group are efficient, effective, appropriate, evidence-based and in line with modern technological advances. To this end we have developed a strong focus on measuring and improving clinical performance throughout our organisation. A comprehensive set of clinical performance indicators are collected, measured, analysed and reported on monthly. These clinical performance reports outline and track the performance of healthcare facilities, inform operational decisions, identify opportunities for clinical quality improvement initiatives and inform strategic direction. During the year under review the clinical performance of the business was satisfactory across all operating platforms. In addition, considerable progress had been made in the further development of underlying structures and processes to enable improvements in clinical performance. Much of the progress can be attributed to a strong collaborative effort between the clinical services teams of the platforms. All indicators included in this Clinical Services Overview are reported per calendar year to ensure completeness and consistency, as a significant time lag needs to be provided for in the collection of clinical data. Dr Ronnie van der Merwe Chief Clinical Officer This report gives a brief overview of the Group s clinical performance for the year under review. For a more in-depth description we recommend that the detailed Clinical Services Report, available on the Company s website at www.mediclinic.com, should also be read. CSR

38 MEDICLINIC ANNUAL REPORT 2017 CLINICAL SERVICES OVERVIEW MEDICLINIC SOUTHERN AFRICA CLINICAL PERFORMANCE PATIENT SAFETY Mediclinic Southern Africa has a reasonably high case mix and a high case load of infectious diseases and trauma. The continuous improvement of patient safety remains a priority for Mediclinic Southern Africa and adverse events, as illustrated in Figure 1, are reported and tracked as a barometer of safe patient care. A significant increase of 37.2% in the medication error rate was reported in 2016, which is mainly attributed to an initiative undertaken by pharmacy to improve the identification and reporting of medication errors. An initiative is underway by pharmacy services to identify, report and reduce the number of medication dispensing errors. The fall rate decreased by 6.1% in 2016, while the in-hospital pressure ulcer rate increased by 3.8%. The fall rate and in-hospital pressure ulcer rate are regarded as nursing sensitive indicators and correlate with the number and skills of available nursing staff. Nursing skills levels in Southern Africa have been a challenge for a few years, and the Mediclinic Southern Africa nursing department is strongly focused on improving the situation. Antimicrobial stewardship Antimicrobial stewardship is an important activity in the management of HAI and antimicrobial resistance. Good progress has been made and all indicators showed a downward trend. CLINICAL EFFECTIVENESS Clinical performance measurement of critical care units ( CCUs ) has been refined by implementing the Simplified Acute Physiology Score ( SAPS ) 3 physiological mortality prediction model instead of APACHE IV previously used. SAPS3 is statistically better suited to the Mediclinic population and gives a more accurate prediction of mortality. During 2016, the average mortality rate for patients admitted to CCUs was 16.74% compared to the expected mortality rate of 17.18%. The resultant SAPS3 mortality index was 0.974. The 30-day all-cause re-admission rate increased by 1.9% in 2016. Re-admissions within seven days of discharge accounts for half of these re-admissions and remains a focus area for improvement. The extended stay rate is now expressed as an index, and although this has remained stable over the last 12 months (1.13 in 2015 and 2016), it has shown a decreasing trend over the second half of 2016. INFECTION PREVENTION AND CONTROL Healthcare-associated infections Healthcare-associated infections ( HAI ) remain one of the highest risks to hospitalised patients. The HAI rate reduced by 15.5% during 2016 due to numerous interventions over the last few years. Hand hygiene compliance is an important measure in the prevention of HAI and remains stable at 75.3% and a focus area for improvement. Refer to Figure 2. FIGURE 1: ADVERSE EVENTS MEDICLINIC SOUTHERN AFRICA FIGURE 2: HEALTHCARE-ASSOCIATED INFECTIONS MEDICLINIC SOUTHERN AFRICA Medication errors Falls In-hospital pressure ulcers 2014 2015 2016 0.25 0.26 0.27 Rate per 1 000 patient days 1.02 0.86 1.18 1.05 1.14 1.07 Rate per 1 000 patient days 2.72 2.19 1.85 Adverse event type Calendar year 2014 2015 2016

MEDICLINIC ANNUAL REPORT 2017 39 PROGRESS AGAINST OBJECTIVES Updated its patient safety strategy to incorporate clinical risk management. Developed and implemented specific training initiatives in the areas of operating theatre obstetrics and infection control. Reviewed the current nursing management model. Improved the measurement of clinical performance through various initiatives. Shared clinical information with doctors. Further reduced infection rates through continuous compliance and improvement initiatives. Appointed an additional seven hospital clinical managers (total of 11 appointed). Implemented two clinical pathways in orthopaedic surgery led by doctors. Developed a comprehensive and integrated emergency medicine strategy. Collaborated with Mediclinic Middle East and Hirslanden to obtain a clear understanding of detailed requirements for an electronic health record ( EHR ) system along with platform s readiness as part of the preparation work for the clinical information system project. Complete the implementation of specific patient safety initiatives aimed at preventing adverse events. Implement specific training initiatives that will further enable staff to drive quality improvement continuously. Develop and implement action plans that will improve hand hygiene compliance. Develop action plans to improve medication safety. Refine clinical performance measures further. Share more detailed clinical information with doctors. Further reduce infection rates through the implementation of a comprehensive infection prevention and control strategy. Phase in further hospital clinical manager appointments. Implement a new clinical performance oversight and governance model in collaboration with supporting doctors. Develop (in collaboration with supporting doctors) and implement more clinical pathways led by doctors. Develop a comprehensive and integrated critical care strategy. Implement a national stroke management strategy. Develop a clinical information readiness strategy along with an implementation roadmap.

40 MEDICLINIC ANNUAL REPORT 2017 CLINICAL SERVICES OVERVIEW HIRSLANDEN CLINICAL PERFORMANCE PATIENT SAFETY Hirslanden has the highest case mix in the Group reflecting the complexity of cases treated. However, clinical outcomes remain excellent as is demonstrated by low infection rates and other outcome measures. The fall rate increased by 10.5% in 2016. The increase in the rate is believed to be due to an increased awareness and better reporting, however, the prevention of falls and a reduction in the reported rate remain focus areas. The in-hospital pressure ulcer rate decreased by 5%. INFECTION PREVENTION AND CONTROL Healthcare-associated infections During 2016, all device-associated and surgical site infection rates declined with significant reduction in the rates of all three reported indicators. The reduction is partly related to definition changes, however, a sustained focus on the prevention of infections supports the lower rates. Figure 3 illustrates the device-associated infections. The catheter-associated urinary tract infections ( CAUTI ) rate decreased by 63.6% while the central line-associated bloodstream infections ( CLABSI ) rate decreased by 76.5%. Over the last three years the ventilator-associated pneumonia rate ( VAP ) decreased by 55.8%. CLINICAL EFFECTIVENESS The SAPS II is used to measure clinical outcomes of CCUs. The SAPS II mortality index remains well below the Swiss benchmark of 0.33 at 0.20. The unscheduled re-admission rate decreased by 3.9%, which is in line with improvement noticed in other measures. PROGRESS AGAINST OBJECTIVES Reviewed the compliance of the hospitals with the patient safety policy the majority of the hospitals implemented every item of the policy or was busy with the implementation of the remaining items. Checked the adherence to safe surgery checklist during unannounced inspections compared to the previous inspection, further improvement was noted. Initiated a pilot project on patient-related outcome measurement patients were surveyed on quality of life before and after joint replacement. The results show a significant improvement of pain and movement after the procedure. Compiled a policy on indication quality and introduction of indication boards the implementation is planned for 2017. Successfully started the project on the introduction of fast track orthopaedics in one of the orthopaedic hospitals of the group. Introduced a common structure for highly specialised medicine services. Compiled the definition of the future documentation in catheterisation laboratories and emergency departments the manufacturer is busy with the implementation thereof in our electronic patient record. Completed the re-evaluation of the radiology information system and selected a new system the pilot project has started. Reviewed the integration of medical source data and decided to connect this project to the Hirslanden transformation exercise. FIGURE 3: DEVICE-ASSOCIATED INFECTIONS HIRSLANDEN 2016' 5.2 2015' Rate per 1 000 device days 4.3 2.3 2014' 1.2 1.1 0.4 0.2 0.4 1.7 Catheterassociated urinary tract infections Central line-associated bloodstream infections Device associated infection type Ventilatorassociated pneumonia 2014 2015 2016

MEDICLINIC ANNUAL REPORT 2017 41 Identify patient pathways qualifying for standardisation. Introduce a continuous patient experience survey for all inpatients. Continue with the definitions of the requirements of the system provider model, and develop evaluation criteria to determine the introduction status per hospital. Continue with the rollout of the radiology information system in a second hospital. Introduce a standardised documentation approach for doctors in the electronic patient record. Continue with the rollout of the patient data management system ( PDMS ). Conceptualise the integration of the PDMS and the electronic patient record. MEDICLINIC MIDDLE EAST CLINICAL PERFORMANCE Both Mediclinic Middle East and the Al Noor group of hospitals collected clinical performance indicators for the period under review and the combined figures are reflected in the graphs below. The collection of certain key clinical performance indicators in the Al Noor facilities are mandatory as defined by the Health Authority in Abu Dhabi ( HAAD ). The reported indicators have been standardised across all the facilities and is not limited to the regulatory requirements. The clinical performance indicators for all the facilities are reported on a monthly basis, and include patient safety, infection prevention and control as well as clinical effectiveness indicators. PATIENT SAFETY Mediclinic Middle East has the lowest case mix index in the Group and serves a younger, healthier community. Providing safe care remains a priority across the platform. Figure 4 reflects the rate of adverse events per 1 000 patient days. Medication errors increased markedly by 116.7% during 2016. The increase is due to a reporting drive, with the main contributor being prescribing errors. The majority of the medication errors are identified, and reported, by pharmacy and prevented from reaching the patients. The early identification of prescription errors was enabled by a pharmacy initiative, focussing on identification and reporting of prescription errors. Medication management remains a big focus area for the group. There was an increase in the fall rate from 0.3 to 0.4 per 1 000 patient days recorded for inpatients during 2016. Fall assessments and the required interventions were reinforced across the group. The rate of inpatient pressure ulcers reduced by 60% and can mainly be attributed to the implementation of the appropriate clinical risk prevention strategies and protocols in all clinical areas. FIGURE 4: ADVERSE EVENTS MEDICLINIC MIDDLE EAST Medication errors Falls In-hospital pressure ulcers 0.2 0.3 0.4 Rate per 1 000 patient days 0.6 0.6 0.5 0.6 0.5 1.3 Adverse event type 2014 2015 2016

42 MEDICLINIC ANNUAL REPORT 2017 CLINICAL SERVICES OVERVIEW INFECTION PREVENTION AND CONTROL Healthcare-associated infections A reduction was seen in most of the measures and this is influenced by changes in the definition in line with the 2016 Centre for Disease Control guidelines. In addition, the platform has a sustained focus on infection prevention and control and reducing infection rates further. The HAI rate decreased by 18.8% in 2016. The rate of CAUTI increased by 33.3% over the last 12 months, however, the actual numbers remain low (seven cases). The rate of CLABSI decreased by 37.5% in 2016. CLINICAL EFFECTIVENESS Actual mortality decreased by 7.7% during the period under review and remained lower than the actual mortality for both Mediclinic Southern Africa and Hirslanden. This can be attributed to the young population (average age of 32 years) in the UAE, and generally less invasive and complex surgical procedures performed than in the other two operating platforms. Mediclinic Middle East used the APACHE IV scoring system in the CCUs in the two hospitals in Dubai until September 2016. SAPS3 was subsequently rolled out in all the hospitals in Mediclinic Middle East in October 2016 and reports will be available in the next annual report. The APACHE IV mortality index is 0.62 and well below 1. The re-admission rate decreased by 47.4% from 1.9% to 1% in 2016. All admission types, except oncology, are included in the calculation. Comparable benchmarks are not readily available. PROGRESS AGAINST OBJECTIVES Appointed patient safety officers, established a quality department and updated its patient safety strategy. Successfully had all Dubai-based facilities as well as the Mediclinic Al Ain hospital re-accredited by JCI in 2016. Standardised clinical indicators across the group, and created a central repository: the Vermont Oxford databases were implemented in all the Al Noor facilities; and the SAPS3 was implemented in all the CCUs across the combined group. Combined the clinical services departments of the group and implemented clinical oversight committee structures. Developed clinical key performance indicators ( KPIs ) for doctors. Not implemented, due to infrastructure and resource challenges, a clinical dashboard which does, however, remain a priority for the future. Signed a formal affiliation agreement with Mohammed Bin Rashid University of Health Sciences in Dubai in May 2016 as an accredited external training facility for medical students, and the first medical students started in September 2016. Further developed the current Breast and Metabolic centres at Mediclinic City Hospital to streamline clinical processes. Successfully commissioned and opened the new comprehensive cancer centre in the North Wing expansion at Mediclinic City Hospital. Centralised and consolidated the laboratory services for the group. Relocated the IVF centre previously in Mediclinic Al Noor Hospital to Mediclinic Al Ain Hospital. Reviewed the existing clinical pathways and developed additional pathways in preparation for the implementation of diagnosis-related groups ( DRGs ) and the implementation of a clinical information system. Selected a new EHR system for the group. Continue to focus on the full integration of clinical services of the combined group. Standardise the doctors appraisal process for the combined group and implement clinical KPIs for doctors. Expand and implement new clinical indicators across the group. Expand the outcome database participation and include obstetrics and gynaecology. Implement a clinical indicator dashboard across the group. Formulate the JCI re-accreditation strategy for all the facilities in the group for 2019. Continue to develop clinical pathways as part of preparing for the implementation of DRGs. Update the quality and patient safety strategy for the group.

MEDICLINIC ANNUAL REPORT 2017 43 Formulate a clinical strategy for the units and certain key service lines for the combined group (comprehensive cancer centre, IVF, metabolic centre, cardiology, cosmetics, etc.). Continue to develop the metabolic surgery services at Mediclinic Airport Road Hospital and prepare for accreditation of the centre. Further develop and expand coordinated care initiatives across the group (breast centre, comprehensive cancer centre, metabolic centre, etc.). Continue the centralisation and consolidation strategy for laboratory services in the group. Complete the ISO certification for the laboratories in the Mediclinic Al Noor hospitals. Implement the newly selected HER system across the group, over a three-year period, starting mid-2017. MEDICLINIC INTERNATIONAL Mediclinic International s Clinical Services Department consists of a small team that coordinates clinical services across the platforms. The team provides strategic direction, oversight and accountability, coordinates collaboration across operating platforms and are directly involved in selected projects. PROGRESS AGAINST CURRENT OBJECTIVES The first phase of a master data management programme, compiling and governing data relating to doctors, has been concluded in Southern Africa. The migration from APACHE IV to SAPS3, intensive care outcome measurement tool, has been completed in Mediclinic Southern Africa and Mediclinic Middle East. Clinical operational dashboards have been refined, and an obstetric management operational dashboard developed for the Southern African platform. The measurement of hand hygiene compliance, methodology and data collection tool, has been standardised across Mediclinic Southern Africa and Mediclinic Middle East. A master person index has been developed and implemented in Mediclinic Southern Africa for the identification of healthy neonates. Initiatives are underway to coordinate health technology assessments centrally, and will be further refined. Thought leadership, oversight and close collaboration has been provided in the selection of an EHR system in the Middle East and Southern African platforms. Continued collaboration and support are provided to Hirslanden with the implementation of their EHR system. Refine clinical performance measures. Establish a patient safety sub-committee to standardise and enhance collaboration. Coordinate collaboration of nursing services across operating platforms. Coordinate collaboration of clinical risk management across operating platforms. Source a clinical adverse event and clinical risk management solution suitable for all operating platforms. Continue to provide thought leadership, oversight and close collaboration in the selection of an EHR system in Mediclinic Southern Africa. Continued to collaborate and provide support to Mediclinic Middle East and Hirslanden with the implementation of their EHR systems. Refine and optimise the clinical governance structure to enforce the Ward-to-Board accountability framework across the Group.