Annual integrated report 20 64 Ensuring quality outcomes Over the past five years we have built an integrated quality management system that drives quality improvement across all Netcare divisions. More than 300 quality outcomes and processes are measured and we have shown sustained year-onyear improvements in almost every measure since. Our measures align to the objectives of the Quadruple Aim to deliver best patient outcomes, best patient experience and cost-effective care, together with excellent staff training and support. In 20, we streamlined our quality leadership strategy to focus on four key strategic elements which we regard as being the most important factors in delivering excellent quality outcomes and patient experience, and substantively reducing risks. This focused approach responds to feedback from our teams to simplify our quality objectives to enable a deeper improvement in quality care, and is communicated in an easy to remember slogan, 1-5-5-5. Each division has adapted its strategy to address its unique requirements in respect of quality objectives.
65 Percentage of facilities within each division scoring above 80% for overall compliance with the National Core Standards Hospital division 86.4% 20 88.0% 20 77.0% 2012 Annual integrated report 20 Primary Care division 1 ONE WORLD-CLASS QUALITY MANAGEMENT SYSTEM An integrated approach to ONE unified Netcare quality management system across all divisions to build a culture that consistently meets the highest national and international quality standards. Supported by: > > Quality assurance audits that assess compliance with the National Core Standards and Netcarespecific standards. > > Risk-based policies and standard operational procedures. > > Improvement programmes and training. 74.7% 20 73.3% 20 65.0% 2012 Netcare 911 86.0% 20 88.5% 20 Aligned to the new emergency care regulations. National Renal Care 20 In preparation for ISO9001 certification, the British Standards Institute undertook an independent review of the quality management systems in each division. Divisions are working to close identified gaps to achieve formal certification in 2017. 94.7% 20 83.0% 20 89.0% 20
Annual integrated report 20 66 5 HIGH 5 PATIENT EXPERIENCE To improve patient experience, we have prioritised the following FIVE aspects: > > Responsiveness. > > Cleanliness and noise levels in the surrounding environment. > > Nursing communication. > > Discharge information. > > Medication information. Benchmarked against: United States (US) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which covers over 4 000 hospitals. 20 Hospital division Achieved scores higher than US HCAHPS scores in four out of five aspects. Area for improvement is discharge information. We are testing an SMS discharge information campaign in response. Achieved year-on-year improvement in all five areas against the external Discovery Health feedback survey for hospitals (unpublished). Overall results from 226 009 surveys across all Netcare hospitals RESPONSIVENESS 20 20 HCAHPS 77.2% 79.1% 69.5% 68.0% SURROUNDING ENVIRONMENT: QUIET 20 70.1% 20 70.7% 65.8% HCAHPS 62.0% MEDICATION INFORMATION 20 20 HCAHPS 73.6% 73.6% 53.2% 65.0% NURSING COMMUNICATION 20 20 HCAHPS 84.4% 85.3% 75.7% 79.0% DISCHARGE INFORMATION 20 20 HCAHPS 58.9% 76.6% 77.5% 86.0% Note: Measured against the most recently available US HCAHPS results. As per US HCAHPS, patient feedback measures are shown as the top box scores and only reflect the most positive response to a question. For example, a score of 76.6% for a question asking how often a behaviour was experienced shows the percentage of patients that responded always and excludes usually and never or sometimes.
67 05 ZERO TOLERANCE FOR INFECTIONS Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in healthcare facilities worldwide. Internationally over the last decade, multidrug-resistant gram-negative bacteria have been implicated in severe incidents of HAIs. To further reduce the risk of infection and to implement robust systems to stop the spread of multidrug-resistant infections (commonly known as superbugs), we focused on the following FIVE elements: > > Hand hygiene. > > Antibiotic stewardship. > > Stop superbug bundle CRE risk management. 20 Netcare s antibiotic stewardship programme was globally acknowledged following the publication of a peer reviewed article in the 20 Lancet Infectious Diseases journal. Launched the Safe Hands app to measure hand hygiene compliance and share this data in real time with frontline staff and healthcare professionals. We also added hand hygiene as a behaviour to the Netcare Way. I always practise proper hand hygiene to show my care Introduced a stop superbug bundle toolkit. Annual integrated report 20 > > Surgical site infections. > > Catheter associated urinary tract infections (CAUTI). Rolled out Bluebird to 47 hospitals. This infection and antibiotic resistance prevention software integrates laboratory data with our patient and antibiotic prescription data to ensure high vigilance of antibiotic stewardship and infection prevention measures. Ventilator associated pneumonia 20: 0.4 20: 1.2 : 8.4 Surgical site infections 20: 2.0 20: 1.9 : 2.4 Central line bloodstream infections 20: 0.06 20: 0. : 2.25 Catheter associated urinary tract infections 20: 2.44 20: 2.58 : 3.35 NETCARE HOSPITAL CAUTI RATE (SEPT 2013 SEPT 20) 3.96 4.03 4.30 4.26 3.75 3.93 4. 3.91 3.30 2.58 3.64 3.70 2.68 3.32 2.75 3.67 2. 2.21 2.42 2.53 2.32 2.26 2.36 1.90 2.80 2.47 2.22 3.01 2.18 2.56 2.08 2.80 2.68 2.50 1.96 1.89 3.31 Sep 13 Oct 13 Nov 13 Dec 13 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep CAUTI rate Median CAUTI rate
Annual integrated report 20 68 5 BIG 5 PATIENT SAFETY We have identified the following FIVE patient safety focus areas that can further strengthen the prevention of harm: > > Medication safety. > > Healthcare risk waste. > > Preventing harm: falls and pressure lesions. > > Operating theatre safety. > > Emergency care quality leadership. 20 By September 20, over 80% of hospitals met the specified criteria of our restructured medication safety programme. Implemented a waste management framework to more effectively segregate healthcare risk waste. This will continue to be a focus for 2017. A new approach to our falls prevention programme was launched across all hospitals, which includes a revised falls assessment tool. Tested an international model for pressure ulcer prevention. Learnings will be used to customise the programme for implementation across all hospitals. Healthcare risk waste 79 tonnes incinerated 1 (20: 70 tonnes) 5 187 tonnes treated and landfilled 1 (20: 4 756 tonnes) Overall patient falls have reduced from 0.75 to 0.73 per 1 000 patient days Audits of the Netcare perioperative surgical safety pathway implemented in 20 showed a 19% decrease in adverse operating theatre events Clinical governance Our robust clinical governance structures ensure that safe and ethical healthcare services are provided to patients. The Quality Leadership Committee, a sub-committee of the Board, is responsible for overseeing our quality leadership strategy, and it monitors compliance with our clinical governance framework and performance against quality measures and goals at Group and divisional level. The Clinical Practice Committee evaluates the clinical practice and codes of conduct for doctors across all divisions and evaluates doctor actions against Netcare s values and the requirements of the Health Professions Council of South Africa (HPCSA). Doctor participation is key to our quality improvement programmes, which is facilitated through doctor engagement forums that bring relevant medical expertise and clinical leadership to our quality initiatives. These forums include the Physicians Advisory boards in hospitals, the Clinical Practice Committee and Clinical Ethics Committee, as well as Group-wide educational and review structures, such as morbidity and mortality meetings and continuous medical education events. These forums enable frontline doctor engagement and interdisciplinary team interaction on patient care, and include infection prevention and antibiotic stewardship committees, and theatre safety committees among others. Transparency in quality indicators and measures Our increased ability to measure identified key quality performance indicators is due to our investment in the Netcare Enterprise Data Warehouse, which serves as a central repository for quality data from several IT platforms and software systems. This assists us to share robust data and learnings within individual units and across the Group to build deep improvement capability that is science and evidence based. All our hospitals use outcome and process measures to monitor their year-on-year performance, and they review their performance against other Netcare hospitals of a similar size. Where possible, international and national benchmarks are also considered when reviewing quality. However, while there has been increased standardisation of measures between like-facilities within Netcare, these measures have not been fully validated in terms of sampling strategies, risk adjustment and other criteria to allow for rigid performance comparisons between facilities and to other healthcare systems. www Full SA Quality and clinical governance report. 1 Increases attributable to patient day growth and more effective segregation of waste types.
69 Contribution to healthcare in SA Access to quality data The HMI has raised debate on public reporting of quality measurement in SA and sparked increased pressure from healthcare funders, media, government and consumers for data on quality. However, public reporting is hampered by the lack of a standardised set of measures in SA, with various providers applying different definitions. Netcare is actively participating in an international review of quality measures commissioned by the Hospital Association of South Africa (HASA), as well as contributing to initiatives that raise quality standards in the South African healthcare sector. The publication of our quality improvement initiatives in peer reviewed journals and the presentation of our projects at professional healthcare conferences also contribute to SA s body of knowledge for quality improvement. Reducing the nursing skills deficit Our paper highlighting the potential benefits of broadbased collaboration between private and public sectors and regulatory bodies to create youth employment opportunities in the healthcare sector, has been positively received by National Treasury. The paper outlines the possibility of providing training and subsequent employment to approximately 50 000 nurses across the public and private sectors in SA over an eight-year period. Our people The fourth dimension of the Quadruple Aim emphasises the importance of promoting work that has purpose and meaning, and building a culture of collaboration that creates a collective impact on quality and care. This requires that we consciously incorporate systems that support the wellbeing and development of our workforce in our overall strategy, and that we encourage the contribution of all levels of staff to the larger system of which they are a part. Our employees 19 760 employees (20: 20 094) The decrease is largely due to the strategic downscaling of Prime Cure s managed care division, with a facilitated transfer of staff to other third party service providers.7% employee turnover (20: 18.7%) Annual integrated report 20 Training 71% of our workforce received training with 3 9 employees trained on Caring the Netcare Way, which enhances caring behaviour 707leaders participated in development programmes with 494 attending the Leading the Netcare Way programme, which showed tangible improvement in resilience and empathy
70 Annual integrated report 20 Our quality balanced scorecard is used to track progress against the goals set at Group level for each division and at each facility. Quality leadership accounts for up to 25% of executive management s balanced scorecard. Quality outcomes and process measures make up a significant percentage of key performance indicators for all senior and frontline managers. While no employee engagement survey was undertaken in 20, the year was spent building on the overall positive feedback received in the 20 survey. In particular we focused on the following issues raised by employees: > > Better communication at all levels within the organisation. > > Platforms to raise ideas and to voice concerns. > > Eradicating racism. > > Change management. Road shows were held during the year by the CEO who engaged with senior and middle managers on systems leadership and the eradication of racism. These sessions will be regularly held to provide a platform to communicate the Group s strategy and to share innovative thinking. The introduction of the seventh Netcare Way behaviour to eradicate racism is based on transparently communicating a zero-tolerance stance to incidents of diversity intolerance or racism. Change resilience workshops were conducted to facilitate employee buy-in for strategic projects that aim to realise efficiencies, with change management initiatives implemented to support the continuous business improvement programme. Training on Caring the Netcare Way aims to enhance caring behaviour and is included in our induction programme. It underpins the care and concern we show for each other, our patients and stakeholders. Most of our training investment goes towards developing our pipeline of healthcare professionals and focuses on registered nurses, paramedics and pharmacist practitioners. Beneficiaries of our training spend include our employees and unemployed learners. In 20, 1 345 (20: 2 301 and 20: 2 247) unemployed learners were trained, consisting of 1 8 nursing students with the balance being paramedics. Delays in the accreditation process by the various regulatory bodies of the new nursing training curricula have impacted negatively on the introduction of new entrants to the profession. The industry hopes for resolution on this issue in the near future. Our Employee Wellbeing Programme offers psycho-social support to our employees and their immediate family. It covers a range of issues across financial, legal, and family and relationship matters, to stress, trauma, health and work-related issues. In 20, the overall engagement rate was 13.4% (20:.2%); professional counselling was the most commonly utilised service, making up 57.5% of overall engagement (20: 57.1%). The proportion of Netcare users who were formally referred by Independent Counselling and Advisory Services (ICAS) was 7.1% (5 cases) compared to 6.7% (175 cases) in 20. Results show that managers are increasingly using the service to seek advice and guidance on employee behaviour, and this made up 18.3% of overall engagement (20:.5%). Relationship issues continue to be the most common category, accounting for 19.1% of all difficulties. The percentage of cases where social problems appear to be having a severe impact on an employee s work life is 5.5%, which compares to the benchmark of 5.0%. IR Diversity management: page 52. IR Detail on Leading the Netcare Way in the SA Hospitals report: page 72.
71 Training and development For skills period 1 April to 31 March (aligned to HWSETA) 20 20 20 Annual integrated report 20 Employees trained Paramedics 5 25 492 Nurses attending formal nursing programmes 1 735 719 1 388 In-service programmes for nurses focusing on high-quality patient care 9 191 127 Other 2 13 282 10 207 9 425 Total employees trained 191 11 2 3 11 432 3 % of employees trained that are women 86% 83% 84% Number of training interventions delivered 43 230 27 607 35 548 Training spend Skills development spend 4 R51.4 million R40.6 million R44.6 million Netcare Education Total number of students currently registered at Netcare Education (nursing, emergency and critical care, and management development) 3 496 4 482 4 251 1 Accredited by the South African Nursing Council and registered on the National Qualifications Framework. 2 The increase is attributable to the high uptake in nursing-related continuous professional development programmes and the training offered as part of change management processes. 3 20 restated due to reporting error and 20 restated to exclude non-employees trained at Netcare Education. 4 These amounts only include the direct costs of training as submitted to the Health and Welfare Sector Education and Training Authority (HWSETA).