By Marilyn Keegan
A look at six accredited South African private hospitals and how they managed to operate during COVID
The COVID pandemic has taught the world many lessons. It shifted paradigms that global public health has taken for granted. The question that remains foremost in the minds of many is this: can health systems be made robust so that when the next pandemic or other disaster hits, we will be ready?
Factored into all of this is the burning question as to what impact, if any, quality improvement programmes and accreditation actually do have on healthcare delivery.
In the past 2 years, events at Mediclinic hospitals in South Africa provide a strong case for the value of accreditation, especially accreditation that has become entrenched in hospital operations. It seems that quality improvement programmes and accreditation can and do ensure the foundation and the architecture that produces robust health systems needed to withstand the onslaught of global health emergencies.
Surveyors at the Council for Health Service Accreditation of Southern Africa (COHSASA) noted after several surveys of hospitals in the Mediclinic Southern Africa Group (one of the largest private healthcare groups in South Africa), that not only had standards been maintained but compliance scores in some instances had increased.
It is fair to observe that Mediclinic is one of COHSASA’s oldest clients and that the culture of quality improvement is well rooted. Nevertheless, it became quite clear through separate interviews with six Mediclinic managers that their ability to cope with the COVID pandemic was enhanced due to the structures, the policies, the procedures and the practice of adhering to international standards demanded by accreditation.
Without exception, all the managers interviewed said that the COHSASA accreditation programme had created an environment where everyone knew what to do.
Carl Buhrmann, Hospital General Manager of Mediclinic Bloemfontein whose hospital has just achieved a score of 99 out of 100 in its latest accreditation survey says: “Having the COHSASA policies in place creates order, structure and control and that is what you need in a crisis. Management and staff know what to do; they know what it is expected. COVID created a situation where one does not have weeks to decide on anything; sometimes one only has an hour or a day. The requirements of the COHSASA programme and internal Mediclinic policies have equipped us for this.”
Carmen Savva, Hospital General Manager of Mediclinic Nelspruit: “We have been involved in the accreditation programme for 19 years and are now on our sixth accreditation award, so it is part of our culture. It is not something that we need to do over and above our daily activities; it is ingrained in us; it is part of our DNA.”
An Orderly Structure
“Accreditation requires an orderly structure in the hospital – we have infection prevention and control meetings and patient safety meetings, and we give feedback to the staff. We continually examine our policies and improve them all the time. It is a mindset,” according to Annatjie Meyer, Nursing Manager at Mediclinic Nelspruit.
Hospital General Manager Henk Laskey of Mediclinic Constantiaberg is convinced being accredited helped the hospital cope with COVID. “Definitely, I think that when you focus on systems and processes and when you measure what you are doing and concentrate on quality, the hospital that has these procedures in place – in other words, an accredited hospital – finds it easier to adapt to a crisis like COVID. So, we just tweaked already existing systems at Constantiaberg, courtesy of accreditation, to deal with the pandemic. It definitely gave us a head start.
“I have worked for other hospitals groups that are not in the COHSASA programme and there I definitely missed the structure that accreditation provides.”
Hospital General Manager of Mediclinic Midstream, Dr. Shane Kotzé: “The COHSASA accreditation programme set the basis for quality in the hospital, and it was something we referred back to. It helped us to know what standards we needed to achieve and continuing with the COHSASA Quality Information system (CoQIS) process throughout kept our pencils sharp. We knew what was expected of us and we continued to meet those targets.
“With each wave of the pandemic we measured our performance against our own benchmarks or that of our peers. Where we identified gaps, we made changes to make improvements. We used patient outcomes as one of the measures, and our physicians challenged us to look at finer and more sophisticated targets. We started looking at hospital acquired infections (HAIs) and device infections. We did not let go of our quality measures during the time and I think that was quite important because by chasing only the crude measures, like mortality, one might lose the detail and it’s the detail that contributes to the mortality.”
Mediclinic Pietermaritzburg, Hospital General Manager, Tabitha Lolliot, says:
“I think Mediclinic handled and navigated through the pandemic phenomenally well. I do think a contributing factor to managing everything was our COHSASA accreditation. We all went in blind – none of us knew what was happening.”
Lolliot adds that having governance structures in place and having support from a team at corporate head office really worked in their favour and given all these stressful external pressures on the hospital, the governance structures were so strong that the system didn’t fail.
“It is second nature to us. Having proper policies and procedures in place protects the patients – first and foremost – and also protects the business and the employee. It was that continual focus on quality improvement, even with the limited resources we had at that time – whether it was the 2nd COVID wave when we were overwhelmed or the riots or the flooding. The staff at the hospital pulled together. They knew exactly what was required of them and I put that down to the governance of the company – right from the top levels to governance at hospital level. It is through COHSASA requirements that we were continually focused on questions like ‘what is the right thing to do?’ and ‘how do we put our policies and procedures in place?’.
“Unfortunately, not all hospitals have the structures that we had in Mediclinic. Some of our colleagues in the area struggled due to limited support or lack of access to an infection control specialist or a procurement department to quickly sort out PPEs. The lessons and the opportunity for them could be to relook their audit and government processes which is directly linked to COHSASA, is what got us through. Our advantage at Mediclinic is that we all know what is expected of us in our jobs and in our roles.
Says Lolliot: “Even though you are going through a crisis, you are focused on quality. You don’t want to cross-infect patients, you make sure your zoning is correct and that patients are placed properly. If there is a breakout of infections, you investigate it – you look at what caused it, you looked at how to mitigate that risk and how to go forward. The COHSASA programme requires the infection prevention and control structures to be there and because they were in place, we just had to tweak certain aspects to adapt to the pandemic.”
The CEO of COHSASA, Ms Jacqui Stewart, has always said that achieving accreditation is not a sprint; it is a marathon. It is during the long and winding road of accreditation that there is a transformation in the way staff deal with problems that arise in a hospital. The drastic demands of COVID only emphasised this process. For example, the way many of the Mediclinic hospitals handled operational problems was informed by adherence to standards and quality improvement methods.
“The pandemic created various challenges for us at Mediclinic Vergelegen,” says Hospital General Manager Marquin Crotz: “We suddenly saw a huge increase in oxygen usage requiring more frequent deliveries. Our clinical manager then initiated a review of the oxygen usage with everyone in the chain.
“They investigated what was happening in the wards and found that oxygen flow rates weren’t always optimised for the specific masks through which oxygen was administered. But as more people gained more knowledge about the treatment and how patients responded, oxygen supplies were streamlined to meet actual, not estimated, patient needs.
Marquin Crotz adds that specific treatment action plans were drafted and immediately the clinical team trained all the ward staff on efficient protocols for oxygen use. This was a huge success and shared with other hospitals as well.
“During the COVID waves we also introduced the position of a triage medical officer to prioritise who was allocated the next ICU bed and to assist the physicians in this way. It was a very difficult position to hold because every doctor believes their patient should be next in line, but it was this doctor who made the decision to prioritise care based on clinical data.” says Crotz.
But it is not just a set of observations and anecdotes that should be noted for the argument’s sake. Some hard figures, although not formal research, about how the culture of QI and safe patient care filters into decision-making might be considered.
Mediclinic Midstream, accredited for the first time in 2018, is a 181-bed multidisciplinary hospital situated in the heart of Gauteng and serves a catchment population of half a million people.
Hospital General Manager, Dr Shane Kotze says “We used clinical staff to capture data. Teams were given an early-warning system tool to use, on which they could plot the data and if they had any concerns, they could immediately call upon a Critical Care Outreach Team. There were ICU nurses on the floor. And so, with very minimal tweaks, we could nurse 34 patients in a ward as a high-dependency ward, without having to only direct high-care nursing at a specific patient. We rationalised the nursing notes, we rationalised the measuring of data and we made the patients part of their own recovery. We went down from 108 patient critical events in the second wave to one in the third wave.”
Kotze mentions that they changed the patient diet after realising that patients did not want to eat heavy meals and did not have an appetite, so they didn’t take in nutrition, and they didn’t hydrate themselves. They came up with the idea of smoothies as an option. We asked the dietitians and the kitchens to prepare highly nutritious, high calorie diets so that patients could simply sip through a straw between breaths.
A Galvanised Therapeutic Team
“Our methodology was to follow PDSA methodology on a very rapid cycle. Every day we sat together – a short huddle – and had a Clinical Command Meeting with our core team and relevant doctors. We looked at the current situation – the so-called SitRep – and then we looked at what we needed to do on the day. That could be purely operational, but it could also be about improvement. The next day at the next huddle we would evaluate the preceding 24 hours.” adds Kotze
“We diligently documented every decision and every conversation. We developed a daily huddle board and every day it was plotted out and recorded. So, every day we knew what the situation was and also what action was required from various departments.
“We were also strict in terms of communication. Whatever was discussed and agreed upon was then communicated and we had a standardised methodology to impart this and documenting the fact that such communication had taken place. We made sure we communicated what was expected so that it could be reproduced.
“At no point did we throw the book out. We kept looking at our KPIs and we kept as many of the structures in place as we could. We realised, especially during the second wave, that if one took one’s eye off the ball for a second, no battles against COVID would be won because the whole hospital could potentially be put at risk.
“We found it was essential to stick to the framework and make sure that each and every unit was managed in a structured manner. I think the COHSASA process definitely added something there.
“We held each other accountable. If one department wasn’t quite happy with something, we’d call each other out quite quickly.
“We used the EVPs (self-evaluation against the accreditation standards) quite often during the pandemic to make sure that we weren’t allowing our quality to slip. We looked internally continuously, and we conducted peer reviews of units.
“We also used a ‘robot system’ – stop, continue, go – it was a stop, maintain and implement new processes. If we stopped something, we documented it. If we maintained something or put something new in place, we knew what these were. So, when the COVID wave was over, we knew what to start, maintain or change.
Preparing a response
Marquin Crotz Hospital General Manager of Mediclinic Vergelegen says there were certain standards that were integral to helping the hospitals get through COVID.
“Two areas of standards compliance in the COHSASA programme – disaster management and infection control – were critical in preparing for our response and human resources became very important in terms of the upskilling we had to do.
“We had to re-examine our disaster management plan when we knew that COVID was on the horizon.
“It was quite special to get all the doctors and specialists from the community attending a meeting. They were involved right at the start of the planning process and that for me was key in updating our disaster response plan.
“We had to get more staff trained so they could work – under supervision – and assist in higher level of care situations. We used a lot of theatre staff in other nursing units because we had cut down on our theatre lists. It wasn’t an easy step for staff to take. It was not their normal areas of expertise. I have to take my hat off to the staff; they were always willing to assist – even in unfamiliar territory.
“The second wave in December 2020 was difficult to respond to in terms of resources. That was the biggest challenge. We had to call staff back from holidays to help out.” adds Crotz
A QI culture
Much has been written and said about the pressures on hospital workers during the COVID pandemic. What has not been correlated has been the effect of a QI culture on propagating those actions.
Carmen Savva, Hospital General Manager of Mediclinic Nelspruit says: “We had staff come back to nurse babies in the neonatal unit and deputy nursing managers directing ambulances. On Saturdays and Sundays, the nursing manager and I would sit in the office doing contact tracing. There were no limits, no boundaries. We were all on fast forward.”
Henk Laskey says that Mediclinic Constantiaberg found the second wave of the COVID pandemic in December-January of 2020/2021the most difficult to manage. “We had a massive patient load; we were using anaesthetic machines as ventilators. We had to upskill and train our ward nurses to assist in ICU with ventilators. Some of our doctors assisted the nurses in the ICU helping to prone patients and mix medicines.
“There was one dermatologist who had qualified as a physician. She left her private dermatology practice to work as a physician in the ICU.
“We focused a lot on mental wellness of our staff and psychiatrists organised debriefing sessions for our staff.
Beyond the call of duty
Marquin Crotz, the Hospital General Manager of Mediclinic Vergelegen says: “A prayer group was initiated every Wednesday morning by one of our specialists for all staff for emotional and spiritual support. This was for everyone – whether they were cleaners, nurses or doctors. A paediatrician organised a community support initiative for staff, getting meals to them when they could not get home because they were working long hours.
When the available level of qualified nurses was under pressure, doctors stepped in to support, operating in the role of nurses Says Carl Buhrmann of Mediclinic Bloemfontein: “When we had staff shortages due to them contracting COVID, we moved people around so if there were shortages in the kitchen, we got cleaners to help out. We moved different staff into the laundry. We used security people for completely different jobs than what they had been appointed for, like being porters. Sometimes we had the nursing manager working in the kitchen. This created a team spirit and brought us all closer together.
Dr Shane Kotzé says many staff at Mediclinic Midstream went the extra mile during the pandemic for their patients.
“It wasn’t foreign to see doctors pushing beds around the hospital. We had staff that worked really long hours and were willing to stretch themselves. Our theatre staff were called upon at peaks of the pandemic to nurse patients in our emergency centres and ICUs.
Tabitha Lolliot of Mediclinic Pietermaritzburg believes that the hospital survived due to team spirit.
“I recall in December 2020 that all the staff were recalled from their leave – during Christmas and New Year when people are normally celebrating.
“During the second wave, we had fantastic support from the community. We got support parcels and care packs from people in the Pietermaritzburg area who wanted to rally and thank the staff at hospitals.”
These stories demonstrate that adhering to standards, having policies and procedures in place and working a quality improvement and accreditation programme are indispensable to building a robust health system to withstand future pandemics and health crises.
Allowing patients to be
part of the healing process
Hospital General Manager of Mediclinic Midstream, Dr Shane Kotzé, shared some of the challenges faced during the COVID-19 pandemic as well as their innovative approach to involving the patient in their own healing process.
Hospitals were under enormous pressure due to the severity and volumes of patients during the peaks of the pandemic. Resources were at capacity and teams had to identify new ways of doing things to facilitate the care required by patients. Dr Kotze details how new patient flow patterns were implemented including the introduction of an additional step in the escalation or de-escalation of care which unfortunately still saw resources under pressure.
One of the concepts that was trialled during the second wave was satellite high-care units. Looking back at the data, more than a hundred patients had critical events where they needed unplanned escalation in the level of care to ICU. Kotze adds that healthcare workers are trained to do something in a certain way with these associated processes that limit risks and follow set clinical pathways. However, during this period, there were expectations for them to deliver care to the patients, but they were unable to do so due to the excessive demands made by the volume of patients.
“We had employees who were emotionally exhausted, especially after the second wave. It was in the third wave that we recognised that we were approaching the same challenges again,” he explains. During an early morning huddle, a long discussion was held about what clinical options were available, and how learnings from other parts of the world could assist the teams. The concept that resulted from those discussions was simple: ‘Let’s change it’, By taking the latest thinking in patient safety and empower patients to aid in their own observations of their condition. In other words, let’s give them information. This process was implemented by a senior nurse who ensured that the roll-out process was carefully supervised.
The need for quick adoption by patients was treated with high priority to alleviate the pressures on healthcare workers. Dr Kotze further explains that the roll out to patients needed to maintain care, “We explained to patients about our priority to support them during recovery, and that we want to help them to recover as fast as they feel comfortable to do so,” Kotzé adds.
Patients were issued with pulse oximeters to measure the oxygen saturation levels in their blood and were shown how to use them, the benefits of proning were also highlighted. “We indicated that saturation levels above 92 were ideal and we asked patients to check and record their own readings and call for assistance if needed,” he continues. If patients found their levels were dropping, their oxygen intake was adjusted upwards and vice versa. They monitored themselves and critical events dropped to one in the third wave.
“Patients were informed about the metric they could use to empower themselves, to seamlessly understand whether their condition was improving or deteriorating. They were also advised that when their oxygen levels had to be adjusted, they were to change their position and offered further guidance on proning. A nurse would visit the patients every hour to document their vital data” concludes Kotze.
Mediclinic’s decision to empower the patient to be part of their own healing process proved to be successful even after discharge because patients knew how to monitor their oxygen levels at home. The time to discharge also decreased significantly which was a great steppingstone for the hospital group, its patients and the health sector as a whole.
Managing a hospital in ‘apocalyptic-like’ conditions
The Brookside Mall on fire during the Pietermaritzburg riots in July 2021.
Can you imagine operating a hospital in the middle of winter at the height of a pandemic and in the middle of what looked like a civil riot? Imagine further that oxygen is in limited supply and there is a shortage of food for patients because trucks cannot find their way through blockaded protests. This is not Ukraine. This is KwaZulu-Natal in South Africa in July 2021, when political grievances and economic pressures led to looting and riots. This after a devastating COVID surge only 5 months prior.
Not only did the hospital have to navigate through the pandemic, especially the extreme waves in January and February of 2021, but had to contend with civil unrest, rioting and looting in the town it is situated.
Add to that a supercell storm on the 22 December 2021, in Pietermaritzburg a few months later. It uplifted trees and created havoc in the city. The hospital in the centre of the capital, Mediclinic Pietermaritzburg, flooded. Theatres, CSSD and ICUs were negatively impacted, with water and hail overwhelming the drainage system outside.
One of the staff members helping to mop up the water likened the flood to a cleansing ceremony for the hospital after the year they had been through.
Mediclinic Pietermaritzburg is a private hospital that was hard-hit and the people working at the hospital described it as “working under apocalyptic-like conditions”. “We were so significantly impacted by the second wave of COVID-19 in January 2021 that we were on the brink of running out of resources in the KZN province. There were no private hospital beds left to transfer patients out to,” says Hospital General Manager, Tabitha Lolliot.
These were things you read about in a disaster management situation that now became our reality. I remember a phone call one Friday night at about 22:00 when I was told that the hospital oxygen access points in our ICU and High Care were all in use and patients were still arriving at the emergency centre. The hospital was able to provide additional access to high care beds in other units to ensure that we could assist these patients. It was very stressful. We had to make do with what we had at the time and keep phoning to locate capacity in the different provinces to transfer patients.
The looting and violence of July 2021 impacted our hospital in a major way. Ambulances and oxygen supplies could not get through some areas that were like war zones. We had to bring in our oxygen deliveries under security protection. The main highways were shut and so it impacted our food and fuel supplies.
On Monday 12th July, when the unrest started, by 6am, we already had about 60 staff members that had phoned in to say they could not get to the hospital. Those that did get through arrived very traumatised because they had to drive on pavements to avoid all the rocks and broken glass on the roads, some were even shot at. We had to close our vaccine site because it wasn’t safe for people to come into the hospital. We had to convince nearby shops to accept bulk orders for food from us. These bulk orders would arrive by ambulance to stop looters from attacking them. The bulk order list included toothpaste and toothbrushes because we had staff sleeping overnight to avoid having to travel through troubled areas.
Every night at least three members of hospital management would sleep at the hospital to provide support to the staff and patients. There was no fuel available, so staff had to create lift clubs. Even then, many were running on empty tanks.
One of our catering staff walked 16kms to get to work: Many of our nurses pulled double shifts and stayed over in the hospital, especially our ICU staff: that was the level of commitment.
The other serious impact was the lack of supply of medical consumables and medicines. Two medical supply factories in Durban were torched, one of them our main supplier. Mediclinic corporate office came to the rescue and arranged a helicopter to land at the hospital with essential supplies. They also arranged food parcels for all the staff, which were delivered when the national roads opened.
Food parcels being delivered to the hospital.
The violence also resulted in an increase in trauma cases like car crashes and gunshot wounds, which impacted on our theatres. We had tried to limit theatre cases due to the demand on resources for the management of COVID patients.”
We had different challenges with the different COVID waves. In the first wave with the level-five lockdown our biggest challenge was human resources because that’s when our staff were getting sick. We have a staff complement of 500 and on one day we had 120 staff members off duty – either because they had a high-risk exposure, or they had tested positive, or they were symptomatic. Fortunately, that wave was less significant regarding high patient numbers.
We started to think our way around problems, for example, how were we going to manage high patient loads in the ICUs? We did this through the introduction of team nursing. In effect, this meant that instead of one-on-one nursing, a team of two or three nurses would look after three or four patients. They would move as a team to take care of patients.
With the human resources shortage where people were getting sick, we analysed what was going on and identified the issues (why staff were getting ill) and put a PDSA cycle in place. We identified our tea lounges as being a problem, this is where staff met for their breaks. We also identified the lift clubs as a problem. So, we put actions into place to mitigate these risks.
The nurses would all go home in one car without masks. One person would get exposed and the whole group would get sick. There were lift clubs with people from different departments, we had to trace where each person was working, and who was in that lift club, where they had tea. We created a tea-time rota so that they were not all together at the same time. We created space outside in the gardens so they could have tea breaks in the fresh air and not cross infect each other.
“Thinking our way out of these problems was possible because we had great support from our Mediclinic corporate office. But I believe it is also because we have been accredited several times by the Council for Health Service Accreditation of Southern Africa (COHSASA). This means that thinking through problems and meeting rigorous standards are embedded in our everyday operations and this gave us the operational resilience we needed to meet these different crises,” said Lolliot.
By Marilyn Keegan