In this interview with Ali Naffa, Quality and Safety Officer at Mediclinic City Hospital,
we hear how the organisation is committed to delivering the highest standards of care to patients and the measures put in place across the hospital, including the adoption of clinical decision support solutions, to drive best in class healthcare services.
Ali, please tell us about your role
I am the Quality and Safety Officer at Mediclinic City Hospital and I am in charge of the clinical and non-clinical quality programme, which includes risk management and accreditation. My role is to make sure we have the resources for maintaining clinical outcomes and a safe clinical and nonclinical environment. I’m responsible for maintaining compliance with regulatory requirements and accreditation standards.
I also look into how we can streamline processes around the hospital to ultimately
improve clinical outcomes for patients and patient satisfaction.
One challenge we face is that this is a big hospital with many specialties and a diverse workforce that comes from a wide variety of healthcare systems.
There is a need to standardise practices as much as possible, though getting everybody on board can be a challenge, when there are different schools of thought and people are used to different clinical guidelines.
How do you standardise clinical practice?
One thing we do is develop clinical guidelines. Clinicians discuss different approaches to treatment, and they decide on the best approach based on evidence and research
studies from around the world.
Clinical information resources from Wolters Kluwer, such as Lexicomp, feed into this
process by providing a unified source for medication safety. Lexicomp provides a onestop shop for doctors, nurses, or pharmacists to have discussions using the same reference. And that actually saves a lot of time for everybody. We also use UpToDate, which comes in at the beginning of the process when we are looking for sources to develop the guidelines. It plays a key role in summarising all the evidence in one synopsis.
How do you ensure that City Hospital is delivering safe care to patients?
Every process and service in the hospital has a document that outlines what should
be done for each and every scenario, and that document is evidence-based.
We set expectations through policies, and then we train staff and ask them to read the policies, the procedures, and the competencies. After training, we monitor performance and we do this mainly through direct observation. We observe people practicing, and evaluate them through an audit tool.
We also ask the managers to report on a number of key performance indicators (KPIs) based on their area of practice, and we benchmark against other business units within Mediclinic — including our hospitals in South Africa and Switzerland.
Lastly, we use patient satisfaction surveys to help monitor and improve performance. We have an annual strategy with different areas to focus on each year. One of the key areas last year was medication safety, in terms of improving the prescription process and accuracy of the prescription through appropriateness reviews to reduce error and ensure patient safety.
How are you ensuring compliance to guidelines?
Compliance is usually monitored through direct observation and reported performance measures. We review the records for certain diagnoses that have clinical
guidelines — stroke for example — and we check for all patients who had a stroke
diagnosis to see whether the guidelines were followed.
Then we have another approach whereby the regulator comes over and checks as
an unbiased third party. Joint Commission International (JCI), a not-for-profit organization which accredits and certifies healthcare organizations and programs
worldwide, also falls under this category of an independent third party that can
audit and provide feedback.
How are pharmacists, doctors, and nurses using Lexicomp to help them make appropriate decisions?
Pharmacists like to use the system for checking the therapeutic doses, allergies
and for checking indications. Sometimes pharmacists get medications with unusual
indications and they want to make sure that this is a new indication for a known
medication, for example.
Doctors, on the other hand, use multiple resources, and Lexicomp is now one of the tools they use. They use it to reach agreement with the pharmacists on dosing. Nurses need guidance on how to administer medication and also how to identify any interactions with food.
What has been the benefit of having Lexicomp available to your clinicians?
I have noticed a decrease in the number of medication errors or near misses that
come with wrong prescriptions after the recent Lexicomp training. A near miss is an error in the making that hasn’t reached the patient. So if a prescription is wrong or if a doctor prescribes a medication outside the usual dose, and the pharmacist picks up on that, and corrects it, then that is a near miss.
How do you encourage clinicians to use Lexicomp?
We make them all aware of the resource at their initial orientation when they start
working at the hospital. We also discussed with Wolters Kluwer how we could create internal capability to provide ongoing training as well as develop methods of evaluating awareness and usage of Lexicomp.
Our Wolters Kluwer trainer had a genuine interest in making sure that the ideas were implemented. Her passion and belief in Lexicomp helped ensure that our teams adopted it quickly.
Can you tell us a bit more about how Lexicomp is used to prepare for JCI accreditation?
One of the standards required in the medication management chapter requires an
appropriateness review. ‘Appropriateness review’ is a term that JCI uses to refer to
a process whereby the clinician checks whether the medication is appropriate for
the patient. This includes checking for dosage, interaction, allergies, contraindications, etc.
Now, we don’t dispense all the medication from our pharmacy – we keep some stocks within our units in case of emergency where there may not be a pharmacist. The JCI standard says that if there is no pharmacist, then either another physician or a nurse should conduct the appropriateness review.
To be able to conduct an appropriateness review, the doctor or nurse should receive training and also have a reference tool. Nurses have been trained to use Lexicomp as an appropriateness review tool to ensure that the medication is appropriate for the patient. In terms of complying with that particular JCI standard, which has clear implications for patient safety, Lexicomp plays a critical role in achieving compliance.
How do you use UpToDate to support your quality and accreditation process?
There is a JCI standard that requires a hospital to create five guidelines for any high-volume or critical diagnosis. When a guideline is created, we need to document where the information and evidence came from.
Checking, evaluating and comparing evidence is a sizeable task that can be made much quicker and easier by using a tool such as UpToDate, which already synthesises the evidence and provides recommendations. We use UpToDate to identify the sources and create guidelines.
What impact do you think clinical decision support (CDS) resources such as Lexicomp and UpToDate have on performance?
I know that CDS resources have a positive impact on performance, mainly because we know from studies that human performance declines over time.
Although our human decision-making systems retain multiple variables at any point
in time, we know there are limitations in terms of the number of variables that can be
retained in order to make the best decisions. CDS solutions provide a great supplement to the personal decision-making system.
• Original interview conducted with Ali Naffa, Jan 2020.
• For more information, visit: https://www.wolterskluwer.com/en/health
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