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Strategic Report:

Clinical services
overview

“Our organisational value is ultimately realised at hospital level where Mediclinic employees and partners work tirelessly to enhance the quality of life of our clients and their families.”

Dr René Toua

Chief Clinical Officer

“Our organisational value is ultimately realised at hospital level where Mediclinic employees and partners work tirelessly to enhance the quality of life of our clients and their families.”

Dr René Toua

Chief Clinical Officer

Introduction

Mediclinic provides a wide range of clinical services throughout its divisions. These include outpatient consultation services, pre-hospital emergency services, hospital-based emergency centres, day case surgery, acute care inpatient services and highly specialised services. Support services include laboratories, radiology, radiation oncology and nuclear medicine.  

During the year under review, the clinical performance across the Group made good progress and several patient safety and clinical effectiveness indicators showed improvement. In addition, many initiatives in support of clinical performance and quality improvement were launched and completed. The restructuring and strengthening of clinical services leadership at hospital and corporate levels continued across the Group, as did the refinement of methodologies to accurately measure and report on the effect of quality improvement initiatives on clinical outcomes and sustainable clinical performance.

To ensure complete and comparable results, a time lag is allowed for the collection of some clinical data. All indicators are therefore reported on calendar year.

A key focus area of Mediclinic is its commitment to superior clinical performance which encompasses the quality of clinical processes and outcomes. This is done through a simple, yet powerful clinical performance framework built on a sound clinical governance foundation – collectively, the clinical management model (Figure 1). The model supports a structured approach to clinical management through a clinical governance foundation layer that provides the structures and processes required for clinical performance.

The Company made a significant investment in the improvement of clinical performance; it believes this to be crucial to future success. Clinical performance is quantified and reported on in line with the framework, including detailed monthly reporting with external oversight at both divisional and Board levels.

This report provides an overview of the Group’s clinical performance for the year under review. The detailed Clinical Services Report, available on the Company’s website, provides a more in-depth description.

FIGURE 1: THE MEDICLINIC CLINICAL MANAGEMENT MODEL

Figure key

Where variation in current year data is found to be statistically insignificant when compared to prior reporting periods, the data in the graph is presented as / / .

Where variation in current year data is found to be statistically significant when compared to prior reporting periods, the data in the graph is presented as and an explanation is provided, if available. In these instances it is unlikely that the changes in the numbers are due to chance.

Statistical significance is determined by performing a hypothesis test. A difference is deemed to be statistically significant if the p-value exceeds a 5% critical limit. The indicators reported represent the means of their respective distributions and the hypothesis test examines if the means for successive years are from the same distribution (null hypothesis) or not (alternative hypothesis). This result allows us to conclude if a difference is significant or not. The test statistic for the hypothesis test and the distribution of the test statistic are dependent on the type of data being reported on.

GROUP

Clinical performance

Never events

The implementation of the safe surgical checklist remains a key focus area. Mediclinic only reports on a subset of surgical and procedural never events at present focussing on the correct identification of patients, procedures and sites and the prevention of retained foreign objects. In future, the list will be expanded to include a wider definition of never events.

Length of stay and case mix index

The case mix indexes of the divisions are calculated by using the internally developed clinical and cost-related groupings (“CCRG”) system.

The case mix index of Hirslanden was 1.45 for 2018. This is mainly due to its high load of complex and technologically advanced cases in an older population. In keeping with a high case mix index, Hirslanden’s inpatient length of stay was 4.77 days (measured in calendar days).

The case mix index of Mediclinic Southern Africa was 1.20 for 2018. The inpatient length of stay was 3.76 days (measured in calendar days).

The case mix index of Mediclinic Middle East was the lowest of the three divisions at 1.08 for 2018 due its younger patient population. In keeping with its low case mix index, the inpatient length of stay was 2.90 days (measured in calendar days).

Internal audit

During the reporting period, an internal clinical audit function was established; the audit programme is supported by the Internal Audit department. The audit process will be refined and standardised across the Group in the coming year.

Patient experience

Mediclinic benchmarks and publicly reports on patient experience on a divisional level through Press Ganey®, an internationally recognised leading provider of patient experience measurement for healthcare organisations across the continuum of care. Patients are surveyed after discharge and this valuable feedback helps Mediclinic better understand patients’ needs and adapt care services accordingly. A comparative report will be included in the 2020 Clinical Services Report.

TABLE 1: PRESS GANEY® RESULTS FOR THE 2018 CALENDAR YEAR

Hirslanden Mediclinic Southern Africa Mediclinic Middle East
Participating since February 2017 October 2014 October 2014
Total participating hospitals 17 51 (Jan–June 2018)
50 (July–Dec 2018)
6
Total surveys collected
1 January 2018–
31 December 2018
34 180 40 143 2 345
Overall mean score 87.4 82.0 85.6
 

Performance overview

PROGRESS AGAINST OBJECTIVES
Group-wide Hirslanden Mediclinic Southern Africa Mediclinic Middle East

Patients First at Mediclinic

  • Clinical performance measures and operational dashboards were refined.
  • A patient safety sub-committee was established to standardise and enhance collaboration across
    the Group.
  • An initiative was started to coordinate collaboration of nursing services across divisions.
  • A collaborative forum was established for clinical risk management across the Group.
  • A clinical adverse event and clinical risk management solution suitable for the Group was obtained.
  • Patients were surveyed on quality of life before and after joint replacement as part of the patient-related outcome measurement.
  • A continuous patient experience survey for all inpatients who participate in the Press Ganey® survey was introduced.
  • A master data management programme was implemented to compile and govern data relating to affiliated medical practitioners.
  • Specific training initiatives were implemented to promote best practice with specific clinical procedures that required review.
  • Action plans aligned with the national hand hygiene strategy were implemented to further improve hand hygiene compliance.
  • Action plans were developed to improve medication safety.
  • Additional clinical performance measures were refined.
  • Additional mechanisms were developed to share clinical information with medical practitioners.
  • Infection rates were further reduced through the implementation of a comprehensive infection prevention and control (“IPC”) strategy.
  • The corporate clinical structure was reviewed and implemented to ensure that the Clinical Services department can effectively execute its mandate and responsibilities across the different geographical locations.
  • The clinical committees were re-aligned to support the new corporate clinical structure.
  • The implementation of a standardised performance appraisal process for medical practitioners continued.
  • A scope and project plan for the nursing performance management system was finalised.
  • A Joint Commission International (“JCI”) re-accreditation plan was formulated.
  • The quality and patient safety strategy was updated.
  • A strategy was developed to manage quality indicators (as defined by the regulators).

Value-based care

  • Initiatives have commenced to coordinate health technology assessments centrally. These initiatives will be refined further.
  • The policy on indication quality and the introduction of indication boards was completed and distributed. Hospitals offering oncology treatment are running preoperative (pre-treatment) tumour boards.
  • Fast-track orthopaedics was established in three hospitals and rollout at a further two hospitals is planned.
  • A common structure for highly specialised medicine services was introduced.
  • Additional Hospital Clinical Managers were appointed.
  • Implementation of the new clinical performance, oversight and governance model continued (in collaboration with supporting medical practitioners).
  • A new clinical pathway for obstetric care was developed (in collaboration with supporting medical practitioners).
  • The first phase of the national stroke management implementation plan was completed.
  • The affiliation agreement with MBRUHS was expanded. Mediclinic City Hospital is an accredited external training facility for medical students; the third intake of medical students enrolled in September 2018.
  • Mediclinic City Hospital entered into an agreement for a paediatric residency training programme between MBRUHS and Al Jalila Hospital.
  • Clinical processes at Mediclinic City Hospital’s breast cancer and metabolic centres were further streamlined.
  • The centralisation and consolidation strategy of laboratory services continued.
  • The Mediclinic City Hospital laboratory was successfully re-accredited by the College of American Pathologists.
  • The laboratories in the Abu Dhabi, Al Ain and Western Region obtained ISO certification.
  • A 30% stake in Bourn Hall International was acquired.
  • Existing clinical pathways are being reviewed and additional pathways and guidelines are being developed to prepare for the implementation of diagnostic-related grouping (“DRG”) and the new EHR system.
  • The clinical strategy for certain key service lines has been finalised.

Clinical information systems

  • Continued collaboration and support were provided to Hirslanden with the implementation of its EHR system.
  • Thought leadership, oversight and close collaboration were provided in the selection of an EHR system for Mediclinic Southern Africa and Mediclinic Middle East.
  • Future documentation for catheterisation laboratories and emergency departments was defined.
  • The re-evaluation of the radiology information system was completed and a new system was selected. The pilot project at Hirslanden Klinik Im Park is nearly completed and the go-live for Klinik Hirslanden is scheduled for 2019.
  • The integration of medical source data was reviewed and this project was added to the Hirslanden transformation exercise. Zürich hospitals will be used for the pilot phase.
  • Specific service providers were engaged to evaluate potential solutions for the market in Southern Africa. Mediclinic Southern Africa is in the final stages of finalising a proposal for implementation.
  • EHR rollout commenced at Mediclinic Parkview Hospital and Mediclinic Ibn Battuta.
FUTURE OBJECTIVES
Group-wide Hirslanden Mediclinic Southern Africa Mediclinic Middle East

Patients First at Mediclinic

  • Implement a clinical adverse event and clinical risk management system across the Group.
  • Further refine and optimise the clinical performance model and clinical performance indicators.
  • Further drive collaboration on nursing across the Group.
  • Support the divisions in eradicating never events and decreasing the number of serious adverse events.
  • Refine and optimise the medication management process across the Group.
  • Refine and optimise the clinical governance structure to enforce the Ward-to-Board accountability framework across the Group.
  • Further rollout of the patient-related outcome measurement.
  • Patient Safety Policy compliance audit in 2019.
  • Determine adherence to the safe surgery checklist through unheralded inspections in 2019.
  • Identify patient pathways that qualify for standardisation, especially in terms of fast-track orthopaedics.
  • Develop action plans in collaboration with medical practitioners to prevent adverse events.
  • Improve nursing skills mix and reposition the Nursing Unit Managers to improve clinical outcomes.
  • Develop hospital-specific action plans aimed at improving clinical performance.
  • Improve the overall patient experience.
  • Enhance the national hand hygiene strategy to further improve hand hygiene compliance.
  • Implement additional components of the antimicrobial stewardship strategy.
  • Develop additional action plans to improve medication safety.
  • Review and refine the comprehensive IPC strategy.
  • Implement the Ward-to-Board accountability framework.
  • Define and align the clinical risk management strategy to the Group.
  • Continue the implementation of the adverse events management strategy.
  • Host the second Mediclinic Middle East Annual Research Day in 2019.
  • Define a clear strategy for establishing centres of excellence.
  • Refine hospital-level clinical structures.
  • Refine the clinical strategy for Abu Dhabi and Al Ain.
  • Continue to implement the standardised appraisal process for medical practitioners.
  • Further develop and implement a quality management framework.
  • Implement trauma and urgent care centres.
  • Implement a 24-hour paediatric service at Mediclinic Welcare Hospital and Mediclinic Parkview Hospital.

Value-based care

  • Centrally advise and coordinate clinical research across the Group.
  • The fulfilment criteria of the system provider model will be defined. Subsequently, evaluation criteria will be determined for the level of adherence to the model at hospital level.
  • Appoint additional Hospital Clinical Managers.
  • Continue with the implementation of the new clinical performance, oversight and governance model in collaboration with supporting medical practitioners.
  • Implement clinical initiatives aimed at further improving obstetric care.
  • Complete the final phase of the national stroke management implementation plan.
  • Define a strategy for benchmarking medical practitioners.
  • Continue the centralisation and consolidation strategy for laboratories.
  • Further develop and expand coordinated care initiatives.
  • Continue to develop the obesity surgery service at Mediclinic Airport Road Hospital and prepare for its accreditation.
  • Investigate a robotic pharmacy system.
  • Develop clinical model for Cost per Event and DRG use.
  • Improve the use of generics.

Clinical information systems

  • Continue to collaborate with and provide support to Hirslanden and Mediclinic Middle East with the implementation of their EHR systems.
  • Continue to provide thought leadership, oversight and close collaboration in the selection of an EHR system at Mediclinic Southern Africa.
  • Establish a machine learning capability.
  • Develop an integrated clinical digital roadmap, including artificial intelligence, machine learning and telemedicine.
  • Continue rollout of the radiology information system in a second hospital in 2019.
  • Introduce a standardised documentation approach for medical practitioners in the EHR. The approach is already defined and will be tested at two hospitals in Zürich in 2019.
  • Continue rollout of the PDMS. The division is preparing for the rollout at two hospitals in Zürich.
  • Conceptualise the integration of the PDMS and the EHR.
  • Finalise a feasible proposal for the implementation of an EHR and continue with action plans aimed at improving readiness for the implementation plan.
  • Continue EHR rollout.
  • Comply with the Department of Health Abu Dhabi’s Health Information Exchange requirements.

HIRSLANDEN

Most cases are elective in nature; services such as advanced neonatal critical care and major trauma are provided by the cantonal and university-teaching facilities. Most admitting medical practitioners are self-employed, but medical practitioners working in the fields of hospital-based specialities, such as anaesthetics and internal medicine, are employed at certain hospitals. Radiology, nuclear medicine and radiation oncology services are, in most instances, owned and operated by the hospitals.

Clinical performance

Patient safety

An important aspect of improving the quality and safety of patient care is preventing adverse events that could harm patients, including medication errors, falls and hospital-associated pressure ulcers (Figure 4).

Note
1 The reporting of medication errors is new to the division and data collection is still being optimised.

The 2.84% decrease in fall rate per 1 000 patient days from 2.52 in 2017 to 2.45 in 2018 is not statistically significant. The prevention of falls is a focus area for the hospitals; Hirslanden Klinik Linde is testing a new device to detect unattended stand-up of at-risk patients.

The hospital-associated pressure ulcer rate per 1 000 patient days increased by 30.17% from 0.73 in 2017 to 0.95 in 2018, a statistically significant change. Analysis revealed several challenges in the correct collection of the indicator. Introducing a business partner model in quality management whereby hospital-level Quality Managers report directly to corporate-level quality management will provide further alignment and accountability.

Infection prevention and control

The rate of healthcare-associated infections (“HAI”) and related conditions remained stable in 2018. As these conditions are rare, a single infection causes a high rate based on small denominators.

Figure 5 reflects a decrease in all device-associated infections. The ventilator-associated pneumonia (“VAP”) rate per 1 000 device days decreased by 61.59% from 4.17 in 2017 to 1.60 in 2018, a statistically significant change. Improvement across all device-associated infection rates is largely due to a renewed focus on implementation of and adherence to IPC bundles.

Clinical effectiveness

Mortality

Figure 6 reflects a 1.72% increase in the inpatient mortality rate from 0.95% in 2017 to 0.97% in 2018, however, the variation is not statistically significant and remains in line with the 2016 and 2017 rates.

Re-admission and re-operation rate

The re-admission rate is reported as a 15-day unscheduled re-admission rate as defined by the International Quality Indicator Project. The 6.58% increase in the re-admission rate from 1.51 in 2017 to 1.61 in 2018, as reflected in Figure 7, is not statistically significant.

The 5.11% decrease in the re-operation rate from 1.62 in 2017 to 1.53 in 2018, as reflected in Figure 7, is not statistically significant.

Mediclinic Southern Africa

Most of the hospital cases are elective in nature, but a significant portion is unscheduled, emergency and trauma related. Admitting medical practitioners, excluding emergency medicine practitioners within certain emergency centres, are self-employed and practise independently. Radiology, laboratory and oncology services are also provided by independent practices.

Clinical performance

Patient safety

Medication errors per 1 000 patient days reduced by 23.26% from 1.58 in 2017 to 1.21 in 2018. The values returned to 2016 levels after quality improvement initiatives were implemented.

Neither the 2.65% increase in the fall rate per 1 000 patient days from 1.02 in 2017 to 1.05 in 2018 nor the 7.89% increase in hospital-associated pressure ulcer rate per 1 000 patient days from 0.22 in 2017 to 0.24 in 2018 are statistically significant.

Infection prevention and control

Southern Africa has a high burden of infectious disease, unlike Hirslanden and Mediclinic Middle East where infectious disease is less of a concern. As such, the identification of infectious diseases and community-acquired infections on admission and the prevention of HAI remains a priority for Mediclinic Southern Africa.

Hand hygiene compliance results showed a 15.06% improvement from 65.74% in 2017 to 75.64% in 2018, a statistically significant increase. Hospitals continue to focus on interventions to improve hand hygiene compliance. There is a huge drive to ensure that employees understand the important correlation between hand hygiene compliance and HAI rates.

The catheter-associated urinary tract infections (“CAUTI”) rate decreased by 10.00% from 2.54 in 2017 to 2.29 in 2018, mainly due to improved care bundle compliance and a targeted focus and appropriate interventions after detailed system analysis where it has been identified as a problem. The 1.96% increase in the rate of central line-associated blood stream infections (“CLABSI”) from 2.43 in 2017 to 2.48 in 2018 is not statistically significant. A system analysis is done of each CLABSI case to understand the underlying contributing factors and to implement targeted interventions. The VAP rate decreased by 20.66% from 4.90 in 2017 to 3.89 in 2018, mainly due to regular review of evidence-based care bundle implementation and compliance (e.g. the importance of subglottic suctioning in continuous ventilation).

Antimicrobial stewardship

Considering the high burden of infectious disease in Southern Africa, effectively managing antimicrobial resources and preventing multidrug resistance are critical. Antimicrobial resistance increases with increasing utilisation of antimicrobials, therefore Mediclinic Southern Africa monitors total antimicrobial utilisation in Defined Daily Doses. The total antimicrobial usage and utilisation decreased by 1.95% in 2018.

Clinical effectiveness

Mortality

The inpatient mortality index decreased by 7.73% from 0.94 in 2017 to 0.87 in 2018, a statistically significant change.

Re-admission rate

Mediclinic Southern Africa reports on a 30-day all-cause re-admission rate.

The 1.43% increase in the re-admission rate from 12.50% in 2017 to 12.68% in 2018, as depicted in Figure 11, is not statistically significant.

Mediclinic Middle East

At Mediclinic Middle East, the relationship between the hospitals and clinics is in the form of a hub-and-spoke model, where the multidisciplinary clinics deliver primary care and specialist consultation services, as well as follow-up from and referrals to the hospitals. Each hospital has a few clinics reporting into the hospital structure and they function as a cluster. This enables closer collaboration and improved oversight of activities between the hospitals and clinics. Traumatology is limited to the state health facilities and patients with major trauma are stabilised and transferred to state facilities.

Clinical performance

Patient safety

A patient safety culture is well entrenched at Mediclinic Middle East. It is a “just culture” (Frankl framework) with full support from senior management.

At Mediclinic Middle East both outpatient and inpatient medication errors are reported and are classified as prescription, dispensing and administration errors. The medication error rate per 1 000 patient days decreased by 8.65% from 3.51 in 2017 to 3.20 in 2018, a statistically significant change (Figure 12). There is a continued focus on medication management.

The 20.96% decrease in the fall rate per 1 000 patient days from 0.51 in 2017 to 0.41 in 2018, as reflected in Figure 12, is statistically significant. The hospital-associated pressure ulcer rate per 1 000 patient days decreased by 57.77% from 0.40 in 2017 to 0.17 in 2018, a statistically significant change (Figure 12). Various quality improvement projects were initiated, specifically in the critical care unit where the patient population has higher acuity levels with multiple co-morbidities.

Infection prevention and control

Preventing HAI remains a key patient safety objective for Mediclinic Middle East. This includes standardising processes around infection control (based on international best practices), implementing care bundles around SSI, VAP, CLABSI and CAUTI, and running a surveillance project with multilayer methodology.

Figure 13 reflects an 8.44% decrease in the CAUTI rate from 0.37 in 2017 to 0.34 in 2018 and a 41.67% increase in the CLABSI rate from 1.27 in 2017 to 1.80 in 2018. The VAP rate decreased by 39.68% from 0.54 in 2017 to 0.33 in 2018. All three changes are statistically significant, however, the changes are largely driven by small numbers of events. A change in the Centres for Disease Control and Prevention definition of HAI, especially for VAP, contributed significantly to the decrease in the rate.

Clinical effectiveness

Mortality

The inpatient mortality rate for the division remains low in comparison to the other divisions.

The mortality rate increased by 33.00% from 0.23% in 2017 to 0.31% in 2018, as reflected in Figure 14, mainly due to the establishment of a Comprehensive Cancer Centre in the north wing adjacent to Mediclinic City Hospital in Dubai, as well as legislative changes made to allow natural death in the UAE.

Re-admission rate

The 21.32% increase in the 30-day re-admission rate from 1.10% in 2017 to 1.33% in 2018, as reflected in Figure 15, is statistically significant. Chemotherapy administration, wound care, false labours, maternity-related conditions, lithotripsies, dialysis and removal of an implant are excluded in the 30-day re-admission calculation as the rate refers to unplanned re-admissions.

The increase in the unplanned re-admission rate has been identified as one of the top clinical risks for this division. To effectively manage this risk, a revised reporting framework is planned for categorising all the re-admission cases in a standardised format per department, per diagnosis, and per individual medical practitioner to identify potential improvement areas.

CLINICAL ETHICS SUMMARY

Advanced care planning, end of life and terminal care

Clinical governance structures exist to report, audit and address concerns.

Billing, care management

Operational and clinical management in each hospital are responsible for ensuring the ethical conduct of medical practitioners and employees. An ethics line exists for reporting of fraud committed by medical practitioners and employees.

Competence, scope of practice

Clinical governance structures exist to monitor and address any concerns. Recruiting the correct skills and continuous employee skills assessment are key focus areas. Strategies to ensure employee competency (e.g. formal training, short courses, and clinical facilitators) are followed.

Disclosure, reporting of adverse events

Each hospital has a formal adverse event reporting system. A “just culture” (Frankl framework) is promoted. The reporting system is non-punitive and the recorded adverse events are discussed at the hospitals’ Clinical Hospital Committees. To prevent future incidents of a similar nature, learning from incidents is a key focus area.

Ethical conduct

Operational and clinical management in each hospital are responsible for ensuring ethical conduct of medical practitioners and employees. Human resource policies exist to address issues of misconduct and criminal behaviour.

Euthanasia

Euthanasia is neither practised nor condoned in any Mediclinic facility. All hospitals have control measures in place to ensure compliance with local legislation.

Falsification of documentation, diagnosis, sick leave certificates

Operational and clinical management in each hospital are responsible for ensuring the ethical conduct of medical practitioners and employees. Documentation and clinical coding audits ensure compliance with legal, ethical and operational requirements. An ethics line exists for reporting of fraud committed by medical practitioners and employees.

Forced female circumcision

Control measures are in place to ensure compliance with the respective legislation. Informed consent for any medical or surgical intervention or procedure is upheld by the profession and is entrenched in local legislation.

Illegal practice

Existing policies manage illegal practice, compliance to which are confirmed through audits and accreditation.

Inappropriate care

Appropriate care is a key focus area across the Group and is managed by indication boards at Hirslanden and cost per event at Mediclinic Southern Africa and Mediclinic Middle East. Cost reporting, management process and structures are in place. Complex cases are discussed with treating medical practitioners.

Medical practitioner cover, availability and response

On-call rosters are compiled and available at emergency centres. A management process and reporting system exist to deal with non-compliant independent medical practitioners. Employed medical practitioners are dealt with via an established human resources process.

Medical research

Drug trials and medical research are aligned with the Declaration of Helsinki and local legislation.

All requests for clinical drug trials are approved by an independent, accredited Ethics Committee before it is accepted for evaluation and approval by the respective divisional committees. All approved trials are recorded on a registry and no unofficial drug testing is allowed.

Medical research and experiments are managed by a Clinical Research Approval Committee and related policy. Clinical governance structures exist to prevent untested and experimental treatments.

The Group deals with medical ethical issues on a daily basis. Most of these are covered by formal policies, but some are still elusive and quite complex to deal with by way of policy. In all instances, response and reaction are governed by local legislation and regulations.

Misrepresentations of qualifications and monitoring of medical practitioner performance

Accreditation involves a formal process which confirms registration, qualifications and credentials. In addition, an informal process is undertaken to solicit performance information of the medical practitioner from peers.

Medical practitioners are monitored through annual validation of registration; investigations of deteriorating hospital clinical quality indicators; mortality audits; SAE investigations; investigation of patient, medical practitioner and employee complaints; medico-legal investigations; ethics line reports; feedback from Clinical Hospital Committee meetings; direct reporting by medical practitioners; and informal feedback from employees regarding recurring concerns.

Patient protection

Occupational health specialists provide a service at each hospital. On acceptance of employment, all healthcare employees are screened for pulmonary tuberculosis, and screened and vaccinated against Hepatitis B if they do not have sufficient antibodies. In the event of an increase in the incidence or an outbreak of Methicillin-resistant Staphylococcus aureus, healthcare employees are screened and decolonised, if necessary. Flu vaccines are offered annually to employees. Other vaccines, e.g. diphtheria and measles, are offered when there is an indication; when there is an increase in cases in a specific area; or as post-exposure. In Hirslanden, radiation exposure and compliance with prevailing acceptable exposure limits are monitored centrally.

Pharmacy

Pharmacy policies, procedures and audits ensure compliance with legislation, ethical and operational requirements.

Organ trade

The organ donation and receipt process is carefully documented and complies with relevant legislation.

Remuneration, kickbacks

Perverse incentives are prohibited. Corporate Office and hospital management ensure strict compliance with established rules.

Termination of pregnancy

Strict control measures exist to ensure legal compliance. In addition, the Group allows employees freedom of choice as to whether they wish to refrain from participating in any terminations of pregnancy for moral, religious, ethical or related reasons.

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