Hospital functions like a well-oiled machine

When a hospital is accredited for a sixth time, pundits would say it is a safe assumption that it is functioning like a well-oiled machine: only a few tweaks are necessary to meet rigorous international standards.

  

When a hospital is accredited for a sixth time, pundits would say it is a safe assumption that it is functioning like a well-oiled machine: only a few tweaks are necessary to meet rigorous international standards.

Instead of hospital staff quivering at the idea of “an accreditation audit,” the stage in the accreditation journey has been reached where professionals have conversations and discuss compliance or non-compliance with standards as equal peers.

This is the experience of Nursing Manager Suné Kilian and the multidisciplinary team at Mediclinic Worcester in the Western Cape, a hospital that has been accredited half a dozen times since 1997.

At an external survey from May 30 to June 2 this year, the hospital scored a phenomenal 98 out of a possible 100. After examining all requirements in depth, the Board of COHSASA had no hesitation in conferring a four-year accreditation award on the hospital in August 2022.

This 182-bed, multidisciplinary, specialist private hospital is situated in the Cape Winelands District. It is the only acute, private hospital in Worcester and has a wide catchment area that includes more than 20 surrounding rural towns.

Suné Kilian has been a part of the COHSASA journey at the hospital since its first accreditation in 1997 and is therefore well acquainted with the requirements of the quality improvement programme and how the different areas of the hospital need to work together to achieve compliance with the standards.

She reached out to unit managers of various hospital service areas to ask of them how they found the accreditation experience, given the hospital’s exemplary accreditation history. They all felt that meeting standards and working according to policies and procedures has become embedded in the DNA of all the hospital’s operations.

“COHSASA standards have become our way of doing things,” says Kilian. “It is also Mediclinic’s way. We receive guidance from our corporate office. It is a way of living. It is not a tick box exercise. What surveyors see is what we do every day; we are not putting on a show for them. It is not an add on, it is part of what we do as a matter of course to ensure that our patients receive the best possible care.”

Like most hospitals in the country, Mediclinic Worcester was affected by the COVID-19 pandemic. However, the hospital maintained elevated levels of compliance with the accreditation standards despite major challenges posed by the pandemic.

Says Kilian: “Our nursing units have been staffed by people who have worked together for a long time. Even during the toughest times, we got together in huddles every morning and supported each other. We worked as a team and spoke through our difficulties. Staff were encouraged to take part in debriefings. Although they were very tired and had to learn new procedures quickly, they coped.

“We did not have weeks to make decisions, we had hours. The situation changed constantly. But because we had a good framework in place – the requirements of COHSASA and the Mediclinic policies and procedures – we could work from this to guide us. We noticed this particularly in the areas of infection control and disaster management.

“What we learnt from COVID-19 is that we don’t need a long time to make changes – we can do it more quickly! We are indebted to personnel at our corporate office who made intelligent strategic decisions that helped guide us on the frontline. They provided us with various potential scenarios, giving us direction for each one.

“During these extraordinary circumstances, we continued our focus on patient care and did not refuse admission to any patient. We took in all patients presenting at our emergency unit. The first COVID-19 wave that hit us hard, and we were treating up to 70 COVID patients a day. Despite the pressures this placed on the hospital, we got through it all!” says Kilian.

Mediclinic

A PROUD TEAM…Mediclinic Worcester receives a sixth accreditation award from COHSASA CEO, Ms Jacqui Stewart (holding the certificate). She congratulated the diligent team that made the prestigious four-year award possible.

Back row (from left): Gys Mostert, Human Resource Business Partner; Gina Pietersen-Olivier, Unit Manager – Medical; Shamila Daniels, Unit Manager- ICU; Jeanine Smit, Hospital Secretary; Johandi Le Roux, Unit Manager – Obstetrics; Anrietta Smit, Patient Experience Manager; Claudette Taylor, Unit Manager – Surgical; Johanna Webster, Patient Safety and Infection Prevention Control Manager; Monique Els, Learning and Development Facilitator and Johann Fransman, Technical Manager.

Front Row: Jacques van Wyk (Hospital General Manager), Jacqui Stewart (CEO COHSASA), Suné Kilian (Nursing Manager).

Mediclinic 2

A valuable certificate… (from left): Mediclinic Worcester Hospital General Manager, Jacques van Wyk, Jacqui Stewart, the Chief Executive Officer of COHSASA and Nursing Manager Suné Kilian.

“We regard COHSASA accreditation as a positive experience. It provides us with a process that we are assured we are working according to international standards. If something is wrong, we do not fall apart – we fix it. And sometimes we have different opinions on matters and then we discuss it with the surveyors. The unit managers say the COHSASA surveyors make them feel so at ease so that even if they felt slightly nervous at the start of the survey, by the time it is finished they were completely relaxed,” says Nursing Manager, Suné Kilian.

Well done Mediclinic Worcester!

Recent Blog Articles

Stay in Touch

We bring you the latest research, expert opinions, and industry updates in healthcare safety and quality – so you’re always in the know.

Follow us on social media

Nourhan Kawtharani


Nourhan, a quality and safety coordinator with eight years of experience in ambulatory healthcare in Lebanon, aims to deepen her understanding of the systemic and holistic approach to healthcare through this fellowship.

She aims to identify gaps and develop tailored interventions that address specific contexts rather than applying general solutions. Engaging with diverse professionals and perspectives during this educational journey will expand the application of these concepts across different cultural settings.

Nourhan emphasizes the importance of promoting a culture of continuous learning and improvement within healthcare institutions, considering it a vital leadership responsibility to integrate quality and safety initiatives into the organizational culture.

Nourhan's commitment to patient safety and quality management includes sourcing practical resources and transforming insights into actionable knowledge to drive continued progress in healthcare practices and outcomes.

This will close in 0 seconds

Elom Otchi


Elom is passionate about improving quality of care and patient safety outcomes.

In view of this, he has had the opportunity to work in various capacities with various organisations including AfIHQSA, WHO, UNICEF and others undertaking research, supporting the development of national quality policies and strategies, facilitating the establishment of quality governance systems across all the levels of the health sector and building capacity of national and sub-national quality leads/teams to institutionalize the practice of quality and patient safety across the continent.

He has also worked extensively across all levels of care in the health sector of Ghana, including leading the Quality & Patient Safety program in its largest teaching hospital.

I would like to use this Fellowship as a learning platform and an opportunity to acquire the requisite knowledge, skills and competencies to complement ongoing efforts by like-minded individuals and organizations to continuously advance improve the quality and patient safety in Ghana and the continent.

This will close in 0 seconds

Stephen Taiye Balogun


Stephen is a Senior Programme Officer at the Institute of Human Virology in Nigeria as well as Country Representative for Health Information for All (HIFA).

Stephen plans to use this opportunity to maximise his impact by championing the cause of patient safety and quality in Nigeria and across Africa.

Stephen says "Quality and safety is a major wheel through which universal healthcare coverage can be achieved. The goal is to be a bridge in the gap between the International Quality Improvement and Patient Safety community and my country to ensure rapid spread, adoption, implementation and practice."

We are looking forward to working with both Stephen and our 2020 winner Rhoda Kalondu over the next year.

This will close in 0 seconds

Dr Rhoda Kalondu


Rhoda is the Head of the Patient Safety Unit at Kenyatta Hospital in Nairobi and wants to use this Fellowship to learn how to establish a culture of safety and develop systems for assessment and analysis at her institution, and more widely. As well as this, Rhoda intends to develop and execute an intervention to improve patient safety in Kenyatta National Hospital.

It is one thing to institute measures and processes for improvement, but quite another to change the culture of an environment. Rhoda's ambition to lead others in this change inspired the panel.

This will close in 0 seconds

Dr Subhrojyoti Bhowmick


I am an MBBS graduate from Calcutta University with a Gold Medal in Gynecology & Obstetrics.

I have completed M.D in Pharmacology from IPGME& R, Kolkata and have over 12 years of experience in the field of Clinical Research, Pharmacovigilance and Medication management in Hospitals.

I have completed certification in Clinical Research Administration & Project Management from Stanford University, USA and in Patient Safety from Johns Hopkins University, USA.

I am an Assessor for National Accreditation Board for Hospitals & Health care providers (NABH), India assessing hospitals for medication safety and clinical quality standards and NABH Assessor for Ethics Committee Accreditation program in India as well.

I serve as the Chairperson, Institutional Ethics Committee of Health Point Hospital, Kolkata and am associated with 2 other Hospital ethics committees as a member.

I finished my Fellowship in Healthcare Quality from the International Society of Quality in Healthcare (ISQua) from Ireland in 2017.

I have published several research articles and have also authored a chapter on “Regulations governing Clinical Trial” in the book “Fundamentals of Clinical Trial & Research”.

I am a peer reviewer for prestigious international journals like the British Journal of Clinical Pharmacology, CNS Drugs and Drug Safety case reports.

I am the recipient of the UK Seth Oration Award for Best Clinical Pharmacology paper by the Indian Pharmacological Society in 2009 and the “Most promising Healthcare professional in Patient Safety in India” award by the Asian African Chamber of Commerce and Industry in October 2018.

Recently in April 2019, I received the Young Quality Achiever award by Consortium of Accredited Healthcare Organizations (CAHO), India for 2019 for my work in the field of medication safety and clinical research.

I have a keen interest in teaching and am visiting adjunct faculty of Pharmacology at KMC, Mangalore, India and for Healthcare technology at MAKAUT, Kolkata, India.

I was associated with Stanford University School of Medicine, in the USA as a Senior Clinical Research Associate from 2015 to 2017 and have certification in Biostatistics, Evidence-based Medicine and Medical Writing from Stanford University.

Currently, I am working as the Clinical Director of Academics, Medical Quality and Clinical Research at Peerless Hospital and B K Roy Research Centre, Kolkata.

I am very happy and thrilled to receive the prestigious ISQua Lucian Leape Patient safety Fellowship Award for 2019 and I look forward to honing my skills further in the field of healthcare quality and patient safety through my experiences during this fellowship.

I sincerely believe that successful completion of this fellowship will help me evolve as a more confident Patient safety leader in India who in turn can provide significant inputs on policy changes through NABH for the Indian healthcare system.

This will close in 0 seconds