Greetings from Singapore

1

Welcome to Singapore

Healthcare Delivery System Health

Promotion

Primary Care

Acute Care

Intermediate -Long Term Care

Individual & Community

Responsibility

Supported by the Health Promotion

Board

GPs and Private Sector Group

Practices (~ 80% of patients) Restructured

Hospitals & National Centres

(~ 80% of inpatient beds)

Private Healthcare Organisations

(~30%)

Polyclinics (~ 20% of patients)

Private Hospitals (~ 20% of inpatient

beds)

Voluntary Welfare Organisations

(~70%)

Privately/VWO owned or delivered Government owned or delivered

2

Private Sector

• 10 Acute Hospitals

• >1500 Medical Clinics

Public Sector

• 16 Acute Hospitals/Specialist Centres

• 18 Polyclinics

Healthcare Financing Framework

3

Employer

benefits

Medi-

save Cash*

Medishield

& Elder-

shield

Medi

Fund

Government

Subvention

National Healthcare Expenditure (NHE)

Individual Financing Government Healthcare

Expenditure

Based on Principle of Shared Responsibility

• Individuals and families: healthy living and saving for healthcare expenses

• Providers: efficient delivery of cost-effective care

• Insurers: mitigating financial risk associated with illness

• Government: safety net, help the needy, channel subsidies to the poor and sick

S i n g a p o r e H e a l t h c a r e I m p r o v e m e n t N e t w o r k

How we got started?

7 Nov 2012

National Agenda Setting Forum

Singapore Healthcare Improvement Network

The red dot is an

epithet used for

Singapore

The leaning “e”

represents

collaboration –

leaning on each other

to support & enable

each institution & the

initiatives within the

network.

The bold, black font

represents the

strength & passions

of the network

“By healthcare institutions for healthcare

institutions – Towards better patient outcomes”

Chairman : Dr Lee Chien Earn, CEO, CGH Co-Chairman : A/Prof Tai Hwei Yee, CQO, NHG

Singapore Healthcare Improvement Network Who are we?

10 NEW MEMBERS

23 FOUNDING MEMBERS

SHINe is a Philosophy SHINe

Institutions

Set & align priorities

Develop strategies for SHINe & within

their institution

SHINe Council & SHINe (Network)

Operational arm of SHINe

(setup groups, meetings, surveys, etc)

SHINe Office

“Brains” and Leadership of

implementation for SHINe

SHINe Faculty and/ Workgroups

Building National Capability, Capacity & Culture towards Better Patient Outcomes

All Teach, All Learn, All Share

Idea : Evidence-based changes; Innovate locally based on needs

Will: Senior leader visible commitment, Peer Learning sessions

Execution: Promotion of testing and learning on a day-to-day basis; Focus

on reliability and results ; Mentorship support from internal and external

sources; Learning Network with open sharing of data & experiences

SHINe

SHINe Council (cluster, AIC & MOH)

National Curriculum

Learning Activities, e.g

conferences, Inspire,

talks, workshops

Agenda Setting Forum

CQPT, MOH

SHINe Office (support, facilitate, enable)

Funds

IT Data Portal

Structure Overview

Improvement Activities,

e.g. LSI, surveys

Updated on1 Sep 2016

SHINe’s Process

LSI workstream (topic)

Info systems & data

Focus areas

Effective Multi- Disciplinary

teams

Institutional Leadership

Involvement of patient and family

Innovate Care Process Delivery

Learn (pilots, spread sites)

Integrate into practice

Spread to areas with

similar segment of

patients

Measuring team/s performance and patient outcomes

Agenda Setting Forum 2012

Priority 1. Financial design to secure Safety and Quality

Priority 2. Holistic efforts to Right-site care

Priority 3. Safe care: Medication Safety

Priority 4. Patient-centred care and prevention

Priority 5. Prevention of Healthcare-associated infection

Agenda Setting Forum 2014

Continue with priorities set in 2012 New priorities

Priority 1: Patient Experience

Priority 2 : Better, timely and useful data

Priority 3 : Improve Communications and Handoffs and transition

• Personal effectiveness – understanding basic concept of PSQI

• Team effectiveness – different roles would require different skills

to manage and improve systems

• Organisational effectiveness

– align strategy, structure and roles

for PSQI goals

• Quality and safety staff

– support functions at all levels

Pre-professionals

Professional

SHINe is about People

Level 2

(Team)

Level 3

(Organisational

Leadership )

Level 1

(Individual)

Basic

Expert (Quality Professionals)

Level 4

National Curriculum Enhancing System wide PSQI Capability and Capacity

Large Scale Initiative

An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. ( based on IHI Breakthrough Collaborative)

Takes effective, proven healthcare practices and make these practices ubiquitous across multiple healthcare institutions in a region or nation.

Focus Of SHINe’s LSI

Professor Michael E. Porter, Harvard Business School; Value-Based Health Care Delivery, Introduction to Global Health Delivery; July 6, 2009

Evidence based Medicine Evidence on what to do Context systematically stripped out

Evidence based Delivery Evidence on how to organise for reliable and efficient execution Context explicitly built-in

Planning for a Large Scale Initiative

1. Establish a common focus area and develop a local change package with subject matter experts using best available evidence.

2. Recruit institutions to participate.

3. Institutions pilot elements of change package in various patient

population segments to derive workable local processes and must demonstrate highly reliable and sustained outcomes.

4. Spread and scale successful sustainable pilots to all clinical areas so that all appropriate patients benefit from the change package.

5. Create a learning and social network amongst participating institutions

to accelerate learning through regular calls, visits and learning sessions.

Focus of LSI work is on local testing of changes, learning, adjustment and regular assessment of progress

15 April 2014

to 30 April 2017

Reduce Harm by 30% in 3 years

Large Scale Initiative Driver Diagram

Driver Diagram: a tool that organises information and theories about what we are planning to do and how that will effect a change in the outcome.

Workstream Primary Driver

Medication Safety Promotion

Surgical Safety Promotion

Healthcare Infection

Prevention

• Design Highly Reliable Process for Segment of High-Alert Medications ― Hypoglycaemic Agents ― Opioids

• Develop a highly effective and collaborative multi-disciplinary team • Support a Culture of Safety • Promote Patient and Family Centered Care

• Design Highly Reliable Processes for Correct Site Surgery • Optimise antimicrobial prophylaxis for surgical procedures • Prevent Venous Thromboembolisms • Develop a highly effective and collaborative multi-disciplinary team • Support a Culture of Safety • Promote Patient and Family Centered Care

• Design Highly Reliable Process for Segment of Infection Prevention • Catheter associated urinary tract infections (CAUTI) • Design Highly Reliable Process for Hand Hygiene • Develop a highly effective and collaborative multi-disciplinary team • Support a Culture of Safety • Promote Patient and Family Centered Care

Reduce Harm by 30% in 3

years

Overview of LSI participation

INSTITUTION MED SAFETY HAI SURG. SAFETY

1. ANG MO KIO THYE HUA KWAN HOSPITAL

2. CHANGI GENERAL HOSPITAL

3. INSTITUTE OF MENTAL HEALTH

4. JURONG HEALTH SERVICES

4. KK WOMEN’S & CHILDREN’S HOSPITAL

5. KHOO TECK PUAT HOSPITAL

6. NATIONAL DENTAL CENTRE SINGAPORE

7. NATIONAL HEART CENTRE SINGAPORE Shared Shared

8. NHG POLYCLINICS Shared

9. NATIONAL NEUROSCIENCE INSTITUTE With TTSH With TTSH

10. NATIONAL SKIN CENTRE

12. NATIONAL UNIVERITY HOSPITAL

13. REN CI HOSPITAL Shared

14. ST ANDREW’S COMMUNITY HOSPITAL

15. SINGAPORE GENERAL HOSPITAL

16. SINGHEALTH POLYCLINICS Shared Shared

17. SENGKANG HEALTH

18. SINGAPORE NATIONAL EYE CENTRE Shared

19. TAN TOCK SENG HOSPITAL With NNI With NNI Shared

The Sequence for Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Institute for Healthcare Improvement

Workstream Progress - using IHI Faculty Assessment Score

SHINe is an important initiative that open the doors for cross clusters sharing and learning without the fear of comparison (Although this still happens). It provide a platform to level set all PSQI teams and also allow some form of common lingo to unite the Quality Movement. With SHINe, it allows us to see and think as a team in PSQI work. Less on just the PSO job. More time must be given to make SHINe work and the tools stick.

Mr Lee Chee Seng, JurongHealth

SHINe has added tremendous value by: Providing a platform of learning, training and project guidance. Rallying support from senior management Creating legitimacy to our work by engaging leadership, with regular

on site visits, encouraging the teams and leaders to meet up to discuss the work.

Being a source of inspiration for others looking to have more involvement in improvement in their area.

Dr Siow Yew Nam, KKH

SHINe commits the whole institution to the project - long term. So there's leadership support and sponsorship, and allocation of time resources (e.g. protected time) to carry out the work. SHINe allows us to see that we're not struggling alone. We're able to get feedback from outside our own "healthcare system" SHINe brings in the expertise, comments and feedback from both local as well as international faculty, in how we can bring meaningful improvement.

Anonymous, SHP

SHINe’s value proposition is the dedicated platform for learning & engagement in quality improvement and systematic focus on culture & change management.

Prof KH Tan, KKH

By having a network of like-minded people solving similar problems, we can tap on each others perspectives and experiences to come up with better solutions for our own institutions.

Anonymous, CGH

SHINe provides us a platform to reflect on our learnings, challenges as well as collaborate and learn from other institutions. The IHI methodology taught us how to drill deep to sustain a change. This methodology is applicable in all aspects of PSQI work.

Anonymous, TTSH

Quality improvement for patient safety gives value to the work Priscilla Chng, KTPH

Through learning from others, it has given us awareness of possible ways of doing the improvement. And also given us inspiration that eventually we will get there when we work hard at building the quality and safety framework in JurongHealth

Anonymous, JurongHealth

Structure Of LSI

LSI Executive Lead

LSI Program Director

Medication Safety

Faculty

Healthcare Associated

Infection

Faculty

Surgical Safety

Faculty

Institution

Leadership,

Program

Manager

and Teams

Institution

Leadership,

Program

Manager

and Teams

Institution

Leadership,

Program

Manager

and Teams

Institution

Leadership,

Program

Manager

and Teams

Institution

Leadership,

Program

Manager

and Teams

SHINe Office /

Improvement

Advisor Group

Subject Matter Expert Group

Roles Of Central Resources

• Executive Lead/Program Director – Overall in charge of LSI , organises all LSI activities

– Reports periodically to SHINe Council – Leads Improvement Advisor Team and Workstream Faculty – Tracks institutions progress and ensures sharing of knowledge

within LSI

• Work stream Faculty & Improvement Advisor Team – Designs detailed Change Package (CP) and measurements that are

focused and prioritized for Singapore. – Helps to coach institutional teams on improvement and change – Assists in sharing and promulgation of knowledge – IA team reviews monthly team reports submitted and provide

coaching inputs to teams and score team progress in the Extranet.

• SHINe Office – Provides logistics support

Institutional Level Roles

• Institutional Senior Sponsor – Responsible for planning and execution of Change Package in

institution

– Typically Medical Director or Nursing Director

• Institutional Program Manager – Individual with clinical improvement skills who will coach and work

with identified teams to implement change packages

– Tracks institution activities and measurements

– Liaises with LSI Program Director, institutional sponsor

• Institutional Improvement Teams – Groups of 4-8 healthcare staff identified to pilot & implement

various change packages in appropriate areas of institution

Local and International Faculty

Prior local improvement work

NHG Safety Collaboratives - Medication Safety, Critical Lab Results, MRSA Prevention, High Alert Medications

WHO High 5 Surgical Safety Checklist

International Best Practices

Developing a Change Package

Example: Medication Safety Promotion – High Alert Medications (Oral Hypoglycaemics)

Primary Driver Secondary Driver Key Change Areas Change Concepts Testable Idea (actionable)

Differentiate: Eliminate look-alikes and sound-

alikes (LASA)

1. Use of tall-man lettering for the medication labels during

prescribing and picking of oral hypoglycaemic agents

2. Change the labelling for high dosages of hypoglycaemic agents

(e.g. Metformin 850mg) to uppercase while maintaining labelling

for low dosages (e.g. Metformin 250mg) in lowercase.

Adjust the physical environment such that drugs of

the same class or look alike are kept apart

Optimize the Work Environment for Safety 1. Store look alike drugs a distance apart

Standardize training scope / materials for new doctors

on Oral Hypoglycaemic Agents (OHA)

Standardise 1. Orientation of new doctors on safe and good prescribing of oral

hypoglcaemic agents

Provide prescribing standard /protocol Eg, for "Nil by Mouth" cases, system/protocol to ensure no

accidental seving of medicine

Automate careful 1. Include warning prompts in the IT clinical support system if 2

sulfonylureas are prescribed.

2. Include common brand names in brackets behind the Drug names

of oral hypoglycaemic agents in drop-down list of medications in

electronic presription system and pharmacy system

Improve medication labels for patients Improve communication 1. Larger medication labels for patients, useful especially for

elderly

Counter-checking of drug dosages by pharmacists Decrease Reliance on Vigilance 1. Counterchecking of dosages with the prescribing doctor if the

pharmacist discovers discrepancy with the previous dosage

Standardize the format of hospital discharge memos Improve communication 1. Work with the hospitals to clearly list the medications on

discharge memos

Improve access to information 1. Provide patients with a detailed list of their medicines ie active

drug list so they will know when a wrong drug is prescribed.

Improve communication 2. Patient Information Leaflet (PIL) containing images of drugs are

printed on demand for patients

Improve communication 3. Common indications in 4 languages pasted on the medication

pack for patients

Standardise dilution of insulin infusion and labels Standardise 1. Standardize dilution of insulin to a concentration of 1 unit/ml,

i.e. 50 units of insulin to be diluted to 50 mls normal saline.

(Rationale: 1 to 1 conversion)

2. Fix dilution for IV Insulin infusion in eIMR - 1 unit/ml by diluting

50 units insulin in 50 mls syringe

Standardise and simplify inpatient insulin protocol Standardise 1. Standardize the Inpatient Diabetes Insulin Protocol to all the

discipline.

Introduction of HiKpak Reduce reliance on memory 1. HiKpak (Hyperkalemia pack), in which insulin, U100 insulin

syringe , 20 mls syringe, IV Dextrose 50% 40mls, plus dosage and

monitoring guide is enclosed in the pack.

Training for doctors and nurses during orientation on

insulin and OHGA use.

Improve access to information 1. Familarise the use of the insulin protocol to all new doctors and

nurses during the orientation programme.

2. Education on insulin and OHGA use to doctors and nurses during

orientation.

Simplify and standardise the dosage form of insulin

dispensed to inpatients from pharmacy

Simplify 1. All Insulin be dispensed and labelled for single patient use.

Alternatively, Insulin dispensed as prefilled injectable pens for

single patient use.

2. Eliminates need to withdraw insulin.

3. Single patient use insulin can be returned to patient upon

discharge.

Improve documentation around Insulin through use

of order sets with standardized protocols for ordering

and dosing of Insulin, and monitoring of patients

Simplify 1. Simplify the orders of the Inpatient Diabetes Insulin Protocol and

provide guides for references in the variance group (e.g. Dialysis

patient, Patient that is Nil by mouth).

Standardize insulin syringes used in the hospital Use Contraints and Forcing Functions 1. Within hospital, standardization of the insulin syringes. Only one

type of insulin syringes will be supplied for ward use. For example,

AH/ KTPH - standardise to 50 U insulin syringes, standardise to TTSH -

100 U insulin syringes)

Place protocols and ordering information on the

patient's chart where they are easily accesible

Improve access to information 1. S/C insulin protocol is placed together with the Blood Glucose

Monitoring result within the Inpatient Medication Record so that it

will be easily accessible to the nurses and S/C insulin can be given

as per protocol

Enhancement of eIMR functionality related to insulin

order:

1. Auto-population of H/C monitoring upon

prescribing of insulin

2. Auto-population of Dextrose order

Automate careful 1. Auto-populate H/C monitoring templates in eIMR upon order for

all insulin regimes. Example: Hourly H/C for IV infusions, Hourly

H/C x 4hrs for IV bolus, H/C at 4 hrs after S/C Actrapid eg stat at

10pm.

2. Auto-populate IV Dextrose 50% 40 mls with order of IV Insulin

bolus

Label DM medications as "HAM" Use Warning and Reminders Label all DM medications as "HAM" during dispensing including

instruction not to serve if NBM.

Policy of independent double-checks for all High-

Alert Medications.

Apply system redundancies Implement a policy of independent double-checks for all High-

Alert Medications.

The policy should include a clear process for an independent

double-check and documentation.

Enhancement of eIMR functionality related to insulin:

1. prompt if changes in dietary & infusion orders

Automate careful 1. Labelling of insulin/OHGAs in eIMR as a “class” - Prompt for

changes in dietary & infusion orders. Linking online dietary orders

and insulin/OHGA order to eIMR. Requires labeling insulins/OHGAs

in eIMR as a "class". Eg. DM - Metformin/VildagliptinCritical Result Flag Stat: Ensure critical lab information

is available and presented in a format that is easily

understood to those who can take action

Improve access to information 1. Lab will contact wards of the critical result (<4mmol/L)

2. Nurse to record the result and read back.

3. Nurse to inform doctor stat

Make capillary blood blucose monitoring results

available online

Use technology 1. Capillary blood glucose monitoring made available online

Valuable source as catchments of extreme values and fluctuations.

(Eg. The IT support COBAS system allows detection of glycaemic

values extremes and will be useful tool for enhancing

hypoglycaemia detection process.)

- Ability to monitor intervention outcome

- Ability to monitor compliance to monitoring schedule Eg. Entry

times

- Use in early intervention for the prevention of events

Ensure medication reconciliation is done for all

patients who are receiving HAM

Reduce handoffs Ensure medication reconciliation is done for all patients who are

receiving insulin.

Design protocols for immediate administration of IV

Dextrose by qualified nursing and pharmacy staff

safely for "prompt"early reversal of hypoglycaemia

before the doctor arrives

Monitor patient on drug effect and use protocol

wisely

1. Nurses to infuse IV Dextrose 10% 50mls over 15 mins via infusion

pump if BGM <4mmol/L and drowsy.Inform the team doctor while

infusing the Dextrose.

2. Nurses to recheck the BGM in 15 mins time & patient will be

reviewed by the team doctor.

3. If BGM is <4mmol/L but patient is alert and can take orally, to give

15 gram of carbohydrate.

4. Recheck BGM in 15 mins later

Include reminders about contra-indications, dosage

modifications for conditions, monitoring at relevant

points of care, and in a manner that is easily viewed

and understood

Reduce reliance on memory 1. Introduction of Inpatient Diabetes Protocol

2. Stick the guide on the Inpatient Medication Record for all patient

on BGM to aid the nurses on the actions to be taken when the BGM

is <4 mmol/L or >22 mmol/L

Improve communication Improve communication Improve communication between Medical, Nursing, Dietician,

Patient and Family

Inpatient Diabetes Care Team (IDTC) Improve access to information and standardisation 1. The IDTC is established with the objectives:

• To identify at-risk diabetic patients admitted with diabetes

mellitus as co morbidity Improve glycaemia management in

hospital by providing assistance to the primary team

• To prevent acute complications of dysglycaemia

• Reduce delayed discharge by early formulation of effective

discharge plan

• Facilitate patients' transition to appropriate post-hospital DM care

• Collect data to assess achievement of outcomes

2. The IDTC is a multidiscplinary team consists of physicians, APN,

pharmacist, diabetes nurse educator, care coordinator, dietican and

podiatrist. The team will review DM based on certain triggers/

inclusion and exclusion criterias.

Design Highly Reliable

Process for Segment of High-

Alert Medications

Hypoglycaemic Agents : Oral

(OHAG)

Differentiate look-alike-sound-alikes for Oral

Hypoglycaemic Agents (OHA) labels

Encourage use of electronic decision aids esp for

prescribing and monitoring

Improve patients' knowledge on drugs for self-

monitoring and management (include diet advisory and

manage dosing during fasting month)

Hypoglycaemic Agents (Insulin)

Learning Session 0

Ongoing support Monthly Program Managers and SHINe Faculty meetings, Monthly team reports

and reviews by Improvement Advisors; On-Boarding Program for new teams, adhoc meetings and phone discussions

Site Visit

Site Visit

Site Visit

Large Scale Initiative Model

Learning Sessions

• 2 Day program held every 6 months bringing all teams together ( 200-400 persons)

• Format : Plenaries, breakout sessions, storyboards, world café

• Engage, coach and teach teams about the improvement methodology, elements of the change package and help teams to plan next steps.

• Platform to share ideas, problem and solutions – All Teach, All Learn.

Site Visits

3-day site visits to all teams every 6 months

Aims :

– Understand institution context and culture

– Provide directed coaching to team and frontline staff

– Engage the leadership team

– Facilitate sharing and Learning between institutions

Participants : Faculty, Leadership team, Program Managers, team members, other institutions

Large Scale Initiative Activities

• 5 Learning Sessions and Program Managers Training sessions

• 4 Site Visits

• 4 Onboarding Sessions for new teams

• Monthly Program Managers meeting, Reports and Faculty reviews

• IHI Open School Learning for all participating Institutions

Teams LS0 LS1 LS2 LS3 LS4

Medication Safety Promotion

4 7 9 10 14

Healthcare Infection Prevention

8 10 12 14 16

Surgical Safety Promotion

0 2 2 5 7

TOTAL 11 18 22 30 37

Our Milestones Where are we now?

Nov 2012

MOH - Agenda

Setting Forum

Jan 2014

Formation of

SHINe Council,

Network and

Faculty

Apr 2014

Learning Session 0

and Launch of

SHINe

April2015

Learning

Session 2

SHINe Office established

Oct 2014

LS 1 and

Agenda Setting

Forum

Feb 2015

Site Visits

starts

IHI Strategic partnership contract signed

Apr 2016

Learning

Session 4

Subscribed IHI Open School

Aug 2015

Site Visits

#2

Sept2015

Learning

Session 3

Reduced IHI Faculty Inputs IA Role done by local Faculty

Fully helmed by Local Faculty

Feb 2016

Site Visits

#3

Launch of LSI to Reduce Harm to Patients

Participation of Patient’s Mother during LS 3

What’s different ?

Old Thinking

• Implement improvement initiatives - result in success or failure.

• Limited focus on sustainability

• Spread is an after-thought, often delegated to the improvement team

New Thinking

• Testing and learning at pilot sites, under multiple conditions

• Work towards achieving sustainable results

• Planning for spread from the start and driven by leadership team.

Sustainable change across all participating institutions Create a shared, re-usable learning structure