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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