Ng Teng Fong Centre for healthcare innovation opens up Singapore's healthcare to the world

Our primary healthcare system faces significant challenges from the growing prevalence of chronic diseases in Singapore. Increased disease complexity and growing patient numbers mean that there is higher demand on resources. One key problem faced previously was the episodic and reactive provision of chronic care which led to low care continuity. A redesign of how we managed patients with chronic conditions was therefore imperative for long-term sustainability.

The NHGP teamlet care model is anchored on relationship-based healthcare and is customised based on the patient's medical conditions. The care model leverages on technology, is sustainable and has been implemented in all NHG polyclinics. An IT dashboard was developed for teamlets to regularly track the outcomes of their patient panel, facilitating quality improvement. Patients with care needs were proactively identified and approached for health screening tests.

IMPACTS:

• The first teamlet was piloted in Toa Payoh Polyclinic in 2015. The development and implementation of the care model took place over three years and has been implemented in all six NHG polyclinics, empanelling about 120,000 patients.
• There was a significant reduction in the proportion of Teamlet patients who had poor control of diabetes (HbA1c <9%).
• A significantly larger proportion of Teamlet patients underwent Diabetic Foot Screening and Diabetic Eye Screening. A significantly higher uptake was also seen for cancer screenings like Pap Smear and Mammogram.

Teamlet Care patients made significantly fewer doctor visits while having more Care Manager visits.

As the only Prosthetics & Orthotics (P&O) Service in Singapore, the TTSH team was faced with limited resources to manage the current and immediate challenges ahead. There is an increasing national workload with increased incidence of lower extremity amputation and stroke needing customized prostheses and orthoses. Long wait times mean patient care was affected, impacting recovery and improvement rates.

One of the key strategic thrusts was to adopt new or emerging technologies to customise fabrication methods. By using available 3D scanners & Computer-Aided design software, the team was able to capture & manipulate a 3D image of a patient's body part. This has enabled them to digitize their otherwise conventional process of manually using plaster-of-paris casting and modifying it by hand. The digital image can be further optimized before it is 3D-printed using additive manufacturing. Overall, digitalisation solves challenges such as manpower and scalability.

IMPACT:

• Digitisation process with 3D manipulation brings better value to patients as the design can be further augmented with complex architecture and geometry for greater comfort, and or varying thickness at different parts of the orthoses to improve strength and durability. This was not possible with the conventional methods.
• Previously, 8 technicians were needed to fabricate 1024 jobs in a year. Now, 6 technicians can fabricate 1152 customized jobs in a year. With the savings in manpower, technicians were put through Job Redesign to up skill them to perform simple clinical tasks such as device repairs for walk-in cases and fitting off-the-shelf products.
• This helped to shorten waiting time from 9-12 weeks to 1-4 weeks, improving clinical outcomes with earlier delivery of customized devices to patients.
• Barriers of entry such as high costs of infrastructure and recruitment of specialised workforce have also been lowered for other hospitals to start their own P&O services.

With TTSH's upcoming expansion plans to Novena Health City in 2030, there is a need to ensure the Hospital has a sustainable and resilient value-based supply chain that can automate processes and transform the workforce.

The existing key challenges are a lack of storage space, congestions at the loading and unloading area and manpower issues such an ageing workforce, and supply chain spending most of their time on administration and routine purchases.

TTSH Material Management Department (MMD) engaged ST Healthcare (STHC) to conduct a preliminary site study in TTSH and initiated a proof-of-concept (POC) for six wards.

IMPACT:

• It has proven that a vendor could support from an off-site facility for all of the medical consumables needs. It reduces ad-hoc orders from nurses, as well as manual transaction of orders and related errors by 80% and 100% respectively. There is also reduction from multiple invoices processed per month to a single invoice processed by Finance.
• The total initial estimated projected man-hour savings from the use of technology is 3300 hours. The success results in a reduction in administrative work, and caters for surges and expansion.
• Through standardization, inventory holdings can then be made using data. With vendors now delivering directly to ST Healthcare, there will be lesser vendors entering TTSH, therefore reducing potential threats to TTSH. With the use of Vertical Lift Module, an inventory storage system, warehouse staff can also be more efficient. It provides a reduction in warehouse footprint by 90.1% and a reduction of manpower by 50%.

Holistic care of elderly patients with hip fractures require prompt diagnosis, early surgery, early mobilization, rehabilitation, falls prevention measures and osteoporosis treatment.

After early surgery, patients recovering from hip fracture require effective post-operative care and rehabilitation to regain pre-fracture mobility and function. The end-to-end care delivery involves a multidisciplinary team spanning across acute and community hospitals, and post-discharge community rehabilitation services. However, this care is often fragmented.

IMPACTS:

• Over a 1-year period of interventions using Value Stream Mapping approach, the team saw improved patient outcomes with significant overall reduction in the average length of stay by 1 week. Readmission rates continue to be low at 8%.
• These translate to cost savings to the hip fracture patients and the institutions.
• The use of standardized workflow and discharge criteria allowed patients to be discharged based on standard assessment, which improved efficiency and reduced variability. New improved versions of the Hip Fracture Education booklet which provide information of patients' entire care journey from acute to community hospital also helped align patients' and caregivers' expectations.

Routine frequent vital signs monitoring (VSM) is often cited as an area which impacts time and resources for other aspects of patient care. It is also disruptive to patients, especially those requiring palliative care.

The project aimed to reduce VSM of Low Risk Haematology-Oncology patients in NCIS safely by 50% using a Nurse-led approach.

APPROACHES:

1. Consensus Criteria were drawn up for Low Risk Patients via brainstorming sessions, survey of doctors and nurses, as well as a criteria review by stakeholders.
2. Nurses were engaged at Role Calls and meetings for empowerment.
3. De-escalation Protocol was formulated for VSM de-escalation of Low Risk Patients. Training sessions were then conducted for all ward nurses.
4. Reminder to Nurses/Doctors to communicate VSM at daily ward rounds
5. Regular review of recruitment and safety data, with interval audits and role modeling by senior nurses

IMPACTS:

• Introduction of Low Risk Criteria and De-escalation Protocol reduced a third of patient admissions which requires traditional 4H monitoring, with no negative impact on patient care.
• There was also a 50% reduction in measured outcomes. Over a 17-month intervention period involving a total of 1065 Low Risk patients, Nurse-led VSM De-escalation resulted in mean monthly savings of 948.4 Nursing Encounters and 2731.5 minutes for Nursing Encounters.
• The time savings were then used to enhance other aspects of patient care such as patient and family education, nurse-patient interaction, patient safety (e.g. falls prevention), ward equipment checks and ward hygiene. Survey of doctors and nurses showed that majority were supportive of adopting Nurse-led VSM De-escalation as routine practice, with nurses highlighting that greater empowerment led to greater confidence, positive behavioural change and greater satisfaction.

SGH embarked on a transformation project to redesign the process of scheduling surgery so that patients requiring elective surgery can receive surgery instructions from the comfort of their own home - reducing an average 45-minute wait time to see a nurse for a 10-minute session that would have conveyed the same information.

With this transformation, patients can now go home straight after consultation and receive information about surgery activities via SMS within the same day in the comfort of their home.

At SGH, surgery scheduling is performed by clinically-trained "Listing Nurses". Following confirmation of surgery with the surgeon, the patient will proceed to the listing room on the same day for surgery confirmation and to get pre-surgery instructions and cost estimates of their planned admission.

On average, it involves 45 minutes of waiting time before patients are called by the listing nurses for a 10 minute face-to-face contact time to confirm surgery activities.

Also, this transformation project leverages on a previous initiative where SGH's surgery order forms were digitised. These electronic surgery forms are referred to when scheduling surgery. As the electronic surgery order form is integrated with the hospital systems - all essential pre-admission tests are ordered and essential information indicated. These features greatly enhance patient care and safety.

This transformation project also looked into job re-designing for Patient Service Associates (PSAs) to undertake surgery scheduling so that listing nurses can focus on patient care.

IMPACTS:

• 91% time saving experienced by patients
• 40% manpower reduction for surgery scheduling
• $1.62 million manpower savings per annum (done by PSAs instead of nurses)
• 100% compliance to patient safety.

NHG Diagnostics processes more than 5 million tests per year in the primary healthcare laboratories. With an increasing number (average 5% year on year) of test loads, it is not sustainable to keep increasing manpower to run the tests.

In addition, manual processes are more prone to transcription error especially in results reporting. It is also open to human subjectivity and self-interpretation. Since 2009, NHG Diagnostics has started technologies adoption to software customisation to replace manual processes for better work efficiency and clinical outcomes, and to create continuous learning opportunities to up skill staff.

IMPACTS FROM YEAR 2016 TO 2018:

• Automation has negated the need to transcribe results manually for more than 90,000 tests per year.
• Patient management has improved. With more tests provided onsite, patients requiring immediate action can be attended to within an hour on the same day with no repeated technical visit. Having results available within same day also allows clinicians to be informed of critical results during office hours to better manage the patient.
• By providing new learning opportunities for staff through new implementations, it has also created a platform for staff to up skill themselves and noticeable reduction in resignations from lack of learning opportunities.
• Laboratory productivity has improved without compromising on turnaround time. Laboratories headcount can be maintained at 1-2 man operationally despite a 61% workload increase.
• As for cost savings, there is a total of 3.31 FTE per year.