Measurements for Improved Quality in Healthcare

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Measurements for Improved Quality in Healthcare

Singapore has been successful in creating a world-class

healthcare system. This report is focused on systematic healthcare improvements based on clinical outcomes indicators and disease registries in Singapore. It is part of the Swedish Agency for Growth Policy Analysis’ Health Measurement Project in which quality measurements in healthcare have been studied in a

Singapore

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Reg. no. 2013/012

Swedish Agency for Growth Policy Analysis Studentplan 3, SE-831 40 Östersund, Sweden Telephone: +46 (0)10 447 44 00

Fax: +46 (0)10 447 44 01 E-mail: info@growthanalysis.se www.growthanalysis.se

For further information, please contact Andreas Muranyi Scheutz Telephone: +91 11 44 19 71 34

E-mail: andreas.muranyi-scheutz@growthanalysis.se

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Foreword

This country report is focused on systematic healthcare improvements based on clinical outcome indicators and disease registries in Singapore. It is part of Growth Analysis Health Measurement project in which quality measurements in healthcare have been studied in a number of countries. The Swedish Ministry of Health and Social Affairs commissioned the project.

The report was written by Andreas Muranyi Scheutz at the Agency’s New Delhi office.

Martin Wikström was the project leader for the multinational study.

Stockholm, April 2013

Enrico Deiaco, Director and Head of Division, Innovation and Global Meeting Places

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Summary

Singapore has been successful in creating a world-class healthcare system, as demonstrated by basic health indicators like infant mortality rate, maternal mortality rate, and life expectancy. This has been achieved at a lower cost, both as percentage of GDP and in abso- lute numbers, compared to other developed countries. The main healthcare challenges are similar to those in many other countries and include non-communicable diseases, the rapidly ageing population, and an increased number of people developing chronic diseases.

The main actor is the Ministry of Health (MOH) that has the responsibility for healthcare and specifically for ensuring that basic medical services remain affordable and available to all Singaporeans through policy planning and coordination. Preventive healthcare programmes (including screening for some cancers) and promotion of a healthy lifestyle are included in the Ministry’s strategy.

The philosophy of Singapore’s health payment system is to make healthcare affordable for most people by subsidies and price controls and to put the responsibility on the individual through mandatory savings within Medisave, the national medical savings scheme.

80 per cent of primary care is delivered by private practitioners with the remaining 20 per cent provided for by public polyclinics. However, hospital care is mainly delivered by public hospitals (80 per cent) with private hospitals providing the remaining 20 per cent.

All public hospitals have been restructured to run as private autonomous companies in order to improve efficiency and financial discipline. They are structured in 6 regional healthcare clusters that encompass primary care polyclinics, tertiary care hospitals and speciality centres.Patients have the freedom to choose any provider in the various sectors.

An initiative for National Electronic Health Records is underway and aims to improve coordination between different healthcare providers and better informed decisions by the practitioner, leading to more accurate diagnosis and a more patient-centric care.

Development towards improved healthcare quality is led by the government and the clinicians, with patient engagement in policy development virtually non-existent.

The MOH has developed National Standards of Healthcare, starting with public sector hospitals. The purpose is to secure that the healthcare provided is appropriate to the needs of Singaporeans and based on current evidence and clinical knowledge. The standards are used to relate measured healthcare quality and identify improvement areas. Performance in the healthcare system in relation to the standards is benchmarked locally as well as internationally to promote continuous improvement.

The Ministry conducts regular studies and surveys; The National Health Surveillance Survey monitors the health status of Singaporeans and the Patient Satisfaction Survey monitors the patients’ perception of care and providers.

Publication of the results from the Patient Satisfaction Survey is meant to spur the healthcare institutions to improve services in relation to their peers. The Ministry also encourages hospitals to publish clinical outcome parameters to inform the public.

The oldest disease registry in Singapore is the Cancer Registry that was established in 1968 by the National University of Singapore. Other registries were started at other insti-

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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE

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tutions. In 2001 the National Disease Registries Office (NDRO) was established by the Ministry and the four existing registries were subsequently incorporated.

The National Registry of Diseases Act was passed in December 2007. It mandates all healthcare institutions to report all cases of reportable diseases and stipulates that patient consent is not required for inclusion of their data into the registries and any subsequent use.

The NDRO was renamed National Registry of Diseases Office (NRDO), which has a mandate to:

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Collect and maintain information on reportable diseases that have been diagnosed and treated in Singapore

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Compile and publish statistics on the epidemiology, management and outcomes of reportable diseases

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Provide information for national public health policies, healthcare services and programmes

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Collaborate with stakeholders to drive public health research

Today it manages 7 registries in cancer, AMI, renal, birth defects, stroke, donor care, and trauma. NRDO has an efficient data collection process, where 90 per cent of data is received in electronic form. Data is validated and encrypted to protect patient confidentiality.

Analysis is done on anonymised data and reported to the MOH, and the hospitals if they so request. Reports and trending are also regularly published on NRDO’s website.

The MOH introduced the National Standards for Healthcare as a reference for performance assessment of the public healthcare providers and a tool to stimulate them to continuous quality improvement. Indicators, some of which are derived from the registry data and other, self-assessed clinical and performance indicators are used in a system of Cascading Scorecards, developed to ensure nationally consistent measurements at every tier of the healthcare system to ensure valid and reliable like-for-like comparisons.

The government has signed a Service-level Agreement with each public hospital; within that agreement the scorecards are included as a management tool and there is an agreement about meeting certain targets.

Results are presented by the MOH to the senior management of the hospital. Governance, rather than financially based incentives, is thus used to push performance improvements.

Based on performance reports, the MOH works closely with the healthcare providers, specifically the hospitals’ Health Performance Offices, to identify opportunities for improvements in those areas where there is concern. The issues detected can be used for goal- setting, which can be included in formal documents, such as Statement of Priorities, agreed between MOH and the Regional Healthcare Clusters/hospitals.

Also regionally, within the healthcare clusters or a specific hospital, there are programmes for healthcare quality improvement using hospital databases, registries or other data. The Chronic Disease Management System of the National Healthcare Group and the work of the Healthcare Analytics Unit at Khoo Teck Puat Hospital are illustrated as examples.

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Sammanfattning

Singapore har framgångsrikt skapat ett sjuk- och hälsovårdssystem i världsklass, bedömt efter grundläggande hälsoindikatorer som spädbarnsdödlighet, mödradödlighet och livs- längd. Detta har åstadkommits till lägre kostnad, såväl i procent av BNP som i absoluta tal, jämfört med andra utvecklade länder. De huvudsakliga sjuk- och hälsovårdsutmaningarna i landet är i likhet med i många andra länder icke smittsamma sjukdomar, en snabbt åld- rande befolkning och ett ökat antal människor som utvecklar kroniska sjukdomar.

Den viktigaste aktören är sjuk- och hälsovårdsministeriet (Ministry of Health) som har ansvar för sjuk- och hälsovård och, speciellt att genom policyplanering och koordinering, för att säkerställa att grundläggande medicinsk behandling inte är för dyr, utan är över- komlig för befolkningen. Förebyggande hälsovårdsprogram (inklusive förebyggande undersökningar för vissa cancertyper) och främjande av en hälsosam livsstil ingår i mini- steriets strategi.

Singapore har som filosofi för sitt betalningssystem för sjuk- och hälsovård att med hjälp av subventioner och priskontroll göra vårdkostnaden överkomlig för de flesta. Samtidigt läggs huvudansvaret på individen genom obligatoriskt sparande inom Medisave, det nationella vårdsparandet.

80 procent av primärvården levereras av privatpraktiserande läkare och de återstående 20 procenten av offentliga polikliniker. Sjukhusvård levereras i första hand av offentliga sjukhus (80 procent) och privata sjukhus levererar de återstående 20 procenten.

Alla offentliga sjukhus har blivit omstrukturerade för att drivas som privata, autonoma företag för att förbättra effektiviteten och den finansiella disciplinen. De ingår i sex regionala hälsovårdskluster som inbegriper primärvård (polikliniker), tertiära sjukhus och cent- rum för högspecialiserad vård. Patienterna kan fritt välja vårdgivare inom alla sektorerna.

Ett initiativ för nationella elektroniska journaler har startats och avser förbättra koordine- ringen mellan olika vårdgivare samt ge läkarna möjlighet att fatta mer välinformerade be- slut, vilket förväntas leda till noggrannare diagnoser och mer patient-centrerad vård.

Utvecklingen mot förbättrad sjuk- och hälsovårdskvalitet leds av regeringen och klinik- erna, medan patienternas deltagande i policyutvecklingen är i det närmaste obefintligt.

Ministeriet utvecklade nationella sjuk- och hälsovårdsstandarder, inledningsvis för offentliga sjukhus. Syftet var att säkerställa att vården som ges är anpassad till singaporianernas behov samt baserad på evidens och klinisk kunskap. Standarderna används för att relatera uppmätt vårdkvalitet och identifiera förbättringsområden. Prestationen inom sjuk- och hälsovårdssystemet i förhållande till standarderna mäts lokalt så väl som internationellt för att främja kontinuerliga förbättringar.

Ministeriet genomför regelbundet studier och undersökningar; den Nationella Hälsokontroll-studien kontrollerar singaporianernas hälsostatus och Patientnöjdhetsstudien kontrollerar patienternas uppfattning om vården och vårdgivarna.

Publiceringen av resultaten från Patientnöjdhetsstudien avser att sporra vårdinrättningarna att förbättra sin service jämfört med liknande institutioner. Ministeriet uppmuntrar också sjukhus att publicera parametrar för kliniskt utfall för att informera allmänheten.

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Det äldsta kvalitetsregistret i Singapore är cancerregistret som startades 1968 av National University of Singapore. Andra kvalitetsregister startades vid andra institutioner. Sjuk- och hälsovårdsministeriet etablerade 2001 kontoret för nationella kvalitetsregister (National Disease Registries Office (NDRO)) och de fyra existerande kvalitetsregistren inkorporera- des.

Lagen om nationella kvalitetsregister trädde i kraft i december 2007. Den ålägger alla sjuk- och hälsovårdsinstitutioner att rapportera alla fall av rapporteringsskyldiga sjukdomar och klargör att patientens medgivande inte behövs för att inkludera deras data i registret och allt senare användande av data.

NDRO bytte namn till National Registry of Diseases Office (NRDO), som har mandat att:

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Samla in och underhålla information om rapporteringsskyldiga sjukdomar som har diagnosticerats och behandlats i Singapore

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Samla in och publicera statistik om epidemiologi, behandling och utfall av rapporteringsskyldiga sjukdomar

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Tillhandahålla information för nationell folkhälsopolicy, sjuk- och hälsovårdstjänster och program

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Samarbeta med andra intressenter och driva folkhälsoforskning

Idag driver NRDO sju register om cancer, hjärtinfarkt, njursjukdomar, medfödda missbild- ningar, stroke, behandling av organdonatorer samt trauma. NRDO har en effektiv datain- samlingsprocess, där 90 procent av data mottas i elektronisk form. Data valideras och krypteras för att skydda patientsekretess. Analys görs på anonymiserad data och rapport- eras till ministeriet samt till sjukhusen om de så begär. Rapporter och trendkurvor publice- ras också regelbundet på NRDO:s hemsida.

Ministeriet införde nationella standarder för sjuk- och hälsovård som en referens för pre- stationsutvärdering av offentliga vårdgivare och ett verktyg för att stimulera dem till kontinuerliga kvalitetsförbättringar. Indikatorerna, varav några kommer från kvalitetsregistren medan andra är kliniska- och prestationsindikatorer som vårdinrättningen själv mäter, an- vänds i ett system av kaskaderande styrkort som utvecklats för att trygga nationellt jämför- bara mätningar på varje nivå av sjuk- och hälsovårdssystemet.

Regeringen har undertecknat ett servicenivå-avtal med varje offentligt sjukhus; inom det avtalet är styrkorten inkluderade som ett styrverktyg och det finns en överenskommelse att uppnå vissa mål.

Resultaten presenteras av ministeriet för sjukhusets ledning. Styrning, snarare än finansiellt grundade incitament, används alltså för att driva på prestationsförbättringar.

Baserat på prestationsrapporterna arbetar ministeriet nära vårdgivaren, särskilt dess sjuk- och hälsovårdsprestationskontor (Health Performance Offices), för att identifiera förbätt- ringsmöjligheter inom de områden där det finns anledning till oro. Problemen som upp- täcks kan användas för målsättande, vilket kan ingå i formella dokument, som överens- kommelse om prioriteter, överenskomna mellan ministeriet och de regionala vård- klustren/sjukhusen.

Även regionalt, inom vårdklustren eller vid särskilda sjukhus, finns det program för vård- kvalitetsförbättring, vilka använder sig av sjukhusdatabaser, kvalitetsregister eller annan data. Systemet för hantering av kroniskt sjuka vid National Healthcare Group och arbetet

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som görs vi sjuk- och hälsovårdsanalytiska enheten vid Khoo Teck Puat-sjukhuset illustre- ras som exempel.

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1 Introduction to the healthcare system

1.1 Basic statistics

Singapore is an island state comprising 710 sq. km, with a population of 5.3 million¹ and the fifth highest GDP per capita globally (USD 59 700², PPP). Basic healthcare indicators suggest that Singapore’s healthcare status is in a world-class position with the fourth highest life expectancy at birth, 81.3 years³, the fourth lowest infant mortality rate (IMR) of 2.65 deaths/1 000 live births (est. 2012), and the second lowest maternal mortality ratio (MMR), 3 deaths/100 000 live births (2010).⁴

1.2 Structure of the healthcare system on the national level The Ministry of Health (MOH) of the Government of Singapore has the responsibility of healthcare, specifically to ensure that basic medical services remain affordable and available to all Singaporeans through policy planning and coordination. Preventive healthcare programmes and promotion of a healthy lifestyle are included in the Ministry’s strategy.

The MOH’s Health Promotion Board (HPB) is the main actor for national health promotion and disease prevention programmes. HPB encourages Singaporeans to lead healthy lifestyles, eat balanced diets, undergo regular health screening, and build positive mental health. For 2011, S$116 million (USD 78 million) was budgeted for various programmes that included obesity prevention and management, health and dental services for school children, and cancer screening.⁵

The main healthcare challenges in Singapore are non-communicable diseases, the rapidly ageing population, and a greater incidence of chronic diseases. The principal causes of death are cancer, coronary heart diseases, strokes, pneumonia, diabetes, hypertension, and injuries.

Singapore’s healthcare spending 2010 was S$ 11.5 billion (USD 8.1 billion⁶) equivalent to 3.96 per cent of Singapore’s GDP⁷. Out of this the government spent S$ 4.18 billion⁸,

1 2012; Department of Statistics, Government of Singapore, available at:

http://www.singstat.gov.sg/stats/themes/people/hist/popn.html

2 2011; CIA - The World Factbook, available at: https://www.cia.gov/library/publications/the-world- factbook/geos/sn.html

3 2010: Source: OECD Health Data 2012; The World Bank World Development Indicators Online. Taken from Health at a Glance Asia/Pacific 2012, OECD/WHO, available at:

http://www.oecd.org/els/healthpoliciesanddata/HealthAtAGlanceAsiaPacific2012.pdf

4 CIA – The World Factbook, available at: https://www.cia.gov/library/publications/the-world- factbook/geos/sn.html

5The list of active or initiated programmes are available on HPB’s website:

http://www.hpb.gov.sg/HOPPortal/faces/HealthProgrammes?_afrLoop=26357516271767297&_afrWindowM ode=0&_afrWindowId=null#%40%3F_afrWindowId%3Dnull%26_afrLoop%3D26357516271767297%26_afr WindowMode%3D0%26_adf.ctrl-state%3Dmkz3hz5nd_4

6 USD 1 = S$ 1.418 (according to IRS exchange rate for 2010, available at

http://www.irs.gov/Individuals/International-Taxpayers/Yearly-Average-Currency-Exchange-Rates, accessed 9 April 2013)

7 Total expenditure on health as a percentage of gross domestic product, for year 2010, WHO (accessed 9 April 2013 at http://apps.who.int/nha/database/DataExplorerRegime.aspx)

8 Ministry of Finance, Government of Singapore, available at:

http://www.mof.gov.sg/budget_2010/expenditure_overview/moh.html, last accessed 9 April 2013

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which is equivalent to 1.44 per cent of GDP.⁹ The WHO reports total expenditure per capita of USD 2 273, PPP.¹⁰

The philosophy of Singapore’s health payment system is to make healthcare affordable for most people by means of subsidies and price controls and to put the responsibility on the individual through mandatory savings within Medisave, the national medical savings scheme introduced in 1984. This entails mandatory savings deducted from salary (7-9 per cent, depending on age group), are individually tracked, and can be pooled and shared within and across an extended family. The funds can be used for hospital care. Three levels of subsidies exist, which can be chosen by the patient at each healthcare episode. Since 2006, Medisave can be used to pay towards outpatient care of certain chronic diseases.¹¹ MediShield is a low cost catastrophic illness insurance scheme that was introduced in 1990. MediShield helps pay expenses from major illnesses, which cannot be sufficiently covered by the Medisave balance. Premiums for MediShield can be paid by Medisave. As an addition, citizens can also purchase private Integrated Shield Plans.

ElderShield is an affordable severe disability insurance scheme that provides basic finan- cial protection for patients that need long-term care, especially elderly patients. To obtain higher daily pay-outs ElderShield Supplement can be purchased from approved private insurance companies. ElderShield as well as ElderShield Supplement premiums can be paid for by Medisave.

Medisave and MediShield are administered by the Central Provident Fund Board.¹² ElderShield is run by assigned private insurance companies.¹³

MediFund is an endowment fund set up by the Government to help people that cannot pay their medical expenses despite Medisave and MediShield coverage.¹⁴

1.3 Actors in the healthcare system

Good, affordable basic healthcare is available to citizens through subsidised medical services and public hospitals.

80 per cent of primary care is delivered by private practitioners with the remaining 20 per cent provided for by public polyclinics. However, hospital care is mainly delivered by public hospitals (80 per cent) with private hospitals providing the remaining 20 per cent.¹⁵

9 General government expenditure on health as a percentage of total expenditure on health, for year 2010, WHO (accessed 9 April 2013 at http://apps.who.int/nha/database/DataExplorerRegime.aspx)

10 Per capita total expenditure on health at US$, PPP, for year 2010, WHO (accessed 9 April 2013 at http://apps.who.int/nha/database/DataExplorerRegime.aspx)

11 Ministry of Health, Government of Singapore;

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/medisave.html, last accessed 19 Dec 2012

12 http://mycpf.cpf.gov.sg/CPF/my-cpf/Healthcare

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/ElderShield.html, last accessed 18 Dec. 2012.

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Medifund.html, last accessed 18 Dec. 2012.

http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/Healthcare_Services/Primary_Care.ht ml, last accessed 19 Feb 2013.

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Primary care is offered at 18 public outpatient polyclinics and 2 400 private medical practitioner’s clinics. The polyclinics offer outpatient medical care, follow-ups of patients dis- charged from hospitals, immunisation, health screening and education, and pharmacy services. The Community Health Assist Scheme (CHAS) caters to elderly citizens.

Singapore has 11 394 hospital beds in 30 hospitals and speciality centres, which yields a ratio of 2.2 beds per 1 000 population.¹⁶ Singapore has 13 public hospitals and speciality centres. There are 6 general public hospitals, a women’s and children’s hospital, and a psychiatric hospital.¹⁷ The 6 speciality centres focus on cancer, cardiac, eye, skin, neuroscience and dental care. Virtually all hospitals and speciality centres are JCI accredited.¹⁸ Since 1985 the public hospitals have been restructured to run as private autonomous companies in order to improve efficiency and financial discipline. In 2000 the restructured public hospitals were divided into two competing clusters; the National Healthcare Group (NHG) and the Singapore Health Services (SHS). However, they remain wholly-owned by the Government and are subject to broad policy guidance through the Ministry of Health.

Further, based on evaluation of the two-cluster system in 2008 the then Health Minister Khaw Boon Wan announced a plan to reorganise the healthcare system along regional lines, going beyond public providers and today 6 regional clusters (Regional Healthcare Systems; RHS) exist.

In contrast to the private hospitals the public hospitals receive funds from the government to allow them to offer subsidised medical services to patients. Subsidies vary depending on the patient’s choice of ward accommodation in three levels; 80 per cent of bed space (class B2 and C) are heavily subsidised, while beds in class B1 are only subsidised to 20 per cent and beds in class A are not subsidised. The public hospitals range in size from 185 to 2 000 beds.¹⁹

There are 16 private hospitals that are generally smaller than the public hospitals, with 20- 500 beds. Some of the private hospitals are run by medical groups such as Parkway Group Healthcare and Raffles Hospital Group, which also have operations in other countries.²⁰ Some private hospitals specialize in offering medical care to international patients and Singapore is considered to be a “medical tourism hub”. Amongst private hospitals, the Parkway Group’s hospitals, Raffles Hospital and the Johns Hopkins Singapore Interna- tional Medical Centre are JCI accredited.

The government also runs residential and community-based healthcare services that cater to long-term care needs, including community hospitals, chronic sick hospitals, nursing homes, sheltered homes for people that have suffered from mental illness, inpatient hospice institutions, home medical, home nursing and home hospice care services, day rehabilitation centres, dementia day care centres, psychiatric day care centres, and psychiatric rehabilitation homes.

Patients have the freedom to choose any provider in the various sectors.

16 Department of Statistics, Government of Singapore. Hospital and public sector clinics:

http://www.singstat.gov.sg/pubn/reference/yos12/statsT-health.pdf, Total population 2011:

http://www.singstat.gov.sg/stats/themes/people/hist/popn.html. Last accessed 18 Dec. 2012.

17 Listing at: http://app.sgdi.gov.sg/listing_others.asp?t_category=HOSPITAL, last accessed 18 Dec. 2012.

18 http://www.jointcommissioninternational.org/JCI-Accredited-Organizations/

19Ministry of Health:

http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/Healthcare_Services/Hospitals.html, last accessed 18 Dec. 2012.

20A list of the major private hospitals is available at: http://www.singaporedoc.com/index.php/private- hospitals.html

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16 1.4 Regional healthcare clusters

The various institutions mentioned above are integrated in 6 Regional Healthcare Clusters based on a regional hospital working with a variety of primary, intermediate and long-term care sector and support services (See Table 1 and Figure 1).

Table 1 Singapore’s Regional Healthcare Clusters.

With Singapore being a city state, the concept of “regional cluster” is not strictly geo- graphically confined. For example the National Healthcare Group (NHG) is the Regional Healthcare System for Singapore’s Central region, but the health services reach out island- wide. The nine polyclinics included in NHG, for instance, are also spread across three other regional health clusters, namely Alexandra Health in the north, and the National Uni- versity Health System and Jurong Health Services in the west. The two national specialty centres part of NHG – the Institute of Mental Health and National Skin Centre – serve patients from all over Singapore, not just those from the Central zone.²¹ Patients are free to choose any healthcare provider, regardless of where they live.

The Agency for Integrated Care facilitates the transition of patients from one care setting to another.

21 National Healthcare Group: https://corp.nhg.com.sg/RHS/Pages/RHS-for-the-Central-Region.aspx

Cluster Managed hospitals

Alexandra Health Khoo Teck Puat Hospital in the north

National Healthcare Group Tan Tock Seng Hospital in the central region, Institute of Mental Health and one national specialty centre

SingHealth Singapore General Hospital, KK Women's and Children's

Hospital and five national specialty centres National University Health System National University Hospital

Jurong Health Services Ng Teng Fong General Hospital (upcoming) and Jurong Community Hospital in the west

Eastern Health Alliance Changi General Hospital in the East

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Figure 1 Map of Singapore indicating location of public hospitals and speciality centres.

Source: MOH Holdings Pte Ltd., reprinted with permission.

1.5 Electronic Health Records

An initiative is ongoing to build a system for National Electronic Health Records (NEHR).

The vision is “one patient, one record” and the goal is to extract and integrate all clinical information for one person from all his/her encounters in the healthcare system into one patient-centred record. This will give authorised healthcare providers access to the patients’ entire health history. The data will be available to care providers in hospitals as well as in primary care, giving instant access to the medical history of the patient. The expectation is that this will improve coordination between different healthcare providers and lead to better informed decisions by the practitioner, in turn leading to more accurate diagnosis and a more patient-centric care.

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2 Healthcare Quality

2.1 Discourse and development on healthcare quality

The development towards greater focus on quality in healthcare is fuelled mainly by the government, as regulator, major purchaser, and provider, rather than by patients and citizens.²² The focus has shifted from structural approaches to a broader multidimensional concept that includes monitoring of clinical indicators and recognising and measuring medical errors.

Another group active in the discourse and promotion of systematic quality-improvement efforts are the clinicians, who want to know how they are performing vis-à-vis others, locally as well as internationally.

The Healthcare Quality Society of Singapore (HQSS) was formed in 2007 with the following objectives²³:

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To facilitate exchange of information and data on healthcare quality principles and practices, e.g. through workshops and publications.

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To formulate recommendations, guidelines and standards by consensus working groups.

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To promote the education of all healthcare quality professionals both in the medical institutions and in the community.

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To foster research in healthcare quality.

2.2 National Standards of Healthcare

The MOH has developed National Standards for Healthcare (NSHC), starting with public sector hospitals. The purpose is to secure that the healthcare provided is appropriate to the needs of Singaporeans and based on current evidence and clinical knowledge. The standards are used as reference to the healthcare quality measured in the clinics in order to identify improvement areas. The performance in the healthcare system in relation to the standards is benchmarked locally as well as internationally to promote continuous improvement. The standards are expected to evolve as the healthcare delivery system develops and as new knowledge and evidence become available.

2.3 National Health Surveillance Survey

The Ministry of Health has conducted regular health surveys since 1992, and the National Health Surveillance Survey (NHSS) is one of these regular studies. NHSS was performed in 2001 and 2007 and the third study is currently being conducted.²⁴ The purpose is to collect information on the general health status of the Singaporeans. In the current study, 18 000 households have been randomly selected and participants have their weight and length measurements taken and are interviewed about their health and lifestyle habits.

22 M K Lim, “Quest for quality care and patient safety: the case of Singapore”, Qual Saf Health Care 2004;13:71–75, available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758053/

23 Source: HQSS web page, available at http://www.hqss.org/

24 Source: Press Release from Ministry of Health, Government of Singapore, available at:

http://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2012/national_health_surv eillancesurvey2012/press_release.html, last accessed 18 Dec. 2012

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Topics such as diabetes mellitus, hypertension, high blood cholesterol, obesity, regular exercise, smoking, alcohol consumption, cancer screening, and primary care patterns are covered in the survey. The purpose of NHSS is to monitor the health status of the population and track progress towards national health targets. The current study goes on from November 2012 to June 2013.

2.4 Service Quality

An annual Patient Satisfaction Survey is conducted.²⁵ It is commissioned by the Ministry of Health and carried out by an independent survey company. The survey assesses the level of patient satisfaction, service-quality attributes, including facilities, skills and care shown by the health-care professionals, and collects suggestions for improvement. The purpose is to encourage hospitals, national speciality centres and polyclinics to constantly improve their services and address key concerns of patients.

In the last survey, 12 355 patients participated from June to September 2012. The results are published²⁶ and detail the name of the individual healthcare institution, what rating they have received and changes compared to the results from the 2010 survey.

In the 2012 survey patients were particularly happy with the performance of the hospitals’

Specialist Outpatient Clinics (SOCs) The results for polyclinics was somewhat mixed with 13 out of 20 polyclinic receiving higher overall satisfaction scores in 2012 compared with 2010, while 7 received lower scores.

Dissatisfaction was detected with waiting times and coordination of care and transfer of information amongst Singapore’s public healthcare institutions.

2.5 Clinical Quality

2.5.1 Primary Care

Quality and efficiency of primary care can be measured in a number of ways.²⁷ Studies assessing the efficiency of Singapore’s primary care have been published. Niti et al. measured the avoidable hospitalization rates in Singapore and assessed the trends and inequali- ties of quality in primary care.²⁸ The results were that avoidable hospitalization rates had decreased between 1991 and 1998, suggesting improvement in the quality of primary care.

However, persisting demographic inequities were pointed out. In another study, Toh et al.

reviewed case-records of patients with diabetes mellitus that were treated at selected Spe- cialist Outpatient Clinics in the National Healthcare Group. In their conclusions they pointed out large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further.²⁹

25 Source: Press Release from Ministry of Health, Government of Singapore, available at:

http://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2012/patient_satisfactionsu rvey2012.html, last accessed 18 Dec. 2012

26https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2012/patient_satisfactio nsurvey2012.html

27 Leiyu Shi, “The Impact of Primary Care: A Focused Review”, Scientifica, Volume 2012 (2012), Article ID 432892, http://dx.doi.org/10.6064/2012/432892

28 M Niti, T P Ng, ”Avoidable hospitalisation rates in Singapore, 1991-1998: assessing trends and inequities of quality in primary care”, J Epidemiol Community Health 2003, 57:17-22

29 M P Toh et al ”Measuring the quality of care of diabetic patients at the specialist outpatient clinics in public hospitals in Singapore”, Ann Acad Med Singapore, 2007, 36(12):980-6

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The MOH is currently extending the National Standards for Healthcare to also cover primary care and they have developed score cards to be used for performance monitoring and feedback cycles, followed by quality improvement initiatives (See section 5.3 below).

2.5.2 Secondary and Tertiary Care

The MOH has introduced performance indicators that allow the healthcare providers to chart their own progress as well as to benchmark themselves against each other and other centres of excellence. As a means to promote greater transparency, the Ministry has also encouraged the hospitals to publish the clinical outcomes of common procedures on the Internet.³⁰ The aim is to provide the public with accurate and useful information on healthcare quality in Singapore while enabling healthcare providers to ask meaningful questions on how care can be further improved.³¹ The indicators from the International Quality Indicator Project (IQIP) from 1997 are used, sometimes complemented with additional indicators.³²

Comprehensive Quality Improvement at all levels – the NUHS example

To give an example, the National University Hospital System (NUHS), one of the six regional healthcare clusters [consisting of the National University Hospital (NUH) – a tertiary hospital with more than 1000 beds and more than 6300 staff, the National University of Singapore’s (NUS) Yong Loo Lin School of Medicine, and the NUS’ Faculty of Den- tistry] tracks clinical quality indicators across the different departments and some of the indicators are published on their webpage (See Table 2).³³ The following categories of indicators are monitored:

•

Those mandated by National Standards for Healthcare – MOH Directive

•

NUHS Balance Scorecard known as “Total Excellence Performance Management System (TEPMS)” – Hospital Initiated

– Benchmark – IQIP Indicators

•

Specialty-specific Indicators (compare with ACHS³⁴, NHS³⁵)

•

Other Quality Indicators

•

Service Quality Indicators

30 A selection of websites managed by public hospitals, which contain published clinical outcomes:

http://www.ktph.com.sg/main/pages/1446

http://www.kkh.com.sg/AboutUs/ClinicalOutcomes/Pages/Home.aspx

http://www.sgh.com.sg/Patient-Services/Our-Commitment-to-Patients/Pages/quality-measures.aspx http://www.cgh.com.sg/Medical_Specialities/Clincal%20Outcomes/Pages/clinical_outcomes.aspx

http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/qualityinnovation/PerformanceIndicat ors.html

32 The Quality Indicator Project and the International Quality Indicator Project were started by Maryland Hospital Association, and was later acquired by Press Ganey Associates, Inc.

http://www.internationalqip.com/.

33 http://www.nuh.com.sg/about-us/clinical-outcomes.html

34 Australian Council of Healthcare Standards

35 National Health Service (UK)

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Data includes volumes and types of procedures and clinical outcome. Also healthcare- associated infections, i.e. infections that patients acquire while receiving treatment in the healthcare setting, are reported.

NUHS’ Health Performance Office (HPO) is driving change by sharing the indicators’ data with clinicians and other staff as well as ensuring that they are entered into the departments’ performance targets. The HPO addresses process owners so they themselves can initiate needed change.

•

Acute Myocardial Infarction

•

Cataract

•

Childhood Asthma

•

Child Epilepsy

•

Childhood Leukaemia

•

Chronic Obstructive Pulmonary Disease (COPD)

•

CT Planning for Radiation Therapy

•

ERCP (Endoscopic Retrograde Cholangio-pancreatogram) & Upper Gastrointestinal Bleeding

•

Elective PCI Mortality Rate

•

Gastric Cancer

•

Heart Surgeries

•

Hospital-wide Indicators – Hand Hygiene

– Inpatient Falls

– Unscheduled ICU Returns – Ventilator-Associated Pneumonia

•

Liver Transplant

•

MRSA

•

Hand Hygiene

•

Nasopharynx Cancer

•

PCI Door-to-balloon time

•

Paediatric Cancers

•

Rhabdomyosarcoma osteosarcoma

•

Paediatric Blood & Bone Marrow Transplant

•

Paediatric Liver Transplant

•

Paediatric Kidney Transplant

•

Paediatric Kidney Dialysis

•

Stroke

•

STEMI Mortality Rate

•

Surgical Site Infections – Hip Arthroplasty

– Coronary Artery Bypass Graft (CABG) Infections

•

Very Premature Infants

Table 2 Some of the areas in which clinical outcome is measured and published by NUH.

The senior management are provided with a dashboard where they can see the latest analysis and trends in one glance.

Through various programmes, general, or adapted to requirements of specific professional groups, staff from different categories has been trained in quality improvement.

NUH was the first hospital in Singapore to be conferred the Joint Commission Interna- tional (JCI) accreditation in 2004 and the Singapore Service Class Award 2004. NUH is also the first and only hospital in Singapore to achieve triple ISO certification simultane- ously – ISO 9001:2000 (Quality Management System); ISO 14001:1996 (Environmental

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Management System); and OHSAS 18001:1999 (Occupational Health Safety Management System) 2002.

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3 National Disease Registries

Cancer, end stage renal diseases (ESRD), stroke and acute myocardial infarction (AMI) are major causes of morbidity and mortality in Singapore. Therefore the Ministry of Health decided to set up the National Disease Registries Office (NDRO) in 2001 for information collection on these conditions for policy formulation and programme management. From 2002 and forwards NDRO consolidated four registries that were already functional but managed by four different organisations and established a new registry, the Stroke Registry.

In conjunction with the establishment of The National Registry of Diseases (NRD) Act in December 2007 the NDRO was renamed The National Registry of Diseases Office (NRDO) of Singapore.³⁶ The NDRO’s mandate is to:

•

Collect and maintain information on reportable diseases that have been diagnosed and treated in Singapore.

•

Compile and publish statistics on the epidemiology, management and outcomes of reportable diseases.

•

Provide information for national public health policies, healthcare services, and programmes.

•

Collaborate with stakeholders to drive public health research.

With the establishment of a Donor Care Registry in 2009, to monitor living kidney and liver donor outcomes and post-donation complications, and the National Trauma Registry in 2011, the NRDO is currently managing seven registries (Table 3).

Table 3 List of Disease Registries managed by NRDO.

3.1 Data Collection

Managers of healthcare institutions and medical practitioners are, in compliance with the NRD Act, obliged to report through notification (electronic or hardcopy) all cases of reportable diseases.

36 http://www.nrdo.gov.sg/

Started Registry Comments

1968 Singapore Cancer Registry Acquired from National University of Singapore 1987 Singapore Myocardial Infarction

Registry

Initially managed by MOH and then the Singapore Cardiac Data Bank before handed over to NRDO in April 2007

1992 Singapore Renal Registry Acquired from Singapore General Hospital 1993 National Birth Defects Registry Acquired from KK Children’s and Women’s Hospital 2001 Singapore Stroke Registry

2009 Donor Care Registry Monitor outcomes and complications of living kidney &

liver donation 2011 National Trauma Registry

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Both active and passive methods of case finding are employed by NRDO. In the first case screening for cases is done through Electronic Medical Records (EMR) access, where allowed by the hospitals; in the latter case, doctors and nurses notify NRDO on behalf of their institutions. About 90 per cent of the data comes in the form of electronic files, while the remaining 10 per cent still comes in hard copy, which is hand delivered or sent by reg- istered mail to preserve the confidentiality of the patient data. Most of the data collection for the registries is carried out at public and private hospitals. When patients suffering from reportable disease conditions are detected by a GP, these patients are referred by the GP to the acute hospitals where the NRDO captures the majority of cases.

The case finding documents come from multiple sources: lab reports, claims reports, death registrations, and hospital discharge reports. Every Singaporean has a unique personal identification number, which makes it straightforward to avoid duplicate entries. The EMR access allows easy and efficient data gathering. However, certain details in the cases may be absent in the EMR entry, and need to be extracted manually from case notes. Examples of such data can include detailed staging of cancer or histopathology of cancers. These details can only be found in the case notes in the medical record office of each hospital.

Data items collected can broadly be classified into the following sections:

•

patient demographics

•

past medical history including risk factors

•

diagnostic elements, e.g. laboratory values, histology

•

treatment

•

complications/extent of disease

•

outcome

The data items depend on the registry; not only the disease characteristics determine the selection, but also the history of the registry. Below is a comparison of data items con- tained in the Singapore Cancer Registry, which dates back to 1968, and the younger AMI, stroke and ESRD registries (Table 4). The detail in the data varies between the registries.

The Cancer Registry is the oldest and contains only the basic level of detail. At the time when the registry was started the purpose was to see trends. In the 40+ year history of the Cancer Registry the selection of data items has been the same, with the exception of two additions:

•

Smoking status

•

Whether the cancer was detected through screening

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Table 4 Comparison of data items in the Singapore Cancer Registry and the younger Singapore Myocardial Infarction Registry (AMI), Singapore Stroke Registry and Singapore Renal Registry (ESRD).

Clinical images, like those from CT and MRI, are stored digitally at the hospitals. In the disease registries only certain key data items related to imaging are captured, like what kind of imaging was done and the key findings. However, for research purposes it would be possible for the research team to trace and retrieve the images from the hospital’s pic- ture archiving and communication system.

The data captured by the newest registry, the National Trauma Registry, is very comprehensive, with coverage all the way from before hospitalisation to 12 month follow up.

Trauma data in the hospitals are being collated and later submitted to central repository at NRDO. This system has greatly simplified the transmission and submission of data. Inspi- ration for the structure of this registry came from the Victorian State Trauma Registry in Australia.

3.2 Data management and processing

A team of data management staff manages the database to ensure that all data collected for the registries have been validated and encrypted. They also extract de-identified data files to use for analysis.

A team of epidemiologists and biostatisticians analyse the de-identified data and generate reports for MOH on a regular basis and for individual hospitals when they so request. The reports contain aggregate data and trends on incidence, prevalence and mortality of the disease covered by the particular registry.³⁷

The team of quality assurance executives ensures that requests for data go through the proper level of approval and data are released according to the criteria set out in the National Registry of Diseases Act. In addition, the team develops quality assurance policies and processes together with the registry staff in order to ensure registry output of the highest standards. The executives also perform regular audits of the sites and systems, analyse audit data and present the results to the management of Health Promotion Board (HPB) and MOH. External audits are conducted by vendors contracted by HPB. The registries are certified for Quality Management System (ISO 9001), Information Security

37From NRDO web page, http://www.nrdo.gov.sg/page.aspx?id=74, last accessed 20 February 2013.

Cancer AMI/Stroke/ESRD

Risk factors Smoking HPT, DM, Lipids, smoking, IHD,

etc.

Investigation Histological diagnosis Biochemistry, haematology, CT scan/MRI, ECG

Treatment Broadly classified:

surgical/chemo/hormones/radio therapy

Specific medications, surgical procedures, rehabilitation

Outcome Dead/alive

Follow up for 6 months

Dead/alive

ESRD – follow up throughout Discharge destination In patient complications

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Management (ISO 27001) and Business Continuity Management System (SS 540 2008/BS 25999-2:2007). The registries currently contain approximately one million records.

The registries under NRDO administration regularly publish reports that are made available on the website.³⁸ In the case of the Singapore Cancer Registry, the oldest registry, trending goes back all the way to when data collection began in 1968.

3.3 Developmental trend of the registries

As all individual registries had their own structure and software solution, an initial effort was put into creating a common IT structure for all registries; eventually, an Oracle-based system was established. With increasing experience NRDO focused on improving accessi- bility and availability of the data and on establishing a Quality Management System.

Currently the organization works to strengthen transformation and dissemination of information.

3.4 Governance

The MOH appointed the NRDO to run the registry operations. The main users are the Epidemiology & Disease Control Division, the Performance Technology and Assessment Division and the Hospital Services Division. The Health Information Division administers the NRD Act and provides policy oversight on the use and release of data by NRDO.

MOH appoints a Registry Advisory Committee for each registry comprising specialists, clinicians from private sector and public hospitals, and government agencies like the Singapore Armed Forces (for the National Trauma Registry). Composition of the advisory committee depends on the nature of the registry. The advisory committee will provide professional advice to both the disease registry and the MOH.

3.5 Legislation

Singapore is quite unique in the sense that it provides legislative coverage to the registries, thereby allowing collection of data without the need for patient consent. The key areas of the National Registry of Diseases Act are:

•

Facilitate comprehensive coverage, for both private and government sector

•

Control the amount and type of information to be collected

•

Ensure privacy protection and data security

•

Provide clarity and transparency towards use of information

Diseases and conditions of high burden and high impact on public health are covered by the Act, and this is determined by the MOH. New disease conditions have been included in the Act along the way, through a rigorous process, including advice from the Registry Advisory Committee, buy-in from the stakeholders in the health system, and final approval by the Minister of Health.

The NRDO, in an attempt to lower the administrative burden on the healthcare institutions, gives them the option of allowing the NRDO staff to extract the data from the medical records on their behalf, which the institutions would otherwise have to do on their own.

Not surprisingly, this is the favoured option for most healthcare institutions, and this also

38 http://www.nrdo.gov.sg

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saves the institutions the trouble of keeping track of follow-ups required by the registry. In most situations, the information is sent by the healthcare institutions to NRDO electroni- cally either on line or via electronic transmission of listings that contain the minimally required information. Based on the minimum required information, a dedicated team of NRDO staff will then visit the healthcare institutions to collect additional information required by the Act.

3.6 Role of Disease Registries

Traditionally the role of disease registries was to monitor disease from an epidemiological angle, in the recent years the disease registries have progressed to use the data to benchmark care. The registries under the NRDO play a significant role in the following areas, which are further discussed and exemplified in the next section:

•

In epidemiology: recent changes in trends of diseases and the risk factors, projection of disease burden

•

Planning and evaluation of programmes such as women cancer screening programmes

•

Research into etiology of diseases, e.g. cohort study

•

Education – promote awareness of diseases through media articles

•

Benchmarking of care

3.6.1 Epidemiology

NRDO regularly publishes reports and health-fact sheets that contain recent disease trends on its website. Recent statistics on diseases are available on the website for journalists who want to write articles for the general public and by that increase public awareness and prevention of disease.

3.6.2 Evaluation of Programmes

An example of programme evaluation is the evaluation of the national cervical cancer screening programme (CervicalScreen Singapore; CSS)³⁹ using a matched CSS and Singa- pore Cancer Registry (SCR) dataset. In the recent evaluation it was discovered that participation in the screening programme had actually fallen despite declining incidence and mortality as well as improved survival. This disquieting finding was met by a more vigor- ous marketing of the programme, to encourage women to come for screening, including tailored efforts to reach out to specific groups, e.g. women with low education level.

Another initiative is to bundle the cervical cancer screening with other screening such as screening for breast cancer. As the doctors are the key persons who could convince the women to go for screening, the screening programme is working closely with the medical practitioners to boost participation.

CSS was launched in August 2004 and encourages women aged 25 to 69 who have ever had sex to go for Pap smear once every three years. The evaluation was carried out using a matched CSS and SCR de-identified dataset for the 2004-2008 period.

39 http://www.hpb.gov.sg/HOPPortal/health-article/3342

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3.6.3 Programme Planning

Using a geospatial map, frequency of disease occurrence by ethnic groups, derived from registry data, can be mapped onto the constituencies of Singapore. With this geospatial data at hand, preventive efforts can be tailored for various ethnic groups to address the risk factors leading to the development of diseases.

3.6.4 Education

Comprehensive registry data can put the spotlight on specific phases of the healthcare process or specific actors, as an example analysis of data from the AMI registry showed that the door-to-balloon time had shortened, but the time from symptom to door was still pro- longed; the affected people are not aware of what the symptoms imply and the importance of early treatment. An educational effort is therefore warranted and outreach through journalists has been found to be an efficient channel to increase awareness in large population groups on specific messages.

3.6.5 Research

There are approximately 100 data requests per year from researchers at hospitals or aca- demic institutions. Each data request is individually examined and approved by MOH. The linkage will be carried out and the data placed in a secure laptop in the NRDO office. The researcher will have to come to the office in person to analyse the data (See Figure 2).

This is working well as Singapore is a small country and travel time is therefore not an issue.

This procedure was put in place to protect patient confidentiality. In the secure laptop all the identifiable information has been removed, even birth dates of patients have been con- verted to age. NRDO asks the researchers to share their results before they publish their study. This is in order to be prepared for specific questions from the research community or journalists.

Figure 2 Data linkage for research purposes. Source: NRDO, reprinted with permission.

Researchers who are located overseas can only be provided with aggregated data. In these circumstances, NRDO staff performs the analysis and release the aggregated findings.

Foreign researchers physically present in Singapore, will have the same provision for data access as Singaporean researchers.

The data requests eventually lead to a significant number of papers being published usually cohort studies or case control studies.

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3.6.6 Benchmarking

Interest in benchmarking healthcare providers has increased recently. The data are broken down by the seven public hospitals in Singapore and findings shared with the Registry Advisory Committee comprising clinical representatives from each public hospital. Each hospital is also given access to their own data and comparative averages. Each hospital has a Health Performance Office (HPO) that is responsible for analysing performance gaps and implementing initiatives to improve performance where necessary. All findings are presented to the hospitals and they have an open discussion with MOH, NRDO and the Reg- istry Advisory Committee on areas where they can improve (See Figure 3). The benchmarking results are not made public. However, certain hospitals can opt to publish the data on their website (as they have access to their own data).

Figure 3 Benchmarking process as applied by MOH and NRDO. Source: NRDO, reprinted with permission.

Finally, an example of how benchmarking based on disease-registry data and followed up by gap identification and performance improvement can lead to visibly improved patient outcome.

For patients with ST Elevation Myocardial Infarction (STEMI), the treatment of choice is emergency Percutaneous Coronary Intervention (ePCI). The time interval between the patient's arrival at the emergency department and the first device being introduced with the aim of restoring perfusion to the coronary artery (termed door-to-balloon time) should be as short as possible, because shorter door-to-balloon times are associated with better outcomes and reduced mortality.The American College of Cardiology/American Heart Asso- ciation guideline for STEMI recommends ePCI within 90 minutes of first medical contact, or door-to-balloon time.⁴⁰

40 Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines:

developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians.Circulation2007;117:296-329

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In Singapore benchmarking and performance improvement at the seven public hospitals reduced the median door-to-balloon time from 95 to 70 minutes between 2007 and 2010, and an accompanying decrease in 30-Day Mortality from 7.2 per cent to 4.1 per cent was observed (See Figure 4).

In each hospital the cardiologic head is represented on the registry advisory committee.

With all this data they can work with the HPO officers to improve care.

Figure 4 Door-to-Balloon time improvement 2007-2010. Number of patients per time-interval segment and percentage of patients having a Door-to-Balloon time shorter than 90 minutes, excluding transfers and inpatient AMI, upper panel. Adjusted 30-Day Mortality after ePCI (%), 2007-2010 [Adjusted for (age, gender, ethnicity, smoking status, past histories of hypertension, diabetes mellitus, hyperlipidae- mia, AMI, PTCA and CABG and LVSD<50 %), Excluding (Cardiogenic shock, unknown kilip status & transfers)], lower panel. Source: NRDO, reprinted with permission.

3.7 Singapore Tuberculosis Elimination Programme Registry The Singapore Tuberculosis Elimination Programme (STEP) was launched in 1997 as the prevalence of TB in Singapore had remained unchanged at 49-54 per 100 000 population for the previous 10 years.⁴¹ Under the programme the following interventions are performed:

41 Cynthia B.E. Chee & Lyn James, ”The Singapore Tuberculosis Elimination Programme:

Measurements for Improved Quality in Healthcare