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2013:07
Measurements for Improved
Quality in Healthcare
Singapore
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
number of countries.
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
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Table of Contents
Summary .............................................................................................................................. 7
Sammanfattning .................................................................................................................. 9
1
Introduction to the healthcare system ................................................................... 13
1.1
1.2
1.3
1.4
1.5
2
Healthcare Quality .................................................................................................... 18
2.1
2.2
2.3
2.4
2.5
3
3.7
National Healthcare Group Chronic Disease Management System and Registry ...........32
4.1.1 Chronic Disease Management System ................................................................32
Use of Data ................................................................................................................ 35
5.1
5.2
5.3
5.4
5.5
6
7
Data Collection ................................................................................................................23
Data management and processing..................................................................................25
Developmental trend of the registries ..............................................................................26
Governance .....................................................................................................................26
Legislation .......................................................................................................................26
Role of Disease Registries ..............................................................................................27
3.6.1 Epidemiology .......................................................................................................27
3.6.2 Evaluation of Programmes ...................................................................................27
3.6.3 Programme Planning ...........................................................................................28
3.6.4 Education .............................................................................................................28
3.6.5 Research..............................................................................................................28
3.6.6 Benchmarking ......................................................................................................29
Singapore Tuberculosis Elimination Programme Registry ..............................................30
Other applications of patient data for improvement of care ................................ 32
4.1
5
Discourse and development on healthcare quality ..........................................................18
National Standards of Healthcare....................................................................................18
National Health Surveillance Survey ...............................................................................18
Service Quality ................................................................................................................19
Clinical Quality.................................................................................................................19
2.5.1 Primary Care ........................................................................................................19
2.5.2 Secondary and Tertiary Care ...............................................................................20
National Disease Registries .................................................................................... 23
3.1
3.2
3.3
3.4
3.5
3.6
4
Basic statistics .................................................................................................................13
Structure of the healthcare system on the national level .................................................13
Actors in the healthcare system ......................................................................................14
Regional healthcare clusters ...........................................................................................16
Electronic Health Records ...............................................................................................17
National Standards for Healthcare ..................................................................................35
Cascading Scorecards ....................................................................................................35
Score Cards for Primary Care .........................................................................................37
Use of data within a Regional Healthcare Cluster ...........................................................38
Use of data within a hospital ...........................................................................................39
Discussion ................................................................................................................. 40
List of people interviewed ....................................................................................... 41
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 absolute 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
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:
•
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
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 goalsetting, 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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Sammanfattning
Singapore har framgångsrikt skapat ett sjuk- och hälsovårdssystem i världsklass, bedömt
efter grundläggande hälsoindikatorer som spädbarnsdödlighet, mödradödlighet och livslängd. 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 åldrande 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 överkomlig för befolkningen. Förebyggande hälsovårdsprogram (inklusive förebyggande
undersökningar för vissa cancertyper) och främjande av en hälsosam livsstil ingår i ministeriets 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 centrum för högspecialiserad vård. Patienterna kan fritt välja vårdgivare inom alla sektorerna.
Ett initiativ för nationella elektroniska journaler har startats och avser förbättra koordineringen mellan olika vårdgivare samt ge läkarna möjlighet att fatta mer välinformerade beslut, vilket förväntas leda till noggrannare diagnoser och mer patient-centrerad vård.
Utvecklingen mot förbättrad sjuk- och hälsovårdskvalitet leds av regeringen och klinikerna, 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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 inkorporerades.
Lagen om nationella kvalitetsregister trädde i kraft i december 2007. Den ålägger alla sjukoch 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:
•
Samla in och underhålla information om rapporteringsskyldiga sjukdomar som har
diagnosticerats och behandlats i Singapore
•
Samla in och publicera statistik om epidemiologi, behandling och utfall av rapporteringsskyldiga sjukdomar
•
Tillhandahålla information för nationell folkhälsopolicy, sjuk- och hälsovårdstjänster
och program
•
Samarbeta med andra intressenter och driva folkhälsoforskning
Idag driver NRDO sju register om cancer, hjärtinfarkt, njursjukdomar, medfödda missbildningar, stroke, behandling av organdonatorer samt trauma. NRDO har en effektiv datainsamlingsprocess, där 90 procent av data mottas i elektronisk form. Data valideras och
krypteras för att skydda patientsekretess. Analys görs på anonymiserad data och rapporteras till ministeriet samt till sjukhusen om de så begär. Rapporter och trendkurvor publiceras också regelbundet på NRDO:s hemsida.
Ministeriet införde nationella standarder för sjuk- och hälsovård som en referens för prestationsutvärdering 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, används i ett system av kaskaderande styrkort som utvecklats för att trygga nationellt jämförbara 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 sjukoch hälsovårdsprestationskontor (Health Performance Offices), för att identifiera förbättringsmöjligheter inom de områden där det finns anledning till oro. Problemen som upptäcks kan användas för målsättande, vilket kan ingå i formella dokument, som överenskommelse om prioriteter, överenskomna mellan ministeriet och de regionala vårdklustren/sjukhusen.
Även regionalt, inom vårdklustren eller vid särskilda sjukhus, finns det program för vårdkvalitetsförbättring, 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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
som görs vi sjuk- och hälsovårdsanalytiska enheten vid Khoo Teck Puat-sjukhuset illustreras som exempel.
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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-worldfactbook/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-worldfactbook/geos/sn.html
5
The 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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 financial 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
13
Ministry of Health, Government of Singapore;
http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/ElderShield.html, last
accessed 18 Dec. 2012.
14
Ministry of Health, Government of Singapore;
http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Medifund.html, last
accessed 18 Dec. 2012.
15
Ministry of Health, Government of Singapore;
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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 discharged 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 20500 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 International 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/
19
Ministry of Health:
http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/Healthcare_Services/Hospitals.html,
last accessed 18 Dec. 2012.
20
A list of the major private hospitals is available at: http://www.singaporedoc.com/index.php/privatehospitals.html
15
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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).
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
Table 1 Singapore’s Regional Healthcare Clusters.
With Singapore being a city state, the concept of “regional cluster” is not strictly geographically confined. For example the National Healthcare Group (NHG) is the Regional
Healthcare System for Singapore’s Central region, but the health services reach out islandwide. 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 University 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
16
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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:
•
To facilitate exchange of information and data on healthcare quality principles and
practices, e.g. through workshops and publications.
•
To formulate recommendations, guidelines and standards by consensus working
groups.
•
To promote the education of all healthcare quality professionals both in the medical
institutions and in the community.
•
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
18
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 inequalities 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 Specialist 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
26
https://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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 Dentistry] 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
31
Ministry of Health, Government of Singapore;
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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Data includes volumes and types of procedures and clinical outcome. Also healthcareassociated 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
•
MRSA
•
Cataract
•
Hand Hygiene
•
Childhood Asthma
•
Nasopharynx Cancer
•
Child Epilepsy
•
PCI Door-to-balloon time
•
Childhood Leukaemia
•
Paediatric Cancers
•
Chronic Obstructive Pulmonary
Disease (COPD)
•
Rhabdomyosarcoma
osteosarcoma
•
CT Planning for Radiation Therapy
•
•
ERCP (Endoscopic Retrograde
Cholangio-pancreatogram) & Upper
Gastrointestinal Bleeding
Paediatric Blood & Bone Marrow
Transplant
•
Paediatric Liver Transplant
•
•
Paediatric Kidney Transplant
Elective PCI Mortality Rate
•
•
Paediatric Kidney Dialysis
Gastric Cancer
•
Stroke
•
Heart Surgeries
•
•
STEMI Mortality Rate
Hospital-wide Indicators
•
Surgical Site Infections
– Hand Hygiene
– Hip Arthroplasty
– Inpatient Falls
– Coronary Artery Bypass Graft
(CABG) Infections
– Unscheduled ICU Returns
– Ventilator-Associated Pneumonia
•
•
Very Premature Infants
Liver Transplant
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 International (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 simultaneously – ISO 9001:2000 (Quality Management System); ISO 14001:1996 (Environmental
21
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Management System); and OHSAS 18001:1999 (Occupational Health Safety Management
System) 2002.
22
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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).
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
2011
National Trauma Registry
Monitor outcomes and complications of living kidney &
liver donation
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/
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 registered 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 contained 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
24
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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
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 picture 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. Inspiration 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
37
From NRDO web page, http://www.nrdo.gov.sg/page.aspx?id=74, last accessed 20 February 2013.
25
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 accessibility 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
26
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 electronically 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 Singapore 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 vigorous 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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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 prolonged; 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 academic 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 converted 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.
28
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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 Registry 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 Association 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
29
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
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, hyperlipidaemia, 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:
30
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
•
Directly Observed Therapy (DOT) in public primary health care clinics
•
Monitoring of treatment progress and outcome for all cases by means of a National
Treatment Surveillance Registry - the Singapore Tuberculosis Elimination Programme
(STEP) Registry
•
Preventive therapy for recently infected close contacts of infectious tuberculosis cases
Mandated by law, the STEP Registry receives TB notification and data on treatment progress for every tuberculosis patient treated until an outcome is achieved. The registry also
alerts physicians if patients default on treatment or do not respond as expected. The STEP
Registry is hosted at Tan Tock Seng Hospital (National Healthcare Group). Since 1998, the
notification report has included disease characteristics, sociodemographic information,
country of origin, immigration status, and year of arrival in Singapore of TB patients. A
recent study based on STEP Registry data showed that the proportion of foreign-born persons with TB increased from 25.5 per cent in 2004 to 37.6 per cent in 2009. Unskilled
workers from countries with high incidences of TB accounted for the highest number of
and greatest increase in foreign-born TB case-patients.42
the first five years”, Bull World Health Organ. 2003; 81(3): 217–221, available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2572427/, last accessed 18 Dec. 2012
42
Khin Mar Kyi Win et al., “Tuberculosis among Foreign-born Persons, Singapore, 2000–2009”, Emerging
Infectious Diseases, 2011; 17(3), available at: http://wwwnc.cdc.gov/eid/article/17/3/10-1615_article.htm , last
accessed 19 Mar. 2013
31
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
4
Other applications of patient data for
improvement of care
4.1
National Healthcare Group Chronic Disease Management
System and Registry
Information technology and registries for clinical information support are critical components of high-quality chronic disease management. The National Healthcare Group (NHG)
developed an enterprise-wide chronic-disease management system (CDMS), which links
key administrative and clinical information to provide seamless care for patients with
chronic diseases, i.e. diabetes mellitus, hypertension, dyslipidaemia, stroke, and cardiovascular diseases. This system includes a complete disease registry that is utilised to give the
physicians clinical support. In the first phase, an enterprise-wide diabetes registry was
established in 2007.43 Other disease registries have been added in a phased manner.
•
Diabetes
2006 – 2007
•
Hypertension/Dyslipidaemia
2008
•
Stroke
2009 – 2010
•
Asthma/COPD/Obesity/IHD/Heart Failure
2011
•
Chronic Renal Disease/Osteoporosis
2012
The registries were set up when there were only 2 regional healthcare clusters, although
after the second restructuring to 6 clusters in 2009 the registries have continued to serve
the original institutions. This implies that the registry covers 3 acute hospitals, 9 primary
care polyclinics, and national speciality centres across 3 regional healthcare clusters, serving a population of more than 2.2 million.
4.1.1
Chronic Disease Management System
Administrative and clinical data for every patient is extracted from the various systems and
ported to an Operational Data Storage (ODS) that includes all services, costs etc. Rules
based on the patient data have been developed to identify chronic diseases patients in the
ODS, and only those patients’ data are ported to a Chronic Disease Management (CDM)
Registry (CDMR) and Datamart (CDMD). Through rules, the patients are further stratified
based on the severity of disease. Rules are based on diagnostic codes (currently only inpatients in tertiary care institutions), pharmacy records, and lab test results. See Figure 5.
43
Bee Hon Heng et al., “The Singapore National Healthcare Group Diabetes Registry – Descriptive
Epidemiology of Type 2 Diabetes Mellitus”, Ann Acad Med Singapore 2010;39:348-52, available at:
http://www.annals.edu.sg/pdf/39VolNo5May2010/V39N5p348.pdf, last accessed 18 Dec. 2012
32
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Figure 5 Work flow of CDMS. From the Source Data Layer, i.e. production system, various patientrelated data, administrative as well as clinical, is ported every night to the Operational Data Store (ODS)
and from there chronic-disease patients are identified and stratified with a rules-based algorithm. The
Chronic Disease Management Registry is used to provide physician with decision support and clinical
history of his/her patients. From CDM Datamart data can be extracted for multiple use, like performance
management, presentations etc. Source: National Healthcare Group, reprinted with permission.
Written consent from every patient is needed to allow their data to be entered in the
CDMS. Very few patients are reluctant to give their consent. Access to data is only
allowed for the clinicians that are attending to the individual patient. Special users, like
researchers, need approval from the ethics committee and the consent of the data owner
and the registry custodian to be allowed access to the data. The patient identifier is only
retained if necessary for the research, for example when it requires the combination of
different databases, but usually the identifier is removed before the data is provided to the
researcher.
In the system, the physician has easy access to the patients’ clinical history. Information
about the patient’s programme enrolment, all clinical data related to cardiovascular disease
and diabetes are compiled on designated pages, for the doctor to view easily. Special pages
are also dedicated to endocrine and CKD data, respectively. The physician is provided with
clinical decision support by the system. As a patient’s data is collected in the CDMS, the
10-Year Coronary Heart Disease Risk Category of that patient is automatically calculated.
The CDMS gives clinical alerts to the physician regarding his/her patients. The system can
also create standard reports, on cluster, clinic or patient basis with static data or historic
data for trending.
These reports can reveal if disease managing is done in a sufficiently stringent way and
whether resources are adequately used. They can also demonstrate trends in health status
of the patients in the CDMS.
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Electronic integration goes all the way to the examination of the patient, e.g. electronic
blood pressure (BP) measuring equipment was acquired, and the results of the measurements channelled directly into the system. Ease of use, and additional convenience as the
data is entered automatically in to the records, together have led to an increase in the number of BP measurements done and compliance with disease management protocols has
therefore improved.
34
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
5
Use of Data
5.1
National Standards for Healthcare
The aim of MOH is to collect a balanced set of measures that monitor clinical outcomes,
efficiency, effectiveness, customer satisfaction, and resource utilization. The measures are
used to develop improvement strategies and then take action to make these strategies a
reality.
To set common targets the Standards and Quality Improvement Division of MOH developed the National Standards for Healthcare, the purpose being to ensure that the healthcare
delivered is appropriate to the patient’s needs based on current evidence and clinical
knowledge across the continuum of healthcare.
Initially, acute hospitals have been in focus, as this area is dominated by public services
and is the area where the MOH spends most money. The standards are gradually being
extended to also cover community hospitals and primary care.
The National Standards for Healthcare cover seven domains:
•
Accessible Care
•
Learning Institutions
•
Appropriate Care
•
Physical Environment & Amenities
•
Patient-centred Care
•
Public Health
•
Safe Care
Assessment is made in two ways. One is off-site monitoring by MOH of performance indicators that the hospitals already measure and provide to MOH. This kind of data can be
waiting-time data, data from the registries, etc. However, there are some indictors for
which a hospital’s self-assessment is necessary, for example, patients are to be assessed by
specialists in a timely manner.
The deployment approach of hospitals’ self-assessment is based on regular collaborative
engagement for the benefit of the patients. The standards do not imply a top-down
approach, rather a collaborative deployment, with regular engagement to ensure clarity of
definitions, purposes of standards, and jointly developed action plans for implementation.
5.2
Cascading Scorecards
A concept of cascading scorecards is used. The idea is to have nationally consistent
measurements at every tier of the healthcare system to ensure valid and reliable like-forlike comparisons. At the highest level, guidance is offered by the MOH’s vision and
mission44; aiming for better health, better care, better value, and a better future for patients.
Under the National Health System Scorecard, the focus in Tier 1 is on health status and
outcome, which is similar to the OECD scorecard framework. The basic question is: With
all the things that are done for the healthcare system, are we delivering better health status,
life expectancy, disability status, healthy life expectancy, etc? In Tier 2, the contents relate
to determinants of health; smoking rate, obesity rate, etc. Finally in Tier 3 the health
system performance is scored. The question to be asked is; how are the healthcare
44
http://www.moh.gov.sg/content/moh_web/home/about-us/vision-mission-values.html
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
providers performing in the pathway of care, from primary care, via acute care, step-down
care and end-of-life care? On the scorecard for Tier 3, the pathways of care are on the
various columns and on the rows are domains covered by the standards (Figure 6).
Figure 6 Structure of MOH Cascading Scorecards. Source MOH, reprinted with permission.
36
MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
Cascading down from the national score card is the Public Hospital Scorecard, which in
turn can be further drilled down in to the Specialty-level Scorecards. Indicators from the
registries in the Public Hospital Scorecard include “Readmission to hospital within 30
days”, and “Unplanned admission following day surgery”. In the Speciality-level
Scorecards, indicators from the registries are included, for the Condition-specific scorecard
for heart attacks, indicators from the AMI Registry are “ePCI within 90 minutes”, “’All-ornone’ composite”, “30-day Mortality Rate after ePCI”, “30-day Mortality Rate after AMI”,
“Reinfarcation rate”.
The scorecards are not publicly available, but are used by the MOH and the public
healthcare sector for quality improvements. Both the NSHC and relevant Scorecards are
incorporated into the governance agreements between the MOH and public sector
healthcare providers. These agreements lay out the MOH’s expectations of the public
healthcare institution and their operating parameters, and the standards of service and key
deliverables required of the institutions.
Results are presented by the MOH to the senior management of the hospital, and also
occasionally to the hospital board. 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 goalsetting, which can be included in formal documents, such as the Statement of Priorities,
agreed between the MOH and the regional healthcare clusters.
The indicators in the Public Hospital Scorecard can also be seen as “tools” that can be used
to further drive development and innovation on quality indicator measurements and quality
improvements between the MOH and the hospital.
All the indicators are internationally well established. The indicator definitions of the Centres for Medicare and Medicaid or the Joint Commissions are used, which allows benchmarking using the Joint Commission’s annual report “Improving America’s Hospitals”.
The hospitals want to do well against each other, but are even more eager to do well internationally; this leads to a dual push for quality improvements.
The National Disease Registries cover both public and private healthcare providers, and
the MOH is interested in also including the private sector in the feedback and benchmarking cycle. The private healthcare providers are supportive of this because they actually
want to know how they are performing. Also, they compete in an international market and
the additional performance data and benchmarking results may give them an edge over
competitors.
5.3
Score Cards for Primary Care
Work is under way on score cards for primary care and data collection will be centred on
the national chronic disease management programmes. When patients and doctors submit
claims under the MediSave for Chronic Disease Management Programme, it is mandatory
for them to submit clinical data. From those data it is possible to see if the patients are
following the prescribed procedure of care and if their disease is under control. However,
in this case no data comes from the registries.
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
5.4
Use of data within a Regional Healthcare Cluster
In an earlier section (See 4.1) the Chronic Disease Management System (CDMS) of the
National Healthcare Group (NHG) was described. In that case clinical and administrative
data was collected and primarily used to provide seamless care for patients with chronic
diseases and utilise the available patient data through information management to support
management of chronic disease patients by providing the physician comprehensive patientcentred data and clinical decision support.
The NHG Health Services & Outcomes Research (HSOR) unit also uses clinical patient
data available in the various databases and registries of the NHG. However, in this case the
aim is to use Health Services Research to provide evidence for policy and decision making
for quality improvement for patient care. HSOR works with a broad spectrum of methods,
such as Clinical Decision Modelling, Health Economics, Operations Research, Programme
Evaluation, Surveys, Systematic Reviews, and Health Technology Assessment.
To give an example of the value provided by the access to the databases and registries
within the NHG, the following example of research done by HSOR is briefly described.
In this case, patients who are in contact with NHG were profiled by merging information
from the Operations Data Store (ODS), which contains information about all NHG’s
patients, with the information in the Chronic Disease Management Datamart (CDMD) and
other complementary databases.
945 000 individuals were admitted or visited Tan Tock Seng Hospital (TTSH), which is
NHG’s main hospital, and the National Healthcare Group Polyclinics (NHGP) in 2011.
Overall, the most prevalent chronic diseases in the population of TTSH/NHGP patients
were:
•
Dyslipidaemia (24%)
•
BMI ≥23 (22%)
•
Hypertension (20%)
•
Diabetes (11%)
•
Chronic Kidney Disease (8%)
Healthcare utilization:
•
ALOS, ED and IP visits increase with age of the patient and the number of
•
chronic diseases that he/she has45
These results are now followed up with additional work to:
•
Develop a detailed model to predict hospital readmissions.
•
Stratify patients as “well”, “simple”, “complicated” and “frail” and provide specialized
care package for each segment.
•
Analyse cost data to identify patients with high resource utilisation.
45
ALOS = Average Length of Stay; ED = Emergency Department; IP inpatient
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
5.5
Use of data within a hospital
The Healthcare Analytics Unit (HAU) at Khoo Teck Puat Hospital (KTPH) is a hospitallevel unit which focuses on statistical modelling, data mining, text analytics and operations
research that generate actionable insights for clinicians and administrators to enable better
patient care and evidence-based management decision-making at the hospital. HAU
focuses on the practical value of analytics and most of the work is project based. Raw data
is provided by the HPO of Alexandra Health, which is the healthcare cluster within which
KTPH is organised.
Some examples are given below of projects in which clinical or operational data has been
employed to improve operational or clinical processes.
An Infection Control Dashboard (a web-based system) was developed by the unit to spot
patterns and trends in infection and hygiene data. These data are collected by infectioncontrol nurses during hygiene audits in patient wards and combined with patientdemography data.
The purpose of the Infection Control Dashboard was:
•
To offer easy access to the data through an interface, in which the data can quickly be
combined, sliced and diced, to allow operationally relevant comparisons, e.g. according to staff group, ward, or time period
•
To automate generation of standard reports.
The value created is:
•
Easier access to the results gives the users a better opportunity to detect outliers and
delineate regions of increased microbial growth, e.g. according to staff group, ward, or
time period
•
Infection control nurses can now spend more time in the wards doing infection control,
analysing results or working on improvements, rather than writing reports.
In another project, a system based on statistical modelling was developed to predict the
propensity of an appointment no-show for Specialist Outpatient Clinics (SOC). This
gave the SOCs opportunity to schedule their work appropriately, thus improving time
optimisation and saving resources.
On the clinical side, the HAU has developed a risk score for patients with Obstructive
Sleep Amnesia (OSA) in the local setting. When patients with OSA come for surgery and
need anaesthesia, traditionally a questionnaire is used that gives a risk score from a series
of questions. This gives a score in the range of 1 to 6. However, the risk score was developed in the USA and there may be reason to question its validity for an Asian population.
The anaesthesia team approached the HAU to ask if local validation could be made. Using
clinical data from KTPH, a local risk score was derived. The results have been published
and are currently in use to guide the clinicians at KTPH in making decisions.
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
6
Discussion
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 absolute numbers, compared to other developed countries.
The main health challenges are the ageing population and a high and increasing burden of
chronic diseases. Opportunities exist for knowledge sharing, quality improvement and
healthcare integration using information technology.
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. It can be argued that the co-payment model injects a sense of
responsibility in the population with respect to healthcare consumption, but also underlines
the expectation that people have of receiving high quality healthcare. However, there is
hardly any patient engagement in policy formulation and healthcare development. Rather,
healthcare improvement is driven by the government, which has lately shifted focus from a
structural approach to a broader multidimensional concept that includes monitoring of
clinical indicators and recognising and measuring medical errors. Clinicians in the
healthcare system are also active and often pilot change processes to accomplish enhanced
healthcare quality.
Recent initiatives include the development of national standards for healthcare that are
related to performance measures like clinical outcome and other indicators. Benchmarking
is used to identify improvement areas. A system of Health Performance Offices in every
public hospital is leveraged to initiate change processes and gap closure. The feedback
cycle is based on governance and a collaborative approach, rather than financial incentives
and penalties.
Following the establishment of the National Registry of Diseases Act 2007 and the formation of The National Registry of Diseases Office the trend regarding disease registries
has been centralisation and standardisation with regard to collection and data management.
New registries, like the National Trauma Registry, have been inspired by other successful
examples abroad and a highly sophisticated registry has been developed. The use of registries and other clinical information has developed from an epidemiologic angle, to become
more focused on benchmarking and healthcare management.
Also on a regional level (healthcare clusters) there are examples of advanced utilisation of
patient clinical and administrative data for healthcare improvement and management, on a
continuous basis. This can be exemplified by the Chronic Disease Management System of
NHG and on a research-project basis, by the work done at the Health Services & Outcomes
Research group of NHG.
Even on a hospital level there are opportunities to utilise data to improve operational efficiency and care quality. A few examples were given from the work of the Healthcare
Analytics Unit of Khoo Teck Puat Hospital where resource-utilisation improvement and
evidence-based medical-management changes occurred as a result of specific projects.
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MEASUREMENTS FOR IMPROVED QUALITY IN HEALTHCARE
7
List of people interviewed
Dr. Chow Khuan Yew, Deputy Director, National Registry of Diseases Office, Health
Promotion Board, Singapore
Dr. Voo Yau Onn, Director, Standards and Quality Improvement Division, Ministry of
Health, Singapore
Dr. Lim Eng Kok, Acting Director, Performance and Technology Assessment Division,
Healthcare Performance Group, Ministry of Health, Singapore
Dr. Serena Low, Assistant Director, Health Information Division, Ministry of Health,
Singapore
Dr. Jasmine Foo, Health Policy Analyst, Health Information Division, Ministry of Health,
Singapore
Dr. Heng Bee Hoon, Director, Health Services & Outcomes Research, National
Healthcare Group
Dr. Matthias Toh Han Sim, Public Health Physician Consultant, Information Management Corporate Development, National Healthcare Group
Dr. Sandhya Mujumdar, Deputy Director Medical Affairs (QA), National University
Health Systems and Founding Member, Healthcare Quality Society of Singapore
Dr. Kristine Teoh Leok Kheng, Consultant, Department of Cardiac, Thoracic & Vascular
Surgery, National University Heart Centre, Singapore
Dr. Bhaskar Eti, Health IT Policy Analyst, Information Systems Division, Ministry of
Health Holdings, Singapore
Ms. Claudia Olsson, Managing Director Southeast Asia, Access Health International
Mr. Wu Dan, Team Lead, Healthcare Analytics Unit, Khoo Teck Puat Hospital (KPTH),
Alexandra Health System.
41
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