Our Quality Journey: Endless But Highly Satisfying

06 Oct 2010

By Minister for Health, Mr Khaw Boon Wan

Venue: Suntec Convention and Exhibition Centre

1. Singapore healthcare is not perfect. But it is not bad. Last year, the International Institute for Management Development’s (IMD) World Competitiveness Yearbook rated our healthcare infrastructure as the 4th best in the world. And the World Economic Forum (WEF) Global Competitiveness Report ranked Singapore as the 3rd lowest in infant mortality and the 7th highest in life expectancy. 

2. Singaporeans enjoy a high standard of healthcare, achieving universal coverage with society spending only 4% of its GDP on healthcare services. This is a remarkable achievement which has amazed those who are familiar with health economics and comparative healthcare systems.

3. This is an outcome of a long journey in healthcare quality which began 4 decades ago. Let me briefly mark out the milestones on this journey.

Strengthen Primary Healthcare

4. First, we strengthened our primary healthcare system. These were the low hanging fruits, low investment with high return.

5. We went on a comprehensive programme to create modern polyclinics, get them to focus especially on chronic disease management, and bring their services close to population centres. We provided free vaccination for key diseases such as diphtheria and measles, achieving childhood immunisation rates that are among the highest in the world. We invested in school health programmes so that preventive health services such as health screening, immunisation, dental health care and promotion programmes on healthy lifestyle practices were made available to every child.

6. When the Hepatitis B vaccine became available, we were among the first in the world to include it in the national childhood immunisation programme, achieving near universal coverage for all children below two years old. This has eliminated hepatitis B infections among young Singaporeans. 

Rebuild Old Hospitals

7. Second, we embarked on a drive to rebuild our hospitals which were all built before the Second World War. This is a massive investment in capital expenditure and we have to do it in stages as we cannot afford to close down too many beds for reconstruction at the same time. 

8. We started with the rebuilding of the Singapore General Hospital in the 70’s. This was followed by the rebuilding of Tan Tock Seng Hospital, Woodbridge Hospital, Toa Payoh Hospital and KK Hospital. This massive hospital rebuilding programme is finally coming to a close with the rebuilding of Alexandra Hospital into the recently opened Khoo Teck Puat Hospital. It has taken us 3 decades to complete this programme. In a decade or two, the rebuilt hospitals will have to begin a new rebuilding programme. For example, the rebuilt SGH will be nearly 40 years old in 2020 and will likely have to be completely rebuilt before it turns 50. We are laying the foundation for its rebuilding by embarking on the Master Planning of the entire Outram Campus.

Build New Hospitals

9. Third, even as we rebuild old hospitals, we have to build new ones, in order to expand our total capacity to cope with an expanding population. The programme started with the National University Hospital in the 80’s.

10. The next new hospital is the Jurong General Hospital, which I will ground-break next month. We will get it open before 2015, to serve the residents living in the west.

11. After that, we will likely have to build another general hospital in the latter half of the decade. This is to meet the expanding population living in the in the north east. Given the long lead time in building a hospital, we have started to look for a good site for this new hospital. This is forward planning and not yet a firm commitment to build one. But with expanding population, I see it as inevitable, sooner or later.

Build Capabilities

12. Fourth, as we invest in the hardware of healthcare, we invest even more in the software, particularly in our doctors, getting them to specialise and sub-specialise. We launched the Healthcare Manpower Development Programme (HMDP) in the 80’s and as we had access to more resources, we expanded it in a big way.

13. Under HMDP, almost all our specialists have opportunities to work and be trained in the best medical centres overseas. Thirty years of investment in the HMDP have yielded huge dividends. Our specialists and sub-specialists are world-class. In most specialties, basic training can now be done locally, instead of overseas. We in turn have become the trainers and the training ground for doctors in the region wanting to sub-specialise.

14. We continue to send our specialists overseas under HMDP to pick up finer skills and latest innovations, to hone their skills and to network with the best in the world. We have also extended HMDP to the other healthcare professionals, especially the nurses, pharmacists and other allied healthcare workers.

15. Along the way, we have expanded our investment in medical education by setting up a new medical school offering a joint degree with the Duke University. The first batch of the Duke-NUS Graduate Medical School students will graduate next year. A third medical school offering a joint degree with the Imperial College is now being planned, for first year intake in 2013.  

16. We have also invested in nursing, with expanded intakes and a new undergraduate School of Nursing, so as to build up a cadre of Advanced Practice Nurses. We have expanded the intake of undergraduate pharmacy training and are studying post-graduate pharmacy training. We will be investing in local undergraduate training capability for allied health, which is critical for an expanding elderly population.

Get Financing Model Right

17. Fifth, healthcare is an expensive business. Medical excellence comes with a high price tag. We have to make sure that healthcare does not become a bottomless pit, as it will not be sustainable. Building new hospitals and training doctors are relatively technical problems. With money and good global networking, we can largely get what we want. 

18. However, how to sustain a high performing healthcare system to cope with rising, and sometimes unrealistic expectation of the people is not so straight forward. The healthcare sector is fraught with moral hazards. 

19. We spend a lot of time thinking through the healthcare financing model. We inherited the British National Health Service Model. We carefully grafted onto it some elements of the US competitive market and the European risk-pooling insurance system. As individuals, we need to save regularly for a rainy day when we fall sick and need money to pay for good doctors and nurses. As a society, we need to collectively help those who are vulnerable because either they are from the lower income group and have little saving, or are unfortunate to be struck with a major illness or are frequently sick. Our healthcare financing model, which we refer to as the 3Ms, combine a compulsory health savings account (Medisave), a high-deductible health insurance (MediShield) with a humane taxation-funded safety net (Medifund and heavy Government subsidy). It achieves universal coverage, offering multiple layers of protection so that no Singaporeans will drop out of the social safety net as a result of a severe or prolonged medical illness.

20. After 20 years, our 3Ms have withstood the test of time. But it still requires constant maintenance and fine tweaking to ensure that subsidies are targeted at those who most need them and good healthcare remains affordable for all.  

Be Best In Class

21. Finally, with the large pieces in place, we have in recent years begun to focus on achieving high quality health outcome as a system. Good doctors and good hospitals deliver good healthcare services. High medical ethics ensure that services delivered are always in the best interests of the patients. We have plenty of these in Singapore, I am sure, as otherwise our macro health outcomes will not be among the best in the world.

22. However, can we say that every doctor-patient transaction in Singapore is flawless from the medical and the ethical view point? Moreover, as medicine is still partly an art, how can we ensure that best evidence-based practices are consistently carried out by all doctors for all their patients all the time? Or to borrow the theme of your conference “My Patient: My Care - Doing the Right Things and Doing Things Right”, how do we ensure that all the patients in Singapore receive such a care that is always appropriate and delivered correctly all the time?

23. I believe we can benefit from adapting proven strategy from the other sectors. For example, as an engineer, it seems to me that we will need processes in place, involving standardisation, documentation, measurement, quality control, defects reporting, compliance audit, transparency and publication, to achieve such an outcome. These are the things that engineers focus on all the time in the factory. I accept that hospitals are not factories and patients are not motor cars. But many doctors have now begun to appreciate the engineers’ approach to quality and safety and think that they have a place in healthcare.

24. Some of our hospitals have adopted the Toyota approach and Lean methodology, with promising results. That was also what motivated our public hospitals to seek accreditation with the US Joint Commission International (JCI). It is not merely to get another accreditation certificate. It is to be part of a global movement in search of better quality and safety solutions, so as to benefit our patients. Almost all our hospitals are now JCI-accredited.

25. And I am glad to read that JCI itself is pushing the quality and safety boundaries wider and deeper, beyond merely auditing and certifying hospitals, into jointly developing solutions which can be replicable to all hospitals. I am sure later we will hear from Dr Mark Chassin more on this area of work and in particular on the Joint Commission Center for Transforming Healthcare. It warmed my heart when I googled the Center’s website and read its mission:

“The Center for Transforming Healthcare has been established by The Joint Commission to solve the most pressing quality and safety problems that are all too prevalent in health care today. These are the problems, such as health care-associated infections and medication and surgical errors, which threaten lives and increase costs. Working with a cadre of hospitals and health systems, the Center develops solutions through the application of the same robust process improvement methods and tools that other industries have long relied upon to improve quality, safety and efficiency. These methods include Lean Six Sigma and Change Acceleration Process.” 

26. Somewhere in the website, it also declared its goal: “to transform health care into a high-reliability industry with rate of adverse events and breakdowns in routine safety processes comparable to jet air travel”. I share Dr Chassin’s goal and look forward to his lecture. Our hospitals should consider participating in the work of the Joint Commission, and similar agencies elsewhere, to help co-develop practical solutions and to learn from others. We should benchmark ourselves against the best in the world, regularly measure ourselves against the best in class, so as to identify the shortfalls and work to close the gap.

27. We have a responsibility to Singaporeans to do our best, not so much to improve our rankings but to save lives and improve their quality of life. We are not starting from ground zero. We have been at it for many years now and there have been success stories.

28. For example, NUH has sought to reduce healthcare associated infection and succeeded in reducing its MRSA infection rate from 0.24 per 1,000 patient days in 2006, to 0.09 in 2010. The other hospitals should follow suit.

29. Another success story is TTSH’s stroke care management model. It has led to significant improvements in the patient’s functional status upon discharge and reduction in readmission rate.

30. All these successes mean avoidance of misery for our patients and saving of money for them.

Conclusion

31. Our quality journey started 40 years ago. But it is an endless journey and the destination ahead is still far off. However with each milestone crossed, we can be satisfied that we have made further progress, saved many more lives and helped many live a much more meaningful life. 

32. I believe this Conference will allow you to learn from one another, and inspire you to want to improve the care that you deliver. I wish you a fruitful Conference.