Speech by Minister at the Launch of the Customer-Centric Initiative (CCI) for the Healthcare Sector

19 Sep 2008

By Khaw Boon Wan

“Let’s raise the bar”

1. In the service industry, good customer service is not sufficient for business success, but it is essential for business survival.  In a competitive market, customers have choices and they can vote with their feet.  If your service is not up to the customers’ expectations, they move their business somewhere else.  Hence, providers go all out to distinguish themselves from the competition, to meet what their customers demand.  The result is constant innovation, greater diversity and customers are spoilt for choice.  This is the beauty of market competition.

It’s more complicated in healthcare

2. In the healthcare sector, “good customer service” is a bit more complicated.  Indeed, the sector has been hesitant to regard a patient as a customer.  Inherent in this mindset is a worry that “good customer service which suggests pampering to what a customer wishes” may sometimes run smack against the duties, responsibilities and ethics of a good doctor.  We struggled with this mindset when we first restructured our hospitals more than 20 years ago. 

3. But we have overcome the initial hesitation and Singapore healthcare is doing well and attracted a large number of foreign patients.  My Ministry’s customer survey of restructured hospitals shows that patient satisfaction is rising.  In 2005, 68% of patients rated their services as “good” or “excellent”.  Last year, this went up to 75%, with the top hospital scoring 83%.

4. Satisfying patients however remains a challenge.  I once had to convince a highly educated new citizen who grew up in China, why the medical service of a hospital here to her child was appropriate.  She was upset that the doctors did not put her baby on drips.  She said that in China, all patients are put on drips.  I have read somewhere that this is indeed the case, but often not because it is clinically indicated, but because it is a source of extra income for the hospitals.   

5. Last week, I got an email from a patient’s relative, complaining that the hospital refused to discuss the patient’s condition over the telephone with him.  He was naturally anxious and was not amused when the hospital asked him to go to the hospital to meet the doctor face-to-face.  But without the patient’s consent and the proper identification of the caller, the hospital was right to protect the patient’s confidentiality. 

6. There are many other examples of challenging encounters.  A patient asking for more sleeping pills has to be properly counseled and often his request has to be rejected.  Antibiotics cannot be freely prescribed on demand of the patients.  Likewise, medical certificates.  Doctors’ duties include telling their patients to drop bad habits, change lifestyles and seeing that they actually comply.  Inevitably, we have to be paternalistic in order to do our job responsibly.

7. On the other hand, when one is sick and feeling unwell, one may not be in the right frame of mind to appreciate anything.  So hospital food tends to taste bland.  And it is human nature to feel that “I am more sick and my need is more urgent than the next person”.  The truth is that patients have different concerns, backgrounds, needs, priorities and intentions.  As a service provider, we must be acutely aware that we are dealing with a real person. Whoever they are, whatever we do, we must demand from ourselves a higher level of care, personal touch, empathy and better follow-up.   

We face tougher challenges

8. If it is difficult to satisfy customers in the healthcare sector, it is even tougher in the subsidised public healthcare sector.  Here, we are confronted with three conflicting objectives: keep medical standard high, cost low, and satisfy the patients’ expectation.  The latter is often defined and measured in non-medical terms: creature comfort, on-demand service with no queue, choosing own doctors and timing for medical appointments.  Satisfying all three objectives is near impossible.  We have to prioritise and make trade-offs. 

9. For instance our medical prescription policy promotes the use of generic medicine.  This way, we keep healthcare cost affordable, without compromising on medical standard.  But some patients would come to our clinics, armed with Internet printouts to demand this branded drug or that health supplement.  We have to say “no” and make another unhappy customer.

10. Waiting time is another difficult problem.  In the commercial world, more customers mean more business and the businessman will simply expand capacity and/or raise prices to meet the rising demand.  The subsidised healthcare sector does not have such an easy option.  We have no problem meeting on-demand emergency services.  But on-demand non-emergency service is clinically unnecessary and will be very costly to provide. 

11. Our popular consultants run busy clinics and sometimes have to squeeze in more clinic appointments than desirable, in order to shorten the waiting time by patients for new appointments.  The alternative of under-booking, with doctors waiting for patients, means higher cost for the patients.  But we can’t simply pass on the higher cost to the patients.  In the public hospitals, we have to make sure the charges remain affordable. 

12. Over-booking is also due to some patients not turning up at the clinic despite having confirmed appointments.  Such “no show” wastes hospital resources as the slot becomes vacant.  To reduce such wastages, our hospitals have to over-book the clinics.  But as actual no-show rate cannot be predicted in advance, such over-booking to correct for probable no-show rate results in unnecessary waiting at the clinics.

13. Yet, this must not be an excuse for deliberately sending patients from pillar to post, keeping them waiting unnecessarily through internal inefficiencies.  Every feedback, complaint and compliment can bring value to how we can make things better for the patient.  They highlight practices that can be expanded to other areas, service gaps and how not to frustrate an already sick patient or anxious relatives.  A structured system for continuous improvement, good listening posts and management responsiveness is therefore a must to make our care delivery a positive experience for both the patients and their relatives. 

Rising expectation

14. But even as service providers are improving, patients’ expectation and demand are rising.  We are grateful for something the first time we experience it, but after a few more encounters, we get used to it as the norm.  They call it the French vanilla effect: the first taste is heaven, by the sixth mouthful, it no longer thrills.

15. The needs and expectations of the patients are also becoming more varied and intense.   People are becoming more varied in their values, needs, expectations and demands.  For example, we cannot assume that all cancer patients want to live as long as possible, regardless of discomfort of treatment.  There are those who will try every possible way to survive longer, but there are also those whose focus is making their remaining time as comfortable, dignified and pain-free as possible.

16. The challenge ahead is for providers to understand thoroughly the needs of the groups of patients they are serving, then provide services that will best meet the needs of the groups at a cost that is acceptable to them.  Develop systems and processes to provide services effectively, efficiently and consistently.   

17. Patients are sick, they want to know quickly what is wrong with them and they hope that the doctors can help them recover fully.  They are anxious, in pain and they seek comfort and compassion.  They will appreciate empathy and be treated with dignity and respect.  Whether in the public or the private hospitals, we should try to satisfy these legitimate demands.  

Get the right people and be inspired

18. This means getting the right people who are competent, caring and compassionate to join our ranks.  Treat them well.  Train them well.  Lead them well.  The bottom line is that good service can only be delivered by people.  We have many of them in our midst.  Let me highlight a few recent examples.

19. Last month, nurse Yan Peng of Changi General Hospital impressed a Malay lady patient whose son wrote in and I quote: “Nurse Yan Peng had been an epitome of compassion.  Her dedication for the job was tremendous.  She spoke the language of the suffering and understood each and every patient’s needs.  While we were there, we would overwhelm her with requests and each time she carried it out tirelessly, only to ask if we required further assistance.  She was approachable and did not have a sullen face.”

20. Another lady patient who had knee joint replacement wrote in about her experience in the TTSH physiotherapy department and I quote: “Though this department is visibly very stretched because of the large number of referrals, I was given the best possible care which came in the form of Mr Keith Adam, who was assigned to my case.  He was very knowledgeable, patient and gave all his patients the emotional support to get through this difficult road to recovery.  This was in contrast with other hospitals where patients who cannot follow-up the exercise regiment were treated as if they were “time-wasters”, causing many to drop off the physiotherapy programme prematurely.  Based on my experience, physiotherapy sessions are a critical part of the recovery process.  However, let’s not forget that the emotional support is equally as important because the therapy sessions can be traumatising and indeed painful.  Having an understanding therapist helps a great deal.  The Ministry of Health and TTSH management really need to give physiotherapists due recognition when they have done an excellent job and TTSH’s Mr Adam is a shining example.” 

21.  Another lady wrote in about her father’s experience and I quote: “Over the last year, my father has been quite the regular patient at the Singapore General Hospital.  Beset by infections made worse by yet more infections, he has gone to the brink of death and back, and along the way, survived end-stage renal failure, the amputation of both his legs, acute peritonitis, and a heart attack, among a slew of other things…In the course of his treatment, we have come across doctors who range from the indifferent to the incredibly caring.   There are those… like Dr Benjamin Chua, Dr Ian Loh, and Dr Nandini, who have gone out of their way to show a sense of personal caring for my father in the worst of times.  Despite their obviously heavy patient loads and busy schedules, these doctors always made time to advise and to explain to us the ins and outs of my father’s condition, and always with honesty and a kind word.  Under these doctors, we have been calmed, educated and assured that my father matters not as just another patient…, but as an individual who deserves the best medical care – even as a subsidised patient…Throughout this time, one doctor who has provided all-encompassing care for my father’s many ailments is Dr Koh Yin Ling… Dr Koh has been a godsend to my family and we feel extremely blessed and grateful for her… When my father had to undergo his amputation, it was Dr Koh who broke the news to us and who followed up on his wounds and aftercare… she always takes my calls no matter the time of day and has never rushed through a phone call or a consultation with us… At our last visit, Dr Koh who is usually very reserved, touched my father’s face gently and wished him well.  She then took his hand and told him to look after himself.  These were small gestures that moved us greatly and we are extremely grateful for having a doctor who clearly cares deeply for her patients and who translates this care into conscientious treatment.  It is doctors like her who restore our faith in the medical profession and who embody the premise that medicine is a calling.  It is doctors like her who make the difference between medical treatment and medical care.  And for that, my family and I are truly thankful.”    

22. These are shining examples of our colleagues who have gone the extra mile and along the way touched many hearts.  By their examples, these wonderful colleagues show that while providing subsidised healthcare is challenging, the right attitude and a good dose of compassion can go a long way to satisfy our patents’ needs, without undermining our mission. 

23. We have made good progress after 20 years of hospital restructuring.  Now, let’s raise the bar.  Let’s get more patients to say “Wow, they do care”.   It is not easy but it can be done.  Singaporeans desire better.