The Inaugural Singapore Clinical Quality Forum

07 Oct 2005

By Mr Khaw Boon Wan, Minister for Health

Venue: Marina Mandarin Hotel

"Is Better Healthcare at Lower Cost Possible?"

Last month, I was in New Caledonia for a WHO Western Pacific Regional Committee Meeting. About two dozen health ministers were there. We discussed many subjects, from avian flu to tuberculosis. 

A Difficult Balancing Act ...

The seemingly impossible task of providing better healthcare at lower cost permeated through the discussions. As though the life of a health minister is not complicated enough, occasional disasters from Hurricane Katrina to terrorist bomb blasts, added to our regular burden. It is tough to be a health minister in an increasingly unhealthy and unsafe world.

I have just read that next year, the US Medicare programme for the elderly will raise its basic premiums by 13%. Despite rising cost, many Americans wondered if they were getting value for their large expenditures on healthcare. 

A recent article in The Economist further assessed the US Medicaid programme for the poor is badly in need of an overhaul. But the public outrage at the government's handling of Hurricane Katrina means that no politicians would dare mention the reform word for a long time.

At New Caledonia, Chinese Health Minister Gao also lamented his challenges. Separately, I read that in one Province, one cancer patient was so frustrated with the high treatment cost, that he put a homemade bomb in a bus to attract public attention to his woes.

Such is the state of most national healthcare systems all over the world.  Every health minister is in search of the magic potion to provide quality healthcare at low cost.  But alas, there is no such magic cure.

With continuing medical discoveries and scientific advances, there is no natural limit to healthcare demand. Ultimately, we are all mortals but many patients or their relatives forget about that fact of life. Often, they would demand full recovery and expect the best possible treatment, with the bill picked up preferably by others. Therein lies the challenge.

But Achieving a Fair Balance

Against this gloomy global healthcare scene, I believe that our healthcare system has done not too bad a job. It is not perfect, but we have largely been able to balance the various competing objectives of maintaining high standard, while keeping cost affordable. 

Last month, my Ministry published a paper on the affordability of Class B2/C hospitalization. A copy is on our website. With large government subsidies, the average Class C hospital bill was below $800. Nine in ten Class C bills were below $1,500; only 1% exceeded $5,000. 

At the same time, even the low-income Singaporeans, earning below $1,000 a month, had an average Medisave balance of around $8,000, enough to cover 10 average Class C bills. The low-income Singaporeans' ability to pay for Class C hospitalization is therefore statistically assured. This is not a trivial achievement, given the high standard of our healthcare services.

Keeping Our Eyes on the Ball

But we cannot guarantee that the present outcome will continue into the future. New challenges on our healthcare system will continue to mount; particularly as more elderly Singaporeans grow in number and as medical science brings forth expensive new treatment modalities and diagnostic tools. Managing healthcare system and rationing healthcare services within limited resources is a continuous undertaking. We cannot lift our eyes off the ball.

We have to continue to look for new ways to deliver better healthcare at lower cost, difficult as it may be. This requires us to cut out wastages, to raise productivity of healthcare workers, to do more with less, to come out with more break-through ideas. Keeping Singaporeans healthy for as long as possible is the key. And should they fall sick, to treat them as far as possible in the community, rather than in expensive hospitals is the strategy. This requires primary healthcare to be up to the job. This is one reason why we are promoting well-trained family physicians, and for every Singaporean to have a regular family physician.

Launching More Skunkworks

Meanwhile, escalating healthcare costs in the developed countries have prompted many hospitals to search for innovative solutions to their many healthcare problems. Increasingly, hospitals are wisely looking to other sectors, particularly the manufacturing sector, for fresh ideas and opportunities to adapt their solutions. Many skunkworks are being set up; these nurture pilots and experiments to test out innovative solutions to common problems. I am encouraged by this global buzz.  I am sure along the way, better ways to deliver healthcare will emerge.

We should be part of this global search for innovative solutions to healthcare problems. We too have initiated a number of skunkworks. We should intensify them and plug into the global innovative network, to share experiences and to learn from one another.

This inaugural Singapore Clinical Quality Forum is part of that effort. It provides a forum for our healthcare workers, from both the public and private sectors to share their experiences, and to inspire one another. The single objective is to make healthcare better and safer for our patients.

We should have the confidence that we can contribute to the global search for better healthcare. Over the past 40 years, we have achieved several world firsts, for instance, in the area of stem cell transplants for haematological diseases . Our doctors and our hospitals have done us proud by winning international awards.

Last year, KK Women's & Children's Hospital became the first in the Asia-Pacific region to receive the Asian Hospital Management Award for Patient Safety and Risk Management. Its Integrated Labour Ward Risk Management Programme, covering speedy staff mobilization, constant reviews and audits, training, and a computerized early warning system has helped KKH to achieve a perinatal mortality rate of 4.9 per 1,000 births - one of the lowest in the world.

In addition, KKH's eclampsia rate has dropped from 101 per 100,000 births in 1995 to 7 in 2004. This is likely the lowest for a tertiary maternity hospital.

Creating the Right Attitude, Opening Minds

To successfully innovate, we need to be willing to adopt new paradigms and mindsets. I am impressed by the readiness of Alexandra Hospital's Emergency Department staff to adopt the Toyota Production System. Their skunkworks have produced results: the ED has cut the waiting time for patients by half.

AH staffs are now ramping up their Toyota-inspired skunkworks to a wider front. For example, in community health screening, they used to have a team of 12 staff screening 22 patients per hour. This was two years ago. Careful application of Toyota approach has raised productivity by 400%: a team of 10 staff can now screen 70 patients per hour. As a result, they are able to bring down health screening cost to $10 per patient.

At their specialist outpatient clinics, they have begun to apply the Toyota approach. Post-operation patients coming for wound inspections used to join other patients for the doctors' attention. Now, they join express lanes specially set up for such patients, where trained nurses can do the wound inspection competently.  Some patients can even skip the clinics altogether, by sending their pictures of their wounds via MMS. The pictures are dated and recorded for comparison by the doctors and nurses. Only those with poor healing, a minority, are recalled to the clinics for further management. This saves patients much inconvenience and cost.

Over in TTSH, their skunkworks to speed up the turnaround of day surgery patients has also produced results. Previously, patients used to have to wait several hours for the doctor to review them before they could go home. Now trained nurses can take on this review role, using a set of approved protocol. As a result, more than 90% of their day surgery patients are discharged within 2.5 hours after surgery, without compromising medical care.    

May A Hundred Flowers Bloom

Let's push on with such innovations and skunkworks. My Ministry has set up a Healthcare Quality Improvement Fund to provide seed monies for such projects.  We will fund up to $50,000 per project. We will provide $1 million a year for this Fund. But we will provide more money if there are many more good ideas. This will encourage our public hospitals to undertake more reviews and pilot more quality improvement projects. The aim is to achieve measurable and sustainable improvements in patient care .

We should use the annual Clinical Quality Forum to report the achievements of these skunkworks. Not all pilots will succeed as planned. So even failures should be shared and reported, so that we do not have to repeat others' bad experiences and pay the tuition fees.

Do Simple Things Well

Quality improvement is not always about esoteric treatment or high-end research. Doing simple things well can often make a big difference to our patients.

For example, a common problem in hospitals is hospital-acquired infection.  One of the most effective solutions is simply proper hand washing; but this requires discipline throughout.

Small changes undertaken in a concerted manner can lead to huge benefits. Take another example of ventilator-associated pneumonia (VAP).  15% to 40% of patients who undergo mechanical ventilation for more than 48 hours develop pneumonia, and patients with VAP tend to have poorer outcomes than those without VAP. Through a programme of surveillance, benchmarking and quality improvement, our public hospitals have reduced their VAP rates in the medical ICU from more than 12% to below 4%. This was achieved through implementing a few simple measures but doing them consistently: raise the head of the bed, omit sedation briefly to see if the patient is ready to be off the ventilator, peptic ulcer disease prophylaxis and deep vein thrombosis prophylaxis. Simple but effective changes. 

Increasing Transparency - Publishing Outcomes

We should compile and publish such clinical outcomes data. This will allow hospitals to compare their performance and learn from one another, besides keeping patients informed.  

Take the example of cataract surgery. With ageing, we now do more than 20,000 cases a year. We have just finished a study on the quality of our cataract surgeries. Our ophthalmologists produce good outcomes, comparable to international standards, with success rates exceeding 95% and safety rates, exceeding 98%. My Ministry will publish the analysis soon.

Even if our results are inadequate, we need to know who have done better and to learn from them. This way, we goad each other on and raise the general standard of healthcare. What we must avoid is not knowing what we don't know.

Ultimately, Have a Heart

But healthcare is ultimately not just about data but about people. The best infrastructure, the most competent doctors and the most robust processes would still be incomplete without the human element - a caring heart, a tender touch, a cheerful smile or an encouraging word.

Good communication is therefore vital if we aspire to excellence in healthcare. Good communication is even more important when events take an unexpected turn.

Conclusion

The quality journey is a never-ending quest. We have much to learn and much to do. We must continue to innovate and experiment. Go for stretch targets and aim to exceed even them.  

I wish everyone a fruitful and rewarding journey. Thank you.