Measurements for Improved Quality in Healthcare
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 institutions. 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 goal-setting, which can be included in formal documents, such as Statement of Priorities, agreed between MOH and the Regional Healthcare Clusters/hospitals.
Also regionally, within the healthcare clusters or a specific hospital, there are programmes for healthcare quality improvement using hospital databases, registries or other data. The Chronic Disease Management System of the National Healthcare Group and the work of the Healthcare Analytics Unit at Khoo Teck Puat Hospital are illustrated as examples.