YEARS OF TRANSFORMING PRIMARY HEALTHCARE

NHG POLYCLINICS

YEARS OF TRANSFORMING PRIMARY HEALTHCARE

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This book is about providing the best primary

healthcare to the community – the NHGP way. Created

to mark the 15th anniversary of the inauguration of

NHGP, it aims to capture the human story behind the

Group’s work across its nine polyclinics. You will hear

the voices of NHGP’s leaders, its doctors, nurses and

Allied Health Professionals and their invaluable support

teams. Together they tell a story of vision, commitment

to quality and passion for healing and make the most

important point – that it always takes a team.

Marking its 15th anniversary in the year Singapore

celebrates its 50th year of independence, NHGP continues

into the future on its journey of quality healthcare.

NHG POLYCLINICS

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NHG Polyclinics 15 Years of Transforming

Primary Healthcare

Copyright © 2015

National Healthcare Group Polyclinics

Published 2015 by

National Healthcare Group Polyclinics

3 Fusionopolis Link, Nexus@one-north

South Tower, # 05-10

Singapore 138543

www.nhgp.com.sg

Tel: +65 6355 3000

Content

Sharon Sim for

ThinkFarm Pte Ltd

3 Changi South Lane

Singapore 486118

Tel: +65 6831 1299

Additional Photography

Ahmad Iskandar

Printed by KHL Printing

ISBN 978-981-09-6855-7

All rights reserved. No part of this publication may be

reproduced, stored in a retrieval system or transmitted in any

form or by any means, electronic, mechanical, photocopying,

recording or otherwise, without the prior written consent of

National Healthcare Group Polyclinics. The information in this

book is current at the time of printing.

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CONTENTS

03About the Book

06Senior Management Messages

10INTRODUCTION

Snapshot: Polyclinics before 2000

14CHAPTER ONE

Racing Boldly into a New Era

24CHAPTER TWO

A Walk Down Memory Lane

32Our Quality Journey

36CHAPTER THREE

Healing with a Heart

44CHAPTER FOUR

Together We Stand52

CHAPTER FIVE

One Care Team

68Serving Our Community

72CHAPTER SIX

Improving Care Through Technology

80Our Patients’ Journey

90CHAPTER SEVEN

Building Relationships for our Future

98Milestones

104Acknowledgements

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06 CHAIRMAN

As the National Healthcare Group (NHG) and

National Healthcare Group Polyclinics (NHGP)

mark our 15th year anniversary this year, we

celebrate alongside our country’s Golden Jubilee.

The health of our population is key to building a

strong nation.

As such, we celebrate the many achievements

primary healthcare has made to establish the

foundation of population health in Singapore to

improve our people’s well-being.

The Singapore Government has implemented

initiatives to improve the health of our population,

advance knowledge and practices in medicine

and groom our future generation of healthcare

professionals. The Ministry of Health (MOH) has

maintained a key focus on raising the quality of

patient care and better integrating institutions

across different settings. NHG established the

Regional Health System (RHS) for the Central

region of Singapore and has moved forward as

a family of institutions to achieve a healthcare

system where patients and the population are

at the centre of what we do; where our suite of

healthcare services offered is integrated, seamless,

accessible, affordable and comprehensive.

Our polyclinics have, since the early years, been

instrumental in improving the health of our people,

with important initiatives in maternal and child

preventive medicine and health promotion, as

well as comprehensive care. They have overcome

challenges associated with our rapidly ageing and

growing population by emphasising on optimising

health, allowing individuals to live productive lives

in the community and ensuring that healthcare is

accessible and affordable.

NHGP has over the years built up a strong brand

in Singapore for providing comprehensive,

accessible and affordable primary healthcare

and one that – I am pleased to add – is

committed to being current and relevant to

our constantly evolving healthcare landscape.

Looking back at these 15 years, NHGP has

overcome a multitude of challenges through its

people and innovations and is now a leading

public institution for primary healthcare.

Our staff have also been recognised for their

efforts and dedication to patient care, through

awards at both individual as well as organisational

level for patient care and innovation, clinical

training, research as well as human resource and

IT excellence.

As we forge on in our RHS journey, it is vital to

recognise our institutions’ work in collaborations

and partnerships. NHGP has come a long way

in developing relationships and forming strong

partnerships with stakeholders in the primary

healthcare landscape and within the community.

NHGP has a bright future ahead as it takes steps

towards improving population health through

transforming its primary healthcare delivery model

and leveraging technology to make healthcare

more person-centric.

As NHGP continues in its efforts to advance

Family Medicine and transform primary healthcare,

we are grateful to the Ministry of Health, Ministry

of Health Holdings and our important primary care

and community partners and public healthcare

institutions for their continued support. All our

achievements would also not have been possible

without our people and their tireless efforts. The

management team and every single staff member

of NHGP in the past and present have done

us proud with their dedication and contributions

to our primary healthcare system.

As we celebrate our last 15 years in improving

the health of every Singaporean, let us now look

to the future of NHGP to achieve new milestones

and advances in the field of primary healthcare

and to uphold our vision of Adding Years of

Healthy Life.

Madam Kay Kuok

Chairman

National Healthcare Group

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GROUP CHIEF EXECUTIVE OFFICER NHG POLYCLINICS 0715 YEARS OF TRANSFORMING PRIMARY HEALTHCARE

With Singapore’s rapidly growing ageing

population, there has been a rise in the number

of patients with chronic diseases who require

long-term disease management. This has

changed the way we care for our patients

as well as made it necessary to reshape our

healthcare delivery system.

In support of the Ministry of Health’s

Healthcare 2020 Masterplan to expand

the national healthcare capacity to meet

Singapore’s changing needs, the National

Healthcare Group (NHG) has been redefining

itself and it is heartening to see the progress

of our transformation efforts over the past 15

years, particularly at the National Healthcare

Group Polyclinics (NHGP), NHG’s primary

healthcare arm.

As primary healthcare continues to be a

fundamentally important component in

enhancing population health, it is crucial that we

improve further in how we provide community-

based care. Going beyond illness care, primary

healthcare now focuses on patient education

and empowerment in which our healthcare

professionals actively encourage patients to

embrace a more proactive role in managing their

own health and preventing illnesses.

Taking on a population-based approach, where

a patient’s needs across different healthcare

settings are well-planned and coordinated

across various healthcare institutions and

social welfare organisations, NHGP has

been collaborating closely in tandem with

its healthcare and community care partners.

An example is the development of the Ang

Mo Kio and Unity Family Medicine Clinics as

well as Hougang Family Medicine Clinic @ Ci

Yuan Community Club. Forging such Public-

Private-People (PPP) partnerships with primary

healthcare stakeholders allows us to not only

complement and leverage one another’s

strengths to provide seamless, quality and

affordable care, but also ensures that both

individual and population needs are well-

understood and accurately addressed.

We have also embraced the availability of new

technology and medical advances that have

allowed us to see more patients efficiently and

attend to their needs more effectively. The

electronic medical records system, which was

rolled out in 2006, is one of the many initiatives

that saw us leap into the digital age with its

digitisation process and paperless system.

This system has enabled multi-disciplinary

care coordination in the polyclinics, allowing

care teams to access and retrieve patient

information and history seamlessly.

As we look forward to our healthcare journey

beyond these 15 years, I am certain that we will

continue to stay true to our vision of ‘Adding

Years of Healthy Life’ and advance our goal

of population health. Our upcoming polyclinic

redevelopments in Ang Mo Kio and Yishun

as well as the new Pioneer Family Healthcare

Centre are already testaments to this with the

new and improved coordinated care delivery

model and patient empanelment approach

which will be vital in our shift from illness to

wellness care. They serve as a platform to

continue working closely with our partners and

maximise the well-being of our population. It is

also a testament of our commitment to our one

healthcare, one plan, one team vision where

we will be able to deliver more accessible,

affordable, integrated and quality care to all.

Professor Philip Choo

Group Chief

Executive Officer



CHIEF EXECUTIVE OFFICER08

The National Healthcare Group Polyclinics (NHGP)

has come a long way from its humble beginnings.

With the clustering of the public healthcare

system and the inception of National Healthcare

Group (NHG) in 2000, NHGP has been on an

exciting journey of transforming and integrating

care for our patients. Our staff who have been our

pillars of strength have never backed away in the

face of great challenges and uncertainty.

Instead, it is with this indomitable spirit that

we were able to do what many thought was

challenging or seemingly impossible over the last

15 years. It is our shared vision of ‘Adding Years

of Healthy Life’ to our patients and their families

that kept us going. We constantly examined how

we could help patients in the primary healthcare

setting and move beyond episodic ‘transactional

medicine’. With an ageing population and a higher

prevalence of chronic diseases, it has become

increasingly important to review the current

model of care and be more patient-centred. For

example, chronic disease care management was

introduced in 2002 which features nurses, trained

as care managers, co-managing chronic disease

patients with doctors together with Allied Health

Professionals. In 2005, the first Family Physician

Clinic in Singapore was launched in Ang Mo Kio

Polyclinic to encourage chronic disease patients

to follow up with a regular Family Physician for

continuity of care. Currently, a new care delivery

model is being piloted at Toa Payoh Polyclinic,

which involves the empanelment of a patient

with chronic diseases, to a teamlet of healthcare

professionals led by a Family Physician. It will

be a key feature in the upcoming Pioneer Family

Healthcare Centre, our tenth polyclinic, when it

opens in 2017.

Recognising that advancing Family Medicine

is of paramount importance in order to

transform primary care, NHGP established

the Family Medicine Academy, together with

the Lee Kong Chian School of Medicine, at

Bukit Batok Polyclinic in 2013. This is the first

Family Medicine teaching facility for medical

undergraduates in the community. Its co-

location within a polyclinic provides greater and

earlier exposure of medical undergraduates to

Family Medicine. NHGP also hosts the training of

Family Medicine residents at the Family Medicine

Centre-Resident Continuity Clinic within each

polyclinic, which allows them to hone their skills

to become future Family Physicians.

Another initiative was the establishment of

the Primary Care Academy (PCA) in 2007 to

provide training and development for all primary

healthcare professionals. In 2008, PCA held its

first “International Conference on Healthcare

Transformation: Primary Care Focus”, which

provided a platform for local practitioners to

learn from international experts. The impetus

to transform primary healthcare was thus

augmented.

Over the years, as we modernise our polyclinics,

we continue to seek innovative ways to improve

our services and in the process, pushed

boundaries. Technological innovations such as

ePOS (electronic Polyclinic Outpatient System),

E-Notes (Electronic Notes) were implemented to

improve patient safety and care; self-registration

and payment kiosks as well as mobile apps to

improve patient service and productivity. Telecare

was also introduced to empower patients and

promote self-management.

Our journey over the last 15 years has seen us

overcome several challenges together as one team

with a shared vision. These past experiences have

prepared us well to face the future with great

anticipation. The future of NHGP is exciting and

as we take the next leap forward together, I am

confident that we will continue to play a significant

part in transforming the primary healthcare

ecosystem in Singapore.

Adjunct Associate

Professor Chong Phui-Nah

Chief Executive Officer


Polyclinics


NHG POLYCLINICS 0915 YEARS OF TRANSFORMING PRIMARY HEALTHCARE


SNAPSHOT: POLYCLINICS BEFORE 2000

INTRODUCTION 10

01

0302

“We would have paper folders of patients’ medical records so thick that you had to struggle to pick them up, what more go through all of it to try to make sense of it. There’s the unintelligible writing, the unsummarised notes, all while working very fast to juggle the crowds of patients coming through your consultation room doors.”DR LING SING LINFORMER DIRECTOR

OF FAMILY HEALTH

SERVICES, MINISTRY

OF HEALTH

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08 The waiting area of the Bukit Panjang Maternal and Child Health Centre

06 Health attendant taking the weight and height of a young patient

08

06 07

07 Patients collecting medication from the Pharmacy at the old Choa Chu Kang Polyclinic

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Before the announcement of the re-organisation of Singapore’s healthcare service providers into two Clusters in October 1999, all 16 polyclinics came under the auspices of the Family Health Services (FHS), the primary healthcare arm of the Ministry of Health. Dr Ling Sing Lin, who was Director of Family Health Services from February 1991 to April 1997, describes the manpower challenge faced by the polyclinics then.

“Our supply of Medical Officers fluctuated widely depending on the intake of medical students in each year. More often, we were desperately short of doctors and it meant that sharing doctors among the 16 polyclinics was a necessary measure. It was quite common for doctors to have to run from a clinic at one end of Singapore to another clinic at the

other end. Sometimes the shortage was such that they even had to travel to as many as three clinics all within the same day.”

Another key challenge was the unwieldly paper-based medical records system. Shaking her head musingly, she relates,

“We would have paper folders of patients’ medical records so thick that you had to struggle to pick them up, what more go through all of it to try to make sense of it. There was the unintelligible writing, the unsummarised notes, all while working very fast to juggle the crowds of patients coming through your consultation room doors.”

Taking a walk around the 16 polyclinics in 1999, you would have noticed varying levels of modernity juxtaposed with the dated. In those which were opened in the early 1980s, dimly-lit interiors, consultation rooms created from partitions and starkly lit by rows of fluorescent tubes, and metal bars fronting the collection counters spoke of their longer years serving the public. Others, coming in the later 1990s like Choa Chu Kang and Yishun Polyclinics, were already fitted with newer equipment, up-to-date interior touches and some elderly-friendly facilities.

01 Staff retrieving paper folders of patients’ medical records at the old Clementi Polyclinic before renovation in 2000

02 Bukit Panjang Maternal and Child Health Centre

03 Bukit Panjang Outpatient Dispensary was one of the dispensaries that were progressively consolidated into polyclinics together with Maternal and Child Health Centres

DR LING SING LIN

FORMER DIRECTOR

OF FAMILY HEALTH

SERVICES, MINISTRY

OF HEALTH

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So Dr Ling began the lengthy process of bringing the medical records management system into the 21st century through digitisation. This was continued by Dr Shanta Emmanuel who succeeded Dr Ling as Director of FHS and later saw the National Healthcare Group Polyclinics (NHGP) through the transition of Clustering as its appointed Chief Executive Officer.

There was a key difference characterising the period before and after the Clusters came into being. Before, many layers of bureaucracy had to be navigated in order to get operational approvals. Dr Emmanuel talks about its drawbacks.

“All 16 polyclinics came under my purview, and when it came to seeking approval it could be a time-consuming process. A single request could require other ministries being involved such as the Ministry of Finance for budgetary approval,

INTRODUCTION 12

besides going through many other layers within the Ministry of Health for the right documentation.” She notes that with Clustering, a significant difference was that the reporting hierarchy was flatter within the Cluster and they had more autonomy in decision-making.

New Public Healthcare ClustersIn officially announcing the move to Clusters, the benefits were made clear. There would be greater integration between hospitals and polyclinics to facilitate referrals to hospitals by polyclinics and co-ordinated care for hospital-discharged patients continuing into polyclinic care. Also, the friendly competition between the two Clusters would result in better care at a lower cost for patients. This stemmed from cost-savings through providing centralised services and leveraging on each other’s resources through initiatives such as sharing of best practices.

04 The patient registration area of Choa Chu Kang Polyclinic before its major redevelopment works in 2010

05 Nurses attending a training session in the early days before Clustering of hospitals and polyclinics

0504

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RACING BOLDLY INTO A NEW ERA

CHAPTER ONE14

Starting New It was 2000, the year of the millennia and a landmark year of energy, vigour and passion for public healthcare in Singapore. With the formation of the National Healthcare Group Polyclinics (NHGP) in March 2000 and the official inauguration of NHGP on 20 November that same year, it was a year of many firsts for the fledgling NHGP.

To launch an endeavour is usually the hardest part. “We saw ourselves like cowboys in pioneer land, picking our way through the lalang as we forged ahead with new initiatives. The new ground that we were constantly covering was like our wild, wild west,” Dr Shanta Emmanuel, the first Chief Executive Officer of NHGP, recalls with a good-natured chuckle. She helmed the team from its inception on 1 December 2000 to 26 June 2005.

Pressing NeedsLooking at the seemingly endless to-do list – all of it pressing – at the birth of any new organisation, Dr Shanta Emmanuel cites her three top priorities at the time: to immerse the staff in the new corporate identity, to identify and realise improvements required for the polyclinics to meet the needs of Singaporeans in the 21st century and to bring NHGP as the primary healthcare arm of National Healthcare Group (NHG) into an effective relationship with NHG, its hospitals and its Specialist Centres. And all of it designed to develop an integrated healthcare system that was truly about the best possible patient-centric care.

Imparting the VisionTo address the first priority, she had to imbue her people with vision and purpose.

Setting up a new organisation – the National Healthcare Group Polyclinics (NHGP) – to deliver better and more patient-centric primary healthcare to Singaporeans required uncommon leadership, team effort, grit and the courage to stride into uncharted territory. How did the effort begin? And just what did it take to get NHGP off the ground?

01

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01 Nurses celebrating Quality Day 2002

02 & 03 In the lead-up to

Clustering, former Health Minister Yeo Cheow Tong observing patients during their consultations with doctors at Choa Chu Kang Polyclinic. Accompanying

03

02

10

him were Dr Aline Wong, then Minister of State for Health and Education, Dr Lily Neo, Member of Parliament and Dr Chen Ai Ju, former Director of Medical Services (DMS) of the Ministry of Health


“In order to transit from working for the Family Health Services under the MOH to NHGP, we all had to resign and then rejoin the new company. I was fortunate – 85 per cent of our staff rejoined under NHGP. But I saw that to move NHGP forward successfully, we would all need to have a mindset change from simply just going about our jobs to being impassioned with purpose.

“It was important to let the staff know who we were and what we stood for and to get us excited about the new organisational family we were now in.”

Mr David Kok, Director of Finance, joined NHGP as a management accountant on 1 August 2000, just two months before the inception of NHG Polyclinics. He was excited about NHGP’s new vision, “The first vision of NHGP was to deliver high quality, affordable primary healthcare to families in Singapore. As a person new to the healthcare sector, I learnt a lot from the passionate and dedicated staff working in our polyclinics, especially Dr Shanta Emmanuel, our first CEO and her management team.”

Adding on, David describes how the newly minted NHGP management team led and cultivated strong bonds among the staff. “This was demonstrated in the style of management in NHGP, where everyone was treated as part of the family where Dr Emmanuel was like the head and mother of the family and all staff treated our patients as part of our family too.”

TrainingIn order for staff to be enabled and empowered to deliver in the way they cared for patients, there was a need to invest in training and upgrading their

“We saw ourselves like cowboys in pioneer land, picking our way through the lalang

as we forged ahead with new initiatives. The new ground that we were constantly covering was like our wild, wild west.”

CHAPTER ONE16

DR SHANTA

EMMANUEL

FIRST CHIEF

EXECUTIVE

OFFICER, NHGP

2000-2005



existing skills. Doctors who chose to upgrade their skills in Family Medicine could do so by taking a post-graduate degree in Family Medicine and would thereafter be known as Family Physicians.

However, the public still tended to see doctors as professionals treating symptoms with medication. “We needed to move away from curative medicine to preventive as well as treating the patient as a whole, including looking at lifestyle, social and psychological aspects that could affect their physical health and chronic conditions.”

To improve care through the concept of disease management, Family Physicians identified areas of interest within Family Medicine, such as diabetes, asthma and hypertension and helped to develop clinical guidelines with input from specialists. They were also sent overseas for further training under the Ministry of Health Management Development Programme.

For example, Dr Doraisamy Gowri, Family Physician, Senior Consultant, Regional Director, Primary Care Transformation Office, NHGP, has championed the management of health complications arising from hypertension. She says, ”We convened a team which included primary healthcare and hospital specialists and did our review of international hypertension guidelines. We then came up with our own hypertension guidelines in a flipchart form customised to our context. It was a good learning experience.”

Nurses were also provided with training in caring for patients with chronic diseases, while surgeons from the hospitals were brought in to train and upgrade the skills of Family Physicians so that they could perform minor surgical procedures within the clinics.

The Birth of Care ManagersThe Care Manager role was created, in which a trained registered nurse helped to co-manage chronic disease patients with doctors.

04 NHGP staff briefing the late Dr Balaji Sadasivan, former Senior Minister of State, Ministry of Foreign Affairs and Ministry of Information, Communications and the Arts

05 NHGP staff at a service team excellence course

04

05


Besides thoroughly explaining details such as the right way to use medication devices like inhalers and going through the practice with the patient, the Care Manager would also examine other facets of the patient’s life, such as social, lifestyle and psychological aspects to get a better understanding of the factors contributing to the patient’s condition and make relevant recommendations in the patient’s medical records.

Necessary ImprovementsTraining and upgrading needs aside, the next logical challenge was to identify changes that were needed to improve service delivery in the polyclinics. This was primarily about acquiring equipment and improving facilities as clinics had to make do with what they had in the interest of managing costs. The trade-offs were many.

For instance, regular eye examinations are able to detect and provide early intervention for eye conditions in diabetic patients. Such eye conditions can lead to further complications like glaucoma, retinopathy or even blindness. Previously, Retinal Photography cameras were rotated amongst the polyclinics and hard copies of retinal scans were sent back to the polyclinics for analysis. Inconvenient and inefficient, it ran the risk of patients’ conditions deteriorating further in the process.

Dr Shanta Emmanuel was successful in getting the Ministry of Health’s support to purchase Dialectic Retinal Photography cameras for all the polyclinics without the need for rotation so that these essential examinations could be performed without delay.

Similarly, mammogram machines, which provided life-saving early detection, had only been available in certain polyclinics. “The key aspect was that at our polyclinics, mammograms were subsidised. So now we were able to provide this valuable screening service in an affordable and accessible way in all our polyclinics,” says Dr Emmanuel. By the end of 2002, almost every polyclinic had its own mammogram machine.

Another vital improvement was to equip every polyclinic with its own laboratory and radiography unit. The existing situation had been one where only certain polyclinics had a laboratory. This meant that test samples had to be collected at the other polyclinics and sent to the laboratories every day. Similarly, patients might have to travel to another polyclinic for X-rays.

Time-consuming and labour-intensive, this lengthened the turnaround time between tests,

06 NHGP nurses at a community health screening session

06 07

07 A polyclinic nurse taking a patient’s height and weight measurements

CHAPTER ONE18


A photobook capturing the history of primary healthcare in Singapore – A Legacy In Health – was also launched.

Integrated Care Within the ClusterTo realise the third priority of working together with the other healthcare institutions within the Cluster to provide integrated care, NHGP embarked on digitising its paperwork-reliant medical records system.

Thus began the process of leveraging technology to create the Electronic Medical Records (EMR) system, as well as a host of other electronic tools to facilitate clearer and more effective communication and a higher quality of care within NHGP and the NHG Cluster as a whole.

Among the key milestones was the Direct Access Scheme. Patients with more urgent conditions who did not need to be seen in the Accident & Emergency (A&E) department could be referred

early to the Specialist Outpatient Clinics (SOCs) within one to two weeks. They were seen by NHGP’s doctors with more experience, ranging from registrars and above, who could make the decision for Direct Access. This meant faster turnaround time and reduced inconvenience in waiting for appointments in the SOC. Changes after ClusteringIn all these initiatives and changes, how did staff take to the transition? “The sentiment on the ground was that people were energised by the new identity. It wasn’t just the physical changes like the completely new nurses’ uniform that we designed with orchid flowers printed on it. I think the staff were proud to be part of this new organisation, NHGP, and were invigorated by the upskilling, the organisation-wide improvement in processes and the vision that they all grasped a hold of and ran with. There was a sense of liberation too because the transition typified what Clustering was meant to do – allowing the two healthcare Clusters greater

CHAPTER ONE20

09 Dr Shanta Emmanuel unveiled the NHGP logo at the NHGP Opening Ceremony in 2000

09

10 Guests and NHGP staff attending the launch of NHGP’s Gallery of Memories on 1 October 2002

11 Former Permanent Secretary (Health), Mr Moses Lee, launched NHGP’s Gallery of Memories on 1 October 2002. With Mr Lee is Dr Shanta Emmanuel

10 11


A few senior Family Physicians also made several trips together with NHGP colleagues to India and the Philippines to interview and recruit Medical Officers from 2003 to help bolster the number of doctors in the polyclinics.

When polyclinics were called upon to make primary healthcare available to Singaporeans outside of working hours, night clinics were launched in 2001.

But manpower shortage was again a challenge. Staff were reluctant to take on the shifts outside of regular working hours. To overcome this, Dr Shanta Emmanuel appealed to doctors who were younger and keen to increase their incomes, to take on the additional work time. All staff were also put on night clinic on a rotational basis to ensure that everybody shared this responsibility. Jurong Polyclinic launched its pilot night clinic in January 2001 and by 3 December that year, service hours at all nine polyclinics had been extended to include weekday

lunchtime and Saturday afternoons at certain polyclinics. It was not long before NHGP launched night clinics at six of its polyclinics.

Promising BeginningsTo cap the first two years of its establishment as the administrative and management headquarters for the polyclinics, NHGP was given a triple ISO award in December 2002. It was the first primary healthcare provider in Singapore to be given these awards for Quality Management Systems, which ensure service is consistently delivered because of properly documented work processes, environmentally-conscious practices, and compliance with Occupational Health & Safety standards for both staff and patients.

By the end of 2002, NHGP was more than ready to ride into the following year full of optimism.

CHAPTER ONE22

15 & 16 The first NHG Cluster

Chief Executive Officer, Dr Tan Tee How, at the key handing over ceremony in 2000

15

16


18 NHGP staff enjoying the team bonding and learning activities at the NHGP Quality Week in 2001

17 Former Director of Medical Services of the Ministry of Health Dr Chen Ai Ju with former Health Minister Yeo Cheow Tong observing a nurse attending to a patient’s foot wound

17

18



diagnosis and treatment. Eventually, with a laboratory, each clinic was able to carry out an even wider range of tests, prompting Dr Emmanuel to approach the former Cluster Chief Executive Officer, Mr Tan Tee How, with the idea of consolidating the management of laboratories under a separate diagnostic arm of NHGP to provide imaging and laboratory services in primary healthcare.

In a similar vein, NHG Pharmacy was established out of the need to oversee pharmacy services and set up retail pharmacies. For polyclinic heads, outsourcing of the pharmacy to a vendor meant that they could be relieved of managing the pharmacy, from hiring of staff to ordering drugs.

More importantly, the polyclinics could now support patients who were discharged from hospitals into their care as they could continue providing the same medications that were prescribed at the hospitals. Before this, the polyclinics stocked only standard drugs, while the hospitals prescribed a wider range.

The creation of a retail pharmacy meant that this wider range of medication, including non-standard drugs, would be available to seamlessly continue the care of hospital-discharged patients. Both NHG Diagnostics and NHG Pharmacy were established in 2000.

Building an IdentityTo establish its new identity as NHGP, Dr Shanta Emmanuel also embarked on establishing the organisation’s corporate branding such as its logo of an individual with his family in tow leaping into a bright future filled with the sunshine of health and its website, which would increasingly become the public’s first

encounter with NHGP. All nine polyclinics underwent structural upgrading such as the repainting of exteriors with the new corporate colours – lime green and lemon yellow – and refreshing and upgrading the interiors.

It was all about recognising the “importance of heartware over hardware” and that included an NHGP song which Dr Emmanuel commissioned. The song was created as a way to unite the staff as one team.

In order to document the rapid changes that had taken place in Singapore within such a short time, Dr Emmanuel also spearheaded the creation of the primary healthcare museum. Called the Gallery of Memories, it opened on 1 October 2002 at Bukit Batok Polyclinic.

08 Former Health Minister Yeo Cheow Tong touring NHG Pharmacy at Choa Chu Kang Polyclinic with Pharmacy staff, Ms Ng Mok Shiang

08


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12

12, 13 & 14 NHGP staff at the NHGP

Pledge “I can & I will” event in 2004

autonomy over their institutions and increasing their efficiency,” says Dr Shanta Emmanuel.

Hurdles to CrossBut there were other challenges that had to be overcome.

Under the civil service scheme before Singapore’s healthcare providers were re-organised into the two Clusters, new doctors who were under the five-year government bond to work in public sector healthcare could pay to break their bond in order to work in the more financially-alluring private sector. This meant that the public sector polyclinics regularly faced turnover among their doctors. At one time, there would be only a one-third base of more experienced senior doctors against a base of two-thirds being new doctors in every six-month posting.

The shortage of Medical Officers also meant that the polyclinics were perpetually hard-pressed to keep up with patient numbers. At its most urgent time, each doctor would be seeing more than 100 patients a day. This situation set off its own unique consequences which affected patients as much as doctors who were often left feeling guilty and stressed out that they could not devote enough time to their patients. Dr Lew Yii Jen, former Head of Yishun Polyclinic and Assistant Director of Clinical Services, describes how the shortage eased after Clustering.

“After NHGP was formed, the polyclinic heads were given more autonomy over their polyclinics and an increased budget to employ new doctors and this eased the doctor shortage issue that the polyclinics faced.”


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EnvironmentChoa Chu Kang Polyclinic’s distinctive dome-like structure over its waiting area may have been there from the start, but do you remember that its exterior was painted red? Or that the three-level Ang Mo Kio Polyclinic building had a quaint blue and white coat of paint with a red stripe running down the middle?

Recalling the interior of Woodlands Polyclinic which she headed from October 2000 to September 2014, former Head of Woodlands Polyclinic Dr Doraisamy Gowri describes it with warm affection. “There was a rehabilitation centre on the third level as well as lots of empty space. It was a large breezy clinic with a central playground. I liked the playground the most. Seeing the children, especially those with fever, running to the slides and happily frolicking in the sun was a wonderful sight as it calmed the parents. The sound of children laughing and playing brought good vibes and added such a layer of warmth to the polyclinic’s atmosphere then.”

Children were also a feature at Yishun Polyclinic which housed a preschool centre on its third floor. During mandatory building fire drills, Dr Lew Yii Jen, its Head from October 2000 to June 2003, remembers how staff and patients watched with amusement as children from the centre would come trooping down the stairs in orderly two-by-twos.

There were also other common situations shared by the polyclinics. One was the challenge of keeping in order overflowing paper folders of patients’ medical records. Before renovations to Ang Mo Kio Polyclinic, the Medical Records Office (MRO) was filled to capacity with clutter, says its former Head, Dr Winnie Soon. “There was not enough storage in the MRO, so

01 Patient registration at Hougang Polyclinic before its renovation in 2008

02 Retrieving paper folders of patients’ medical records at Choa Chu Kang Polyclinic

03 & 04 The pharmacy at one of

the polyclinics before modernisation

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case sheets were all over the place, case files were always missing and duplicates were made which compounded the problem.”

To keep operational while undergoing renovations, older polyclinics like Toa Payoh Polyclinic – built in 1988 – underwent upgrading in segments. Coming in after its partial renovation in December 2001, its Head until March 2009, Dr Meenakshi Sundararaman, muses, “While I was impressed with some of the new consultation rooms and the design details like teak wood column panel concealing the entrance to the MRO, there were some parts of the polyclinic that were showing their age. Floor tiles would just pop up from the ground, making noises as if there were mini earthquakes. In some rooms, there were bits of ceiling boards dangling down, threatening to drop on us and you could even see the wiring through the holes in the ceiling. Power outages would happen every now and then.”

Clinic Duties“The first task doctors had to do every day, unless you had a very efficient health attendant who liked you,” says Dr Elaine Tan, who was Head of Hougang Polyclinic from October 2000 to October 2004, “was to sit down and stamp over 100 prescription sheets and lab order forms in pads with your name stamp and clinic stamp, as well as ensure adequate good quality carbon paper was available. We would write the actual prescriptions down on the prescription pad and make simultaneous carbon copies into the patient’s paper case notes. You can imagine that alignment sometimes made for messy reading.” Dr Lew Yii Jen adds his recollections of Yishun Polyclinic. “Each doctor had to collect the Medical

CHAPTER TWO26

Certificate book every morning before they started their day, so this duty acted as an informal punch card system letting me know which doctors came to work on time. Also, I remember the system that we had then was when patients were screened and given small, coloured square queue cards to indicate which consult rooms they were assigned to. This square card would be attached to the front of their individual paper folder of medical records which included the case notes. By 8am, I would have had a stack of 20 case note folders which I would have to clear. I remember that within one hour, we would see an average of 10 patients. So I could virtually calculate how long I would take based on the number of case note folders I had stacked on my desk.”

Dr Elaine Tan recalls many memories – some of them funny. “I stepped into my room one morning

05 Shelves of patients’ medical records in paper folders were part of life in the old Clementi Polyclinic pre-renovation in 2000

05



06 NHGP nurse performing diabetic retinal photography as part of diabetes care

and on my desk was a mysterious set of ink patterns. It looked like someone had done potato printing across the desk. I had a good laugh when I discovered later they were the foot prints of a rat. It had probably fallen from the ceiling, found its way into the ink pad and waltzed across the desk the night before.”

EquipmentLimited access to equipment affected work processes in the late 1990s. For example, at Hougang Polyclinic, diabetes care was very different then, says Dr Elaine Tan. “Once a year, the diabetic retinal photography machine would be parked in the polyclinic for three months and

06

“The first task doctors had to do every day, unless you had a very efficient

health attendant who liked you, was to sit down and stamp over 100 prescription sheets and lab order forms in pads with your name stamp and clinic stamp, as well as ensure adequate good quality carbon paper was available.”

DR ELAINE TAN

FORMER HEAD,

HOUGANG

POLYCLINIC

2000 – 2004



07, 08 & 09 NHGP staff carrying out

daily duties, engaging with patients and welcoming patients at Clementi Polyclinic’s Open House

07

08 09



the private sector, but I noticed something that was different: a change in the air that gave a sense of energy and excitement. There was great hope in the potential of better quality care and services in this new Clustering. There was more attention paid to sprucing up the buildings and the environment, the service quality and the efficiency of processes, besides the quality of patient care. The main challenges were in meeting the expectations of the public. As we worked towards higher standards of care, the patients’ expectations seemed to rise even faster!”

Agreeing with the new sense of purpose that was felt, Dr Winnie Soon adds, “I remember that as polyclinic Heads, we attended a few envisioning exercises where we finally came up with the mission and vision statements.

We wanted not only to add years but it was emphasised that we wanted to add years of healthy life to the people of Singapore.”

This vision, along with a new identity, had to be communicated to all levels of staff.

Open houses in all the polyclinics for community outreach were especially popular and both Dr Lew Yii Jen and Dr Razia Attaree describe their polyclinics’ experiences. From having health promotion booths educating the public on conditions like asthma, to cooking demonstrations organised by nursing staff to empower diabetics to take charge of their own diet and even being judges at baby shows, the polyclinic Heads fondly recall the hard work and great fun of organising these events. Most importantly, these events raised public awareness of healthy living.

11, 12 & 13 Bukit Batok Polyclinic’s

Open House provided an opportunity for the public to get to know the team, pick up health tips and have their blood pressure checked

11 12

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A WALK DOWN MEMORY LANE

CHAPTER TWO24

Find out more from our polyclinic heads as they reveal what their polyclinics were like and the memorable experiences they had in the early years after Clustering.

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CHAPTER TWO28

all diabetic eye checks had to be done during that period of time, mostly on a walk-in basis. If a patient missed this three-month window, they would need to wait another year for screening. Chest X-rays were done with a mobile X-ray van that came around during specific periods too; there were no on-site radiology services in any of the polyclinics. When we first set up a radiology unit in Hougang, we had to settle staff concerns as to who would be seated in the room next to the X-ray unit due to concerns about potential exposure to radiation.”

PatientsHowever, while there were limitations, there were also advantages in those early days. For one, all polyclinic heads agree that patients then were less demanding. Not only that, Dr Razia Attaree, Head of Bukit Batok Polyclinic from late 1997 to 2005, recalls how patients were always very grateful for the care they received. Head of Ang Mo Kio Polyclinic from December 2001 to February 2004, Dr Winnie Soon adds, “We definitely saw more patients per doctor than now but the cases were simpler. We didn’t have to offer screening, the list of medical problems was shorter, our drug list was shorter and the patients were not so old. The lifespan and quality of life of Singaporeans has increased. If we saw a 70-plus-year-old patient, he would most probably be frail, but now we see 80-plus-or even 90-year-olds who look much younger than their age. Also, we used to use more dialects and Malay to communicate. We used to have to rely more on our health attendants as interpreters but now patients mostly speak Mandarin or English.”

Dr Meenakshi Sundararaman shares a heartwarming patient moment, “This elderly patient of mine came into the room cautiously at first and the moment she saw me, her face lit up and she exclaimed in Hokkien, ‘Lokun (“doctor” in Hokkien) you’re here!’ Then she came and held my hand. ‘I thought someone

else was going to see me so I was kia-kia (“frightened” or “apprehensive” in Hokkien). But now that I see that it’s you, I feel better!’”

ColleaguesBeing a new leader to a polyclinic was another challenge that some polyclinic heads had to grapple with.

Having supportive colleagues who became friends was what helped Dr Doraisamy Gowri at Woodlands Polyclinic, “I had to manage a new clinic and my first newborn baby at the same time. On top of that, I was without a deputy for the first year. My doctors were a diverse group and I hardly knew any of them. It was stressful but I learnt to appreciate nursing a lot as my most loyal supporter during those tough times was Sister Chow Choon Har. She taught me everything patiently, sharing her wisdom and experience. I’ll never forget how she would specially buy the most heavenly-tasting sour prunes for me while sharing with me what food to eat for lunch in order to prevent vomiting during my early months of pregnancy when the nausea was unbearable. So my most memorable moments were forged over warm friendships.”

DR MEENAKSHI

SUNDARARAMAN

FORMER HEAD,

TOA PAYOH POLYCLINIC

2001 - 2009


CHAPTER TWO30

Sharing a similar experience, Dr Elaine Tan relates her time as a Master of Medicine in Family Medicine trainee at Ang Mo Kio Polyclinic and the way her colleagues generously extended help that made such a difference to her, “I was blessed with an excellent colleague who was a diabetes nurse educator. She taught me the practical tips of insulin injection techniques, patient education and insulin titration. This was in the early days and we did not have a formal team of nurse Care Managers yet, so it was a precious resource to tap on. To this day, I am grateful and highly respectful of the nurses’ roles in diabetes care because of this early impression of how impactful their role can be, not just to the patients but the doctors.”

InitiativesTrailblazing new initiatives in the early years posed a fair share of challenges. To allow patients access to the polyclinics outside of working hours, night clinics operating from 7pm to 9.30pm were initiated by the Ministry of Health. Clementi Polyclinic was tasked to set up a night clinic in 2001 after Jurong Polyclinic. Dr Helen Leong, its Head from October 2000 to December 2001, recounts the difficulties with manpower and long hours that the night clinics entailed. “The challenge was in having to invite doctors from hospitals and the rest of the polyclinics to be rostered for duty as locum doctors after office hours. It was not uncommon for the pharmacy technicians to close the clinic at about 10.30pm to 11pm as it was the last service station for patients.” Eventually in 2005, the night clinics were closed as the service was adequately provided for by nearby private family doctors in the area.

As the first polyclinic to roll out the Patient Management Patient Accounting (PMPA) System, Choa Chu Kang Polyclinic had the unenviable task of road-testing the system to iron out its kinks. Associate Professor Wong Teck Yee was posted there in 1999 and took over as Head from 2004 until 2006. He recalls it as “a painful experience for everyone in the clinic. We ran into so many issues and staff morale was really low. However, looking at our current system, I feel that all that hard work was worthwhile in the end, as our clinic had a big part to play in something which we take for granted as absolutely necessary nowadays.” Dr Hwang Chi Hong who became Head of Choa Chu Kang Polyclinic in late 2001 relates, “I was returning to the polyclinics after a brief stint in

10 A patient speaking with NHG Pharmacy staff at a Yishun Polyclinic Open House

10


OUR QUALITY JOURNEY32

In our mission to transform primary healthcare for the benefit of patients, clinical excellence and quality patient care are an ongoing journey. With each milestone reached, we strive to do even better. This is part of NHGP’s DNA which is in line with NHG’s four principles: patient-centred care, systems thinking, staff engagement and learning organisation.

A Culture of ExcellenceSince 18 August 2001, NHGP has embarked on our quality journey to set up new and improved processes that enable enhanced service and patient experience. Our emphasis on service improvements led us to set international benchmarks for excellence in primary healthcare and patient safety and to develop a culture of continuous improvement to ensure quality care. NHGP was the first primary care provider in Singapore to receive the prestigious Singapore Quality Class Certification on 30 June 2005 and was the first primary care organisation outside of the United States of America to be accredited by Joint Commission International (JCI) in 2008. These standards are benchmarked against international best practices and provide an excellent basis for the review and improvement of our clinical processes.

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01 NHGP held its Quality Journey launch in August 2001. At the same time, our core services standards of CARE were introduced with C for Confidence, A for Attentiveness, R for Respect and E for Empathy

02 Dr Bobby Stryker (third from left) and his Clinical Practice Improvement Programme (CPIP) team in Woodlands Polyclinic having a discussion on their project

03 In February 2011, NHGP staff used the Value Stream Mapping tool to discuss how to shorten process for children’s care services at the polyclinics

04 & 05 At the LEAN workshop in

November 2010, NHGP staff worked at finding ways to eliminate waste in processes for acute and chronic patients

03 04 05

06

06 The team behind the Value Stream Mapping exercise for improving accessibility to NHGP Podiatry Services for High Risk Patients requiring acute Podiatric management

As an organisation we also adopt a range of process improvement approaches. In May 2006, NHGP started applying LEAN thinking principles into our redesign of the polyclinics. With the focus of LEAN on delivering value through elimination of wasteful activities, it is an essential concept in the journey towards providing quality care.

In 2008, the framework for LEAN was implemented throughout the polyclinics. Till today, staff participate in various LEAN workshops and use tools such as Value Stream Mapping (VSM) that have resulted in numerous improvements ranging from creating better patient experience and safer clinical care to enhanced patient outcomes.

NHGP also embarked on meeting the International Standard Organisation’s (ISO) criteria for quality management and an occupational health and safety system. “In December 2002,

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34

we became the first primary healthcare provider to be given the awards. In this organisation-wide bid, the order and standardisation of processes that had been lacking in the Dental Services Department were finally and fully put in place. Documentation on protocols, service performance monitoring procedures and processes for the ordering of supplies, managing equipment and staff training were standardised across clinics,” explains Dr Joseph Soon, Dental Head of NHGP from 2003 to 2011.

Improvements for Better Patient Outcomes Our patient care innovations, enhanced healthcare delivery processes and better outcomes are all in line with NHG’s Quality Framework to spur clinical leadership and change management in medical and service areas. One of the major initiatives driving these improvements is our Clinical Practice Improvement Programme

07 NHGP Senior Management with the 2013 jigsaw puzzle with staff messages on what culture means to them

(CPIP), which trains and develops core groups of NHGP staff to identify key areas and implement quality improvement programmes to enhance our care delivery for patients.

More significantly, the projects that result from CPIP extend beyond doctors and nurses. In true multi-disciplinary spirit, they also include input from patient service assistants, laboratory technicians and radiographers – driving a culture of excellence throughout the organisation. CPIP projects to date include the enhancement of prevention and early detection initiatives such as mammograms, cervical cancer screening, opportunistic health screening (for diabetes, hypertension, dyslipidaemia and obesity) and diabetic retinal photography.

Improving Patient ExperienceWe continuously improve our

processes to enhance patient experience and much consideration has been put into the thinking behind it. To ensure a more convenient and pleasant patient experience, we have rolled out the enhanced appointment system which offers more predictability on waiting time. We encourage our patients to come for scheduled appointments for planned care and services such as consult visits, nursing services and laboratory tests.

In January 2005, the Contact Centre hotline (6355 3000) was set up to better consolidate resources and expertise, and provide better patient access and experience. Patients with episodic acute ailments – such as fever, flu and cough – who need to see a doctor on the same day are now able to take a queue number via several options available. Through the Contact Centre, patients can call in to make enquiries on services, make new appointments, change existing ones and check for same-day consult slots for their acute ailments.

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08 In January 2007, NHGP, together with SingHealth Polyclinics, held their first combined Quality Forum to share best practices and innovative ideas for patient care in the primary healthcare sector

10 Staff who received several awards on service improvements at the 2011 NHGP Quality Day

11 All smiles from the winning team and individuals

12 Patients can manage their appointments more conveniently with mobile apps and the online booking system

Patients can also use NHGP mobile apps or log on to the NHGP Online Appointment System (www.nhgp.com.sg) to make same-day appointments. These efforts aim to help patients better manage their time and personal schedules, leading to a better overall patient experience at the polyclinics. Mr Lee Chor Leng used the mobile app to book an appointment at Ang Mo Kio Polyclinic in June 2014 and shares its benefits. “I was seen by the doctor within 10 minutes of the appointed time. Previously, I would try to get to the polyclinic early in the morning to beat the crowd.”

08 09

10 11

12

09 Award recipients at the 2010 NHGP Quality Day Award Ceremony with Mr Leong Yew Meng, then Chief Executive Officer of NHGP. The award is given annually to recognise individuals and teams who have participated in CPIP and other improvement initiatives

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HEALING WITH A HEARTCHAPTER THREE36

At the heart of Family Medicine is the focus on the doctor-patient relationship. It fosters knowledge, familiarity and understanding of the patient's history and background and helps develop rapport and trust which are central to the care of patients and their families. Family Medicine training includes person- or patient-centred care.

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Identifying the Need for Family Medicine“Ask any Family Physician if Family Medicine was an easy path compared with other areas of focus and you’ll likely hear an incredulous laugh. In Family Medicine, you need to have a good grasp of the entire breadth of medicine,” says Family Physician, Senior Consultant and Chief Executive Officer of NHGP, Adjunct Associate Professor (Adj A/Prof) Chong Phui-Nah.

She adds, “Consultations are akin to detective work, where we try to elicit symptoms and signs in order to come to a diagnosis. So if you are only familiar with certain aspects of medicine, you may come up short or miss certain key symptoms or signs. That is why in Family Medicine, you have to have a wide scope of clinical knowledge at your fingertips.”

As an integral part of primary healthcare, Family Medicine in Singapore took its inspiration from countries with more established practices such as the UK and Australia. Being aligned with the tenets of primary care, namely, being the first point of contact for the population, providing comprehensive care, co-ordinated care and continuity of care, Family Medicine also embraces personal and preventive care.

The value of Family Medicine is well-documented. At its heart is the focus on the doctor-patient relationship which fosters knowledge and familiarity with the patient’s history and background. It encourages rapport and trust with patients, which are central to caring for patients and their families.

It also emphasises holistic treatment of each patient, looking into various aspects and factors that influence their health rather than using a one-size-fits-all approach.

Dedicated training of doctors in Family Medicine was a major reason for setting up the Family Medicine Development Division.

01 The Family Medicine Academy was officially opened by Guest of Honour, Mrs Tan Ching Yee, Permanent Secretary (Health) at Bukit Batok Polyclinic on 4 September 2012

02 Building rapport with patients is important in managing their health outcomes

03 Mrs Tan Ching Yee, Permanent Secretary (Health) observing a demonstration of a procedure as part of medical undergraduate studies at the Family Medicine Academy


The Family Medicine practice results in a better standard of care: more effective consultations between patient and doctor, fewer cases of unnecessary hospitalisation, better control over chronic diseases and higher patient satisfaction.

Dr Yuen Soo Hwa, a Family Physician with more than 35 years of experience in healthcare who is based at Woodlands Polyclinic, says, “Patients feel assured that they are truly being cared for. They often share with us how nice it feels that someone is following up on them when our Care Managers call to check on their progress.”

Family Medicine TrainingNHGP is an accredited training centre for Family Medicine trainees. The three-year Master of Medicine in Family Medicine degree course was popular in the early 90s and competition for its limited places was intense then. The course, known to be challenging with only two-thirds meeting the passing grade for every cohort, had yearly registrants far exceeding the number of places available. Adj A/Prof Chong Phui-Nah, in the fourth batch of Master of Medicine in Family Medicine trainees, recalls:

CHAPTER THREE38

“In the first two years of the course, it was entirely hospital postings where we had three-monthly rotations in various specialties. As Family Medicine trainees, we simply worked alongside the other specialty trainees, with no one to help us integrate the knowledge and skills acquired during the posting with the primary healthcare context. Then in our third year, when we were posted to the polyclinics, we realised the gaps in our knowledge. That was when we wished that we had paid more attention to certain aspects of the hospital postings which were relevant to primary care. This contributed to how my team and I planned and shaped the new Family Medicine Residency Programme. In 2010 and 2011, we chose to focus on cases more common and relevant in the primary healthcare context to hone the skills of future batches of Family Medicine residents.”

Through his experience as a Master of Medicine in Family Medicine trainee, Senior Director of Clinical Services Dr Lew Yii Jen recalls how presentation and communication skills were useful elements in doing well in the course – from undergoing the selection interview to secure a coveted place in the hugely popular course, to patient profiling and doing write-ups with an in-depth analysis as well as handling questions posed by examiners at the viva and clinical examination segments.

Like Adj A/Prof Chong and several of his colleagues, Dr Lew went on to pursue further training in Family Medicine. He was conferred the title of Fellow in the College of Family Physicians, Singapore in 2004. He and others went on to train later cohorts of trainee Family Physicians. They were also involved in the mock and actual examinations and shared examination tips with trainees.

04 05

04 A doctor undergoing residency training programme at the polyclinic and carrying out a consultation

05 A lecture for residents during NHGP’s six-monthly didactic seminars


“Consultations are akin to detective work, where we try to elicit symptoms and

signs in order to come to a diagnosis. So if you are only familiar with certain aspects of medicine, you may come up short or miss certain key symptoms or signs, and that’s why in Family Medicine, you have to have a wide scope of clinical knowledge at your fingertips.”


When she was put in charge of Medical Manpower Deployment and Development in 2000 as Assistant Director of Medical Affairs – now known as the Clinical Services Division – Adj A/Prof Chong had to handle pressing training issues despite the shortfall in manpower for doctors, with younger, less experienced doctors outnumbering the more experienced senior doctors. The department had to cope with training their own trainees and the six-monthly rotating MOPEX doctors (otherwise known as Medical Officers) while coping with a high patient workload.

In light of more urgent manpower needs, training was often limited to weekly Continuing Medical Education (CME) talks by specialists. Fortnightly lunchtime clinic tutorials were often cancelled if medical manpower numbers dipped. In other words, training of doctors was often put on the backburner.

Adj A/Prof Chong noticed that the learning gaps varied widely between a junior medical officer rotating through the polyclinics and a senior resident doctor. She came up with a two-year list of synchronised CME topics – which were part of the mandated weekly CME talks by specialists and also in-house tutorials at the polyclinics – the choice of speakers and how training was conducted were left to each polyclinic.

As the issue of manpower began to stabilise in subsequent years, emphasis on training once again came to the forefront. In addition, Adj A/Prof Chong and her team came up with the Family Medicine Competency Programme (FMCP) framework in 2007. This was meant as a bridging course for doctors from other countries with the Graduate Diploma in Family Medicine who also

ADJUNCT

ASSOCIATE

PROFESSOR

CHONG PHUI-NAH

CHIEF EXECUTIVE

OFFICER, NHGP


CHAPTER THREE42

primary care training facility in the community for medical undergraduates in Singapore.

Students are exposed to a holistic understanding of the Primary Care setting from the first year of medical school. Looking back, Adj A/Prof Chong, who was responsible for the setting up of PCA and FMA, says, “We have tailor-made our training programme to include communication and consultation skills which are essential in Family Medicine. Medical students can now sit in the ‘hot seat’ during consultations and experience first-hand what it is like to have patients presenting symptoms directly to them. Part of the process is for medical students to connect with patients and come up with differential diagnoses and a management plan at the end of the 10-minute consultation. In fact, students usually feedback that the ‘hot seat’ experience is what they enjoy the most because of its very real aspect in their lives as future doctors and is a rare opportunity. They are also exposed to a multi-disciplinary team approach,

working with nurses such as Care Managers and Allied Healthcare Professionals for patient care.”

Raising Family Medicine’s ProfileTo harness the captive audience that primary care already garnered to raise the profile of Family Medicine, PCA held its first conference with the radical title: International Conference on Healthcare Transformation: Primary Care Focus. The conference highlighted the importance of Primary Care as the cornerstone of any good and successful healthcare system and proved a resounding success.

At the conference, internationally renowned Primary Care experts shared their insights and expertise with our clinicians, administrators and policy-makers.10

11

10 Family Physician, Senior Consultant and Chief Executive Officer of NHGP, Adjunct Associate Professor Chong Phui-Nah addressed the crowd at the Primary Care Forum 2010

11 Adjunct Associate Professor Chong Phui-Nah (right) with international delegates at the 1st International Conference 2008 titled ‘Healthcare Transformation: Primary Care Focus’



Adj A/Prof Chong Phui-Nah discussed how as doctors, it would be challenging to suddenly have to learn to work closely with nurses and Allied Health Professionals. Most doctors had no or little previous experience in inter-professional collaboration with nurses and Allied Health Professionals. This was essential in preparing clinicians for a new care model: the multi-disciplinary team approach. Hence in 2009, Dr Predeebha Kannan, a PCA trainer, conducted the first Inter-professional Collaboration workshop as a preconference event. The workshop saw a high attendance by clinicians and medical educators with interest in inter-professional collaboration and education.

To put into practice the principles of Family Medicine, the teamlet concept and patient empanelment are also being introduced to the polyclinics, beginning with the Transformation of Care model in Toa Payoh Polyclinic in 2014. Patients will benefit from the familiarity of seeing the same doctors they can entrust with their care, in order to build the strong relationship and rapport that is key to practising Family Medicine. The team behind NHGP’s 10th polyclinic, Pioneer Family Healthcare Centre, is also planning to introduce the teamlet concept and patient empanelment to the community when it opens in 2017.

To further the Family Medicine practice, NHGP opened Singapore’s first Family Medicine Clinic (FMC) in Ang Mo Kio in May 2013. This public-private partnership between NHG and Parkway Shenton provides integrated and comprehensive care for patients in the community.

A year later, the second – Unity FMC, partnered with NTUC Unity Healthcare – opened in Serangoon Central. A third FMC, Hougang FMC @ Ci Yuan Community Club, opened in September 2015. It is a public-private partnership with solo general practitioners and will provide integrated, comprehensive and community care to the population.

Adj A/Prof Chong shares her vision for advancing Family Medicine, “The future holds great promise for Family Medicine. We’ve always made it a point to stay ahead of the curve while focusing on the integral relationship of trust and understanding built between Family Physicians and patients and treating patients holistically.”12

12 Ang Mo Kio Family Medicine Centre was officially opened by Mr Seng Han Thong Member of Parliament (Ang Mo Kio GRC) on 11 May 2013


CHAPTER THREE40

hoped to practise Family Medicine at the polyclinics in Singapore.

It was a pivotal move as the Ministry of Health then agreed to allow graduates of this programme – who undertook a one-year rotational posting in the hospitals and six months in polyclinics – to convert their temporary registration with Singapore Medical Council to a conditional one.

In the same year, another training milestone for NHGP was attained when the Primary Care Academy (PCA) was established by Adj A/Prof Chong to train primary healthcare professionals collectively under one roof.

To raise patient service and care standards of clinic assistants at General Practitioner (GP) practices, the PCA also ran training workshops conducted by nurses and pharmacists. These workshops equip GP clinic assistants to provide greater quality of care to patients, such as assisting patients in infection

control, the use of nebulisers and even assisting doctors with electrocardiograms.

Family Medicine training under Adj A/Prof Chong, which had been a part of Medical Affairs or Clinical Services, was finally set up as a division of its own in 2008. It was a breakthrough year for the new Family Medicine Development (FMD) Division.

The new division revamped the Family Medicine training programme for doctors in NHGP. It launched the FMD training programme with the new curriculum planned and developed by its faculty with a tiered approach, targeting various subgroups of doctors with different Family Medicine training needs.

Yet another momentous milestone in Family Medicine training achieved was the opening of the Family Medicine Academy (FMA) at Bukit Batok Polyclinic on 4 September 2013. With Lee Kong Chian School of Medicine as its primary partner, the FMA is the first

06 07

06 Doctors attending a medical forum as part of their Continuing Medical Education (CME)

07 Permanent Secretary of Ministry (Health) Mrs Tan Ching Yee officiated the launch of Family Medicine Academy at Bukit Batok Polyclinic in September 2013

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08

08 The entrance to the Family Medicine Academy at Bukit Batok Polyclinic, the first purpose-built teaching facility with a focus on Family Medicine

09 NHGP nurses receiving their Certificate of Achievement for completing their training in wound care

2005 In May, the first Family Physician Clinic was launched in Ang Mo Kio Polyclinic

2007 Launched Primary Care Academy, the primary

healthcare training arm of NHGP 2008 First International Conference on Healthcare

Transformation: Primary Care Focus In May, the first issue of Plexus, a bi-monthly

newsletter, was launched Family Medicine Development Division was

established in October 2010 Organised by NHG, the Singapore Health and

Biomedical Congress was rebranded from the Annual Scientific Conference. At this platform, internationally-renowned Primary Care speakers shared and engaged with local experts

2011 Four Family Medicine Clinic-Resident Continuity

Clinics (FMC-RCC) were launched in Bukit Batok, Hougang, Toa Payoh and Choa Chu Kang Polyclinics to provide continuity of care and comprehensive care to patients and their families. Two more FMC-RCCs were set up in Jurong and Woodlands Polyclinics by July 2012 and one more was set up in Yishun in 2013

2013 In May, the first Family Medicine Clinic (FMC)

opened in Ang Mo Kio. A year later, a second FMC, Unity FMC, opened in Serangoon Central

On 4 September, the Family Medicine Academy, located in Bukit Batok Polyclinic, was launched with Lee Kong Chian Medical School as its primary partner

2015 On 13 February, the NHG Family Medicine

Residency Programme achieved its Continued Accreditation status from ACGME-I for three consecutive years

In September, Hougang Family Medicine Clinic

(FMC) @ Ci Yuan Community Club was opened

MILESTONES IN ADVANCING FAMILY MEDICINE

09

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TOGETHER WE STANDCHAPTER FOUR44

Cloaked in UncertaintyAt the height of the Severe Acute Respiratory Syndrome (SARS) outbreak in Singapore in 2003, fear reigned. “Nobody wanted to sit next to our nurses in the MRT. It became so unbearable that our staff would change into home clothes before their return journeys just so they wouldn’t have to endure the stares and painfully obvious wide berth that they were given by fellow commuters because of their healthcare uniforms,” relates Dr Razia Attaree, who headed Bukit Batok Polyclinic from 2000 to 2005.

“We all entered this period not knowing what we were in for and as time went on, the news became more grim as the number of infected swiftly increased while the death toll took one life after another in just a short time. Yet in the midst of the fear and uncertainty, I will always remember it also as a time when all of us in the polyclinic instinctively came together. My staff pulled together, really making sacrifices to help each other as well as to dedicate themselves to our patients,” she adds, her eyes misting at the memory.

It was a time that called for sobering moments to assess priorities and decisions about duty over self. Recalling this, Dr Lew Yii Jen, former Head of Yishun Polyclinic, speaks matter-of-factly, “My wife and I discussed it – that in the course of my work, if anything were to happen to me, we were mentally prepared for it.”

Courage ReignsCourage is most often proven true in choosing to fight in the face of fear. The first priority in the battle against SARS was to contain the further

The outbreak of SARS in 2003 drastically altered emergency preparedness in primary healthcare. Read the first-hand experiences of those at the frontline and the lessons learnt.

01

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01, 02 & 03 Nurses and Health

Attendants in Personal Protective Equipment (PPE) taking patients’ temperatures, consulting and helping with masks at the Fever Clinic Tent

04 05

03

04 Patients submitting contact tracing forms before their consultation with the doctor

05 Long queues of patients were par for the course

02


CHAPTER FOUR48

09 Staff in PPE interviewing patients as part of the screening process within the in-house Fever Clinics

10 Nurses preparing thermometers for temperature-taking

09 10



At Choa Chu Kang and Yishun Polyclinics, Fever Clinics with separate medication dispensing counters were set up in tents situated in external areas like the polyclinics’ car parks while there were screened-off in-house Fever Clinics in the remaining polyclinics to screen and treat patients with fever or respiratory symptoms separately.

Associate Professor Wong Teck Yee, Head of Choa Chu Kang Polyclinic from 2004 to 2006, relates his experience, “Our Fever Clinic tentage was set up at the parking lots and I remember that for all of us decked out in full PPE in the heat of the day, it could be unbearably hot. Yet morale was high and everyone turned up for work. I think all who went through that period remember that time well. It was a time that I most felt the spirit of connectedness with all my staff – we are all like family and Choa Chu Kang Polyclinic will always be like a second home to me – but it was especially during such crises that we banded together even more tightly and came together as one. During the outbreak, a patient came through our fever tent and we diagnosed the patient as having SARS. Familiar with the strict protocols, our staff worked seamlessly as a unit to first isolate then safely send the patient to Tan Tock Seng Hospital while ensuring the highest level of protection and safety for all our other patients and staff.”

Steps needed to be taken to reduce the crowds at the clinics, so less urgent services such as pap smears and mammographic screening services were stopped. Home delivery of medications was initiated for patients with stable chronic medical conditions.

At the height of the DORSCON Orange Alert, all other meetings and training sessions were called off. All staff had to do temperature monitoring twice a day and were instructed to put off any non-urgent travel plans.

Dr Lew Yii Jen, also former Deputy Director of Clinical Services, highlights how important quick dissemination of information was at that time, “We knew how critical it was to gain an upper hand in the fight against this rapidly spreading, fast-acting virus by setting the right practices in place from the start. Disseminating this and other instructions swiftly was key. At each morning’s roll call we would make sure the staff were kept informed with the latest updates and throughout the day, when new information came in, staff were kept in the loop through their individual departments.”

11 During SARS, the Fever Clinic Tent was set up in parking lots and staff were decked out in full PPE in the hot weather, persevering in the processing, screening and advising of patients

11



With the emergence of each threat, the impact made from learning from SARS was evidenced and built upon as a foundation. One was in the area of staff responsiveness with the emergency protocols that were in place.

The SARS outbreak led to the development of the screening and triaging process. There was now an automatic fluidity in executing the step-by-step clinic segregation procedures to separate and efficiently direct the flow of patients within the polyclinic, as well as setting up external screening or treatment spaces – such as the Fever Clinics – to isolate and handle patients displaying symptoms, who could pose a higher risk to the rest of the community.

Also, Dr Lew Yii Jen explains that our staff are now familiar with and prepared to take on infection control measures such as wearing PPE in accordance with the DORSCON alert code and correctly wearing their N95 masks. In addition, essential administrative steps such as the health declaration form in various templates and contact tracing protocols are readily in place and can be called into use.

Nimbleness in the deployment of manpower is another part of the SARS legacy that continues to benefit NHGP’s frontline defence in times of crises. Having experienced the importance of a quick response, there is even greater co-operation between staff to take up positions as a team at a moment’s notice during emergency situations.

Perhaps one of the most important after-effects of SARS in emergency preparedness is the critical role of leading by example.

NHGP’s leadership – as one – exemplified in times of crisis what it means to be visible at the heart of the action, together with staff, to walk the talk while conveying a cohesive message as an organisation supporting the nation’s efforts.

Explaining what a difference that makes, Sister Lee Ching Lian says, “We were very encouraged to see our leaders working alongside us through the darkest of times. It bolstered our confidence and that was what kept us all going – knowing that we were all in this together, battling a common enemy to protect our home ground.”

14 Mr Gan Kim Yong, Minister for Health, engaging patients at Toa Payoh Polyclinic to understand how clinic measures have helped patients during the haze period in 2013

14


introduction of the SARS virus through overseas sources. Answering the nation’s call, NHGP led in establishing temperature screening processes for inbound and outgoing passengers at the air, sea and land checkpoints. Fifty NHGP nurses were deployed to screen passengers at the

airport before handing over the surveillance work to a private medical group.

Sister Lee Ching Lian, who led the team at the airport, sheds light on her thoughts then. “At that time of course we had fears but you just have to put aside all other thoughts and focus on doing what you have been trained to do, to ensure that we protect the population while containing any incoming risks.”

Dr Helen Leong, former Head of NHGP’s Infection Control taskforce, adds her experience witnessing selfless dedication. “The SARS outbreak brought out the best in healthcare providers and Singaporeans’ giving spirit. Private family doctors helped as locum doctors in the Fever Clinics set up at NHG polyclinics. There was a tripartite collaboration between the College of Family Practitioners, NHG and Singhealth polyclinics to conduct training sessions on SARS screening procedures and contact tracing for private family doctors. Community talks were held for members of the public. Volunteers came forward to prepare food for the hospital healthcare workers.”

“The SARS outbreak brought out the best in healthcare providers

and Singaporeans’ giving spirit. Private family doctors helped as locum doctors in the Fever Clinics set up at NHG polyclinics.”

CHAPTER FOUR46

DR HELEN LEONG

FAMILY PHYSICIAN,

SENIOR

CONSULTANT, NHGP

06 NHGP staff trying on Personal Protective Equipment at a safety training session on emergency preparedness

06

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SARS and Emergency Preparedness ProtocolThe Ministry of Health and Tan Tock Seng Hospital (TTSH) led in the development of procedures on screening, triage, contact tracing and treatment, with input from the rest of the hospitals. Guidelines were set up on management of the SARS outbreak for Disease Outbreak Responses System Condition (DORSCON) alerts – spanning codes Green, Yellow, Orange, Red and Black – based on the disease situation overseas, its transmissibility, the likelihood of it being imported into Singapore and the impact of that locally.

As part of the requirements depending on the DORSCON alert level, NHGP, in its position at the frontlines, received training for the first time on the use of Personal Protective Equipment (PPE) which included N95 masks, disposable gowns, gloves and face shields. In addition, clinicians wore disposable shower caps and shoe covers when

attending to patients in the isolation room. For severely ill patients in critical condition, clinicians adhered to the protocol to put on Positive Air Pressure Respirators – which staff were trained to use – to attend to them.

Pulling TogetherAs fear of contracting SARS soared, patient attendance at the polyclinics dropped by 70 per cent. Those who did turn up had to fill out health declaration forms which included questions about the presence of fever, respiratory symptoms, travel history and contact history with SARS patients. Anyone having contact with patients with suspected or probable SARS had to be placed under the Home Quarantine Order for 14 days from the time of contact, based on the Infectious Diseases Act. The National Healthcare Group (NHG) set up a database to track patients’ movements within the clinics to facilitate contact tracing. 07

08

07 Temperature-taking at the polyclinics

08 Patients waiting in line with their contact tracing forms to see doctors at Choa Chu Kang Polyclinic

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CHAPTER FOUR50

Besides Choa Chu Kang Polyclinic’s identification and referral of a SARS patient to TTSH, Hougang Polyclinic also attended to and referred a patient with SARS who was traced to an outbreak originating in Pasir Panjang.

The AftermathSingapore was declared SARS-free by the World Health Organization on 30 May 2003. Across the nation and especially for frontline primary healthcare providers like NHGP, SARS had left a legacy of clearly articulated procedures, a new resilience to face future health emergencies and a state of preparedness and vigilance in our people like never before.

The lessons learnt from SARS were tested in the health emergencies emerging in the subsequent years.

In 2009, Singapore faced H1N1 Avian Influenza and the DORSCON alert reached the Orange level – classified as substantial pandemic risk – one step before the Red level. In 2013, Singapore was once again assailed, this time by the thick blanketing haze that reached record high levels of Pollution Standard Index (PSI) of 401, soaring past the hazardous air quality level of 300 on the PSI scale. Then came the threat of the Middle East Respiratory Syndrome (MERS), which shares the virus strain that causes SARS. MERS was first identified in April 2012 affecting mainly Middle Eastern and European countries and resurfaced in May 2015 in a more deadly outbreak in South Korea.

13 Mr Gan Kim Yong, Minister for Health (second from right), discussing with Dr Lew Yii Jen, Senior Director of Clinical Services at NHGP, (first from left) about haze-

12 At the frontline, it was important for patients to fill up forms with personal details. This quickly helped in contact tracing

13

12

preparedness measures at Toa Payoh Polyclinic in July 2013 as Dr Lim Pui San, Deputy Clinic Head of Toa Payoh Polyclinic (seond from left) and other staff look on


ONE CARE TEAMCHAPTER FIVE52

02 03

01

Our doctors work with various healthcare professionals as a team to deliver care to patients with long-term chronic conditions. Over time, staff roles and services have evolved to cater to the varying needs of our patients. Our nurses, dentists and Allied Healthcare Professionals continually refine and lend different kinds of expertise to provide holistic care to patients.

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ADVANCING PRIMARY HEALTHCARE NURSINGArmed with stronger skills and finely-honed roles, pri-mary healthcare nurses have evolved beyond perform-ing administrative tasks to playing a critical role in new levels of patient-centred care.

In the PastMore than 20 years ago, Chow Choon Har was told that she was being posted to Woodlands Polyclinic as a Nursing Officer, making the transition from a hospital to a primary healthcare setting. Back then, the tasks that polyclinic nurses carried out were more administrative in nature. Sister Chow elaborates, “We carried out registrations and gave out coloured cardboard squares indicating stamped queue numbers to patients. Before the Electronic Medical Records (EMR), nurses had to handle case sheets, which included deciphering doctors’ handwriting, acting on instructions, prescriptions or further tests, as well as hunting for misfiled case sheets. At the end of every day, the nursing officer had to go around to the cash collection points at the departments to collect all the monies for the day and verify it against the accounts.” She also recalls having had to undergo theoretical and practical training in the Maternal and Child Health Centre (MCH) which had been the mainstay of polyclinics from its early days until the 1990s.

Evolving Primary Healthcare Nursing In the intervening years, the practice of nursing in primary healthcare has changed radically. In the early years, the National Childhood Immunisation Programme (NCIP) was implemented at all Polyclinics by the Ministry of Health (MOH) to protect children against serious childhood diseases. To ensure high herd immunity in the community, our nurses tracked and

04 Patients’ file notes going into the Electronic Medical Records system

01 A Care Team consisting of different healthcare professionals led by a Family Physician

02 Administering an eye examination in pre-Cluster days

03 A dietitian in discussion with a patient on a dietary plan to better manage her chronic condition

04


“In the last 10 years, primary healthcare nurses have

been scaling up on patient education, child development and growth and are taught measures in early intervention in chronic conditions. Through such constant upgrading of their skills and outsourcing of non-nursing related duties, nurses are now able to practise at the top of their licence.”

monitored the follow-up of all immunisations given in our polyclinics. Today, the Immunisation Programme is enhanced with an expanded list of vaccines and our nurses continue their work to protect children against other infectious childhood diseases. Growth monitoring and developmental progress

checks are also administered by the nurses with all immunisation visits of children from birth to four years of age done at regular intervals in all polyclinics. This is to ensure that children are growing healthily in accordance with their developmental milestones.

Chief Nurse Chen Yee Chui shares her insights, “In the last 10 years, primary healthcare nurses have been scaling up on patient education, child development and growth and are taught measures in early intervention in chronic conditions. Through such constant upgrading of their skills and outsourcing of non-nursing related duties, nurses are now able to practise at the top of their licence.

“Roles have also evolved to include Advanced Practice Nurses (APNs), Nurse Clinicians and Care Managers (CMs). Now more than ever, nurses are empowered to take decisive action not just to provide better care and expedite patients’ access to care, but to initiate assessment and treatment to improve practices in specialisations such as wound care and reaching beyond the polyclinic to enhance health in the community.”

CHAPTER FIVE54

CHEN YEE CHUI

CHIEF NURSE, NHGP

05

05 Senior Nurse Clinician and Care Manager, Ng Soh Mui (left) and Senior Nurse Clinician and Care Manager, Lee Ching Lian



By the early 2000s, the role of assistant nurses had been expanded to include administering diabetic retinal photography screening, foot screening and family planning services, which used to be administered only by registered nurses. “In Child Health,” says Deputy Director of Nursing Services, Jancy Mathews, who oversees the Well Women and

Children Services, “nurses are empowered to decide on safe intervals for the next scheduled vaccination and dosages guided by the decision logic module in the Electronic Medical Records.”

In the last five years, nurses at triage have also been empowered to determine which patients need more urgent care and then fast tracking them to the appropriate channels. Nurses in the Mental Health speciality in the Chronic Disease Management programme are trained to pick up and flag patients with early signs of mental issues such as depression. They can be referred to the specialist in more serious cases, or for health education for mild conditions.

Another highlight has been the introduction of Advanced Practice Nurses (APNs). Becoming an APN involves nurses participating in a two-year Master of Nursing programme, followed by a year’s internship. NHGP had its first APN in 2005; today, seven of the eight APNs are in Chronic Disease Management, managing the more complex conditions seen there, with one in Women’s Health Services. A particularly noteworthy benefit of this training is the ability to pick up warning signs and intervene earlier to arrest issues at the pre-disease state.

Among the milestones in the evolving role of nurses has been the creation of the Care Manager (CM), who works with allied healthcare staff in chronic disease management. As a Care Manager specialising in asthmatic patient care, Sister Lee Ching Lian, Senior Nurse Clinician, talks about being encouraged by an elderly patient she had counselled on inhaler administration.

“It was incredibly heartening to see him on a return visit with his inhaler tied to his belt. He said that he had committed to memory what I said to him about his inhaler being his life-saver. He thought very hard and came up with a solution. He improvised a clever way to tie his inhaler to his clothing so that it would always be at hand. As his Care Manager, I was so impressed with his determination to follow through on my advice. It makes what I do all worthwhile.”

Working as a team with Family Physicians and Allied Health Professionals such as pharmacists, psychologists and social workers has its own special benefits. Sister Ng Soh Mui, Senior Nurse Clinician, describes them. “With the creation of the CM role, we work very closely and feel comfortable to call other healthcare professionals to discuss or consult on issues. The collaboration extends to having group workshops, such as the workshop I conducted with dietitians on diabetes care. We also set and review goals for patients as a multi-disciplinary team.”

Two other important evolutions in primary healthcare nursing are the autonomy to make decisions that would enhance the quality of care and the expansion of roles for nurses.

JANCY MATHEWS

DEPUTY DIRECTOR,

NURSING SERVICES,

NHGP


CHAPTER FIVE56

Certified as an APN in 2009, Sister Carolyn Chan shares her enthusiasm for the future. “We have seen from the recent Nursing Task Force Recommendations that MOH is working towards prescribing authority for non-medical professionals. I am thankful for the strong support by our Family Physicians in NHGP, in tirelessly providing training and developing nursing skills to an even higher level. In NHGP alone, the number of APNs has multiplied by three times since its introduction in 2009! It just indicates the exciting times we have ahead for nursing and I am thrilled to play a role in this work in progress – the transformation of primary healthcare nursing.”

As part of this transformation, the switch from just nurses and ancillary staff working together to a team-based approach to care is yet another change that has impacted nursing. “It makes for a more personalised model of care,” explains Chief Nurse Chen Yee Chui, “where the nurse as the constant member in the team proactively provides holistic care, working with other team members to consider aspects like psychological and social issues that may affect patients.”

Once a Nurse… Beyond the vast changes in the practice of primary healthcare nursing, some things remain the same. “We are first and foremost advocates for our patients,” says Deputy Director of Nursing Services, Yeo Loo See. “Once a nurse, always a nurse,” she adds, smiling.

It is a quality that is inextricably tied to the make-up of nurses. Sister Lee Ching Lian relates a memorable incident about an unkempt patient who reeked of alcohol and was causing a disruption in the polyclinic.

“Most had written him off but I chose to take him aside privately. This tough-looking 45-year-old man started to break down and talked about his background as a retired police officer. In looking for employment to cover his expenses, he was unsuccessful and began drinking to drown his reality. I talked to him about how no situation was hopeless and urged him to start afresh. Weeks later, it was a complete transformation! He took my words to heart and came clean-shaven and in neatly pressed clothes. What really touched me was when he thanked me in such a heartfelt manner, saying that what I had done had made a difference to him.”

Other than caring for patients, caring for fellow nurses remains important too. Whenever patients used to effusively thank her for her care, Sister Angeline Yeo, who has 50 years of nursing experience, would always turn the spotlight on the nurses and staff under her charge as a Nurse Manager. Now, as Assistant Manager in Primary Care Academy, she imparts these same lessons to her nurses and paraphrases Mother Teresa’s quote, “Each day, even in the small things we do, do it with great love.”

RE-ORGANISING DENTISTRYDespite challenging beginnings, the NHGP’s Dental Services Division has come a long way, owing largely to its team’s initiatives and resilience.

Within a span of three years from 1999 to 2002, Dr Peter Chow, then a Dental Officer serving his bond, had the company logo on his name tag changed three times. And it was not because he was job-hopping.


07


07 Dental treatment in a modern consultation room

06 A dental staff member demonstrating dental hygiene tips

06


CHAPTER FIVE58

Before 2000, all dentists working in the six polyclinics with dental departments reported to the Ministry of Health (MOH). However, in year 2000, a very unusual situation unfolded as a result of Clustering. Despite practising at National Healthcare Group (NHG) Cluster’s Jurong Polyclinic as a Dental Officer at the time – like all the other dentists in the public sector during that period – his name tag indicated a SingHealth logo.

Dr Chow explains the curious circumstances in which he was technically a SingHealth employee working in an NHG polyclinic. “Since the National Dental Centre was re-organised under the SingHealth Cluster in 2000, all the dentists, by default, came under SingHealth’s purview. SingHealth then deployed the dentists, including Dental Officers like myself who were at the time serving out our bonds, to work in various public sectors, including the six dental departments based in NHG polyclinics. When NHGP took over the employment of its dentists in 2002, my name tag changed for the third time, to bear NHGP’s logo.”

Growing Our TeamFor several reasons, morale among the public sector dentists was low. A common attitude shared by many dental students was to quickly clear their bonds in order to begin the real culmination of their hard work: practising dentistry in the private sector. This plan seemed thwarted when, tracing back to the time before Clustering, the hearts of many fresh dental students plummeted at the news that the number of years they had to serve in the public sector would be extended, due to greater need of manpower.

On top of that, there seemed to be a shortfall in terms of welfare and even basic training for dentists

before 2000. “We were left to our own devices,” says Dr Peter Chow, “there was no one looking into proper monitoring of our performance or service quality. Our rostering was haphazard. We would just work it out informally among ourselves within the particular polyclinic. If anyone went on leave or was sick and we were short of manpower, we would have to scramble or call in favours from our counterparts in other nearby polyclinics. Training was very much hands-on learning. I remember as a freshly-graduated Dental Officer, my mentor, a dentist two years my senior who was the Clinic Head, handed me a file and from that get-go I had to learn to figure things out quickly while working on the job.”

“Also, stemming from the lack of governance, there was no standardisation of processes such as in sterilisation practices, and dentists were working with outdated equipment,” says Dr Joseph Soon, who was Dental Head of NHGP from 2003 to 2011. There was also difficulty in enforcing

stricter regulatory control among the dentists when disciplinary issues arose. It was not unusual to hear about colleagues who had taken on locum positions at private practices after office hours even though such extra work was not allowed. It also took a toll on the dentists’ performance during their formal working hours as they would arrive exhausted, having expended their energy and strength during their night-time locum jobs.

Something had to give in the situation where the lack of close supervision from an involved overseer

DR JOSEPH SOON

FORMER DENTAL

HEAD, NHGP

2003-2011


“The large volume of patients seen each day ensures that this steep

learning curve is a rite of passage for many new dentists. From the patients’ perspective, we are often the first and last port of call when a dental issue arises.”

CHAPTER FIVE60

carefully to their feedback; as well as holding regular dialogue sessions with numerous stakeholders to put the word out that the culture at NHGP was inclusive, that we cared about our people and were invested in creating the best environment to see them thrive. By 2004, the situation had completely turned around. People picked us as their first choice because they saw us as a breath of fresh air. As an organisation, we began to build a reputation for being innovative and willing to change things in order to improve systems to fit our people’s evolving needs.”

Among the changes that Dr Joseph Soon initiated was to modernise the dental clinics, introducing new equipment such as latest-technology dental chairs and dental X-ray machines. He also launched the non-subsidised dental clinic services which not only allowed the recruitment of more senior dentists to train and supervise the younger ones, it also provided patients with a wider range of dental services beyond the basic services which were already offered in the subsidised dental clinics.

Dr Kenneth Low, the current Dental Services Director who took over the reins in 2011, observes that Primary Healthcare Dentistry in polyclinics is unique in many ways. “For many dentists, it is their first clinical posting after graduation. Here, they develop their clinical diagnoses, improve their practical skills and chairside manners that they retain for the rest of their clinical careers. The large volume of patients seen each day ensures that this steep learning curve is a rite of passage for many new dentists. From the patients’ perspective, we are often the first and last port of call when a dental issue arises.”

DR KENNETH LOW

DIRECTOR,

DENTAL SERVICES,

NHGP


“By 2004, the situation had completely turned around. People pickedus as their

first choice because they saw us as a breath of fresh air. As an organisation, we began to build the reputation for being innovative and willing to change things in order to improve systems to fit our people’s evolving needs.


DR PETER CHOW

FORMER DENTAL

HEAD, NHGP

2002-2003

In today’s modern primary healthcare setting, Dr Low and his current team have their share of challenges amidst an evolving healthcare landscape, yet always deliver results. “The team has moved to a more systematic approach to the delivery of care with protocols from clinical delivery of care to operations. This has allowed us to deliver care efficiently to enable a larger pool of patients to have their oral health needs met. We have seen fewer clinical complications and our patients know we deliver safe and effective care.”

Today the Dental Services Division manages about 50 dentists across five polyclinics. Like the strong and deep roots of the teeth they work with, what sets these dentists apart is a particular resilience that keeps them steady in trying times.

“The challenge has always been to manage the pace of change for the staff, myself included, and the dentists. I take comfort from a good team around me, who have done their best to deliver results consistently despite the changes and inner peace from my faith. The collective wisdom, determination and hard work of the team have helped us achieve some of the milestones and results so far,” adds Dr Low.

Dr Chow explains, “Making the improvements took effort and time, but dentistry is a fraternity in which we all know one another because of the small numbers. This was essential in helping us pick not only the most qualified dentists, but also the ones with the highest sense of integrity and character to lead the department. It proved to be the right approach despite the challenges.”


CHAPTER FIVE62

GROWING OUR ALLIED HEALTH SERVICES From just two services operating individually, to the current five which have come together as a department, Allied Health Services has made great progress.

Adding More Services The five teams comprising the Allied Health Services – consolidated under Clinical Services in 2011 – are dietitians, medical social workers (MSWs), physiotherapists, podiatrists and psychologists. Supported by a small administrative team, the department is a far cry from when it first started.

Prior to the reorganisation of the healthcare providers into two Clusters – when the polyclinics were under the Family Health Services (FHS) – the two Allied Health Services available were those offered by a dietitian and medical social workers. After Clustering in 2000, NHGP’s Allied Health Services started off with that foundation of two services.

Dr Lew Yii Jen, Senior Director of Clinical Services, describes what the situation for Allied Health Services was in the polyclinics shortly after NHGP’s inauguration. “Our dietitian, Ms Chan Mei Yan, who was not full-time with NHGP – splitting her time between the polyclinics and MOH – provided in-depth dietary counselling for patients with conditions such as diabetes, hypertension, lipid disorders, gout or chronic renal disease. Among the medical social workers – we usually had one or two – turnover was high. It was probably due to the heavy workload because they had to see the cases of all nine polyclinics, travelling to each one in turn. It was very taxing for them and between our single dietitian, who also travelled to the polyclinics in turn and the medical social workers, they were only able to visit each polyclinic once in two weeks.”

Allied Health Services not only built up its capability, but also gradually added on more services. As NHGP moved towards chronic disease management in the early 2000s and patients came with increasingly complex issues related to their conditions, including social or psychological, there was an even greater need to attend to the various chronic conditions present in patients by providing a more comprehensive range of services rather than referring them to hospitals.

At the same time, the capability and capacity of Allied Health Professionals (AHPs) were gradually built up as there were greater opportunities opening up in local and overseas undergraduate studies and training for AHPs. Scholarships provided by the Ministry of Health (MOH) made such upgrading of skills and knowledge even more accessible to AHPs, while widening the manpower pool.

With 12 dietitians now, the job scope has expanded to include conducting dietary training for Care Managers and community health promotion and education. This ranges from workshops for mothers with toddlers to talks for the socially disadvantaged at schools and community centres to supermarket tours for staff from corporate workplaces.

MSWs too received a much-needed boost. They attended to patients’ homecare coordination and social and financial needs. But with the launch of the Chronic Disease Management Programme (CDMP) Medisave by MOH in 2006, financial counsellors from the Finance Department took over the handling of patients’ financial needs. This allowed medical social workers to devote more time to doing what they are trained to do – providing counselling for their psycho-social issues.



09

10 11

09 An NHGP psychologist consults with a patient

10 & 11 NHGP dietitians conduct

community outreach work and also share knowledge with their colleagues, demonstrating healthy eating habits and preparation of healthy meals


CHAPTER FIVE64

Podiatry Among the first services to be added was podiatry. In 1996, FHS started a pilot Diabetic Foot Screening (DFS) service at Bukit Batok Polyclinic. With strong research findings backing the importance of having dedicated footcare services that

were shown to have preventive as well as curative benefits for diabetic patients, NHGP was able to justify increasing the number of polyclinics with DFS in the early 2000s.

To further help diabetic patients with foot complications, a podiatry service was established at the Toa Payoh Polyclinic. The service was provided by pioneering Podiatrist Ms Malia Ho, with advice from Mr Adam Jorgensen from the National University Hospital (NUH) and Mr Daryl Du Preez from Tan Tock Seng Hospital (TTSH). Professor Aziz Nather from NUH, Associate Professor Tay Jam Chin and the late Associate Professor Alexandre Chao from TTSH were instrumental in establishing the guidelines for the podiatry service in primary healthcare.

Dr Donna Tan, Assistant Director, Clinical Services, explains the benefits the Podiatry Department has brought to patients. “DFS and Podiatry Services screened patients such as those with diabetes who could develop foot complications regularly and gave them earlier access to treatment if needed at the hospitals. Patients with less serious foot conditions such as corns, calluses and early ingrown toenails

benefitted from the convenience and cost-savings of seeking treatment through primary healthcare. NHGP podiatrists now work closely with doctors, DFS nurses, dressing room nurses and wound care clinicians to better manage diabetic foot ulcers and other foot-related pathologies.”

Podiatry Service Centres were established as separate business units in Toa Payoh, Bedok, Chai Chee and Ang Mo Kio Hub in 2005, but the service was restructured in 2010 and established as the Podiatry Service Department in Bukit Batok, Woodlands, Hougang and Yishun Polyclinics. To further streamline these services, High-Risk Podiatry Satellite Clinics were set up in Toa Payoh and Jurong Polyclinics in 2015 to better cater to patients with diabetic foot conditions requiring early podiatry treatment to prevent acute complications and potential foot amputations.

DR DONNA TAN

ASSISTANT

DIRECTOR,

CLINICAL SERVICES,

NHGP

12

13 A podiatrist explaining the importance of wearing well-fitting shoes

12 A podiatrist demonstrates the process of podiatry treatment

13



PsychologyThe next Allied Health Profession to be added to the Allied Health Services’ suite was psychologists. With patients increasingly having more complex social issues that require psychological intervention, there was a pressing need to aid them in coming to grips with these issues with professional help. In 2007, the department began with its first psychologist. But it was in 2008, with now Principal Psychologist Dr Wong Mei Yin coming onboard, that the department started to grow. She developed psychological programmes for community outreach on topics such as handling depression, anxiety and insomnia. She also came up with guidelines for psychologists on gauging the severity of a patient’s psychological condition, such as depression, to qualify for hospital referral. Another important aspect in which Dr Wong was instrumental was initiating the benchmarks of expectations during treatment that indicate that a condition is progressing.

PhysiotherapyNHGP Physiotherapy (PT) Service was the fifth service to join the Allied Health Services department

when it was launched in August 2008 at Toa Payoh Polyclinic, with one physiotherapist providing therapy in mainly musculoskeletal conditions. As with the other services, the shortage of manpower was initially an issue as the common options for career progressions for physiotherapists were only to be found in hospitals.

Dr Lew Yii Jen explains that experienced professionals were recruited to bolster the team with the help of Senior Physiotherapist John Abraham, who had been practising in the community with voluntary welfare organisations and had a valuable network of experienced physiotherapists. Gradually, by building the capability and capacity of the PT team, the number increased to eight physiotherapists in 2015, alongside seven physiotherapy assistants, in three Physiotherapy Centres in the Bukit Batok, Toa Payoh and Woodlands Polyclinics.

From 2010, the PT team also took on the enhanced role of providing training for undergraduate physiotherapy students from Nanyang Polytechnic,

15

14 NHGP’s Psychology Services began with just one psychologist

14

15 A physiotherapist with a patient


CHAPTER FIVE66

to mentor and nurture future generations of physiotherapists in primary healthcare.

Coming TogetherAfter the five services of Allied Health Professionals came together as a department under Clinical Services, there was a need to increase awareness of each Allied Health Professional service and establish its identity among staff and patients. Hence, individual Allied Health Professional days – where each profile was raised and promoted – were introduced. For example, every year, Dietitian Day and World Social Work Day are each celebrated in March, World Physical Therapy Day in September and World Mental Health Day in October.

The development of the Allied Health Professionals Career Framework in March 2013 also went a long way in cementing Allied Health Services in the position of an established department with attractive and definitive career advancement tracks. Through it, Allied Health Professionals could now opt to advance to Principal level Clinician-Specialist, Clinician-Administrator and Clinician-Educator Researcher positions.

To facilitate team-based care – where doctors, nurses, Care Managers, Allied Health Professionals and care co-ordinators work as a unit to provide patient-centric care – a common notice board in the electronic consultation notes, E-Notes, was instituted to allow the entire team access. Any issues raised during each individual team members’ consultations are posted there, keeping everyone aware.

It took work for different professionals with different professions to learn to collaborate in patient care. As

NHGP progressed towards establishing the relatively new concept of inter-professional collaboration within primary healthcare, training was provided to ease the transition. Dr Donna Tan elaborates on what the training entailed.

“The Primary Care Academy conducted the training in 2013 and 2014 in order to establish and introduce the principles of collaboration, team-based care and inter-professional learning into Allied Health Services’ daily consults with patients. The invited international experts used case studies to impart communication skills which are essential in inter-professional collaboration. Besides that, we also conducted training within Allied Health Services for role clarification for various members of the healthcare team and lessons on conflict resolution within teams.”

Progressing amidst ChallengesWhile great leaps have been made in Allied Health Services so far, the challenge, says Dr Donna Tan, lies in better defining how Allied Health Professionals can work closely with the rest of the healthcare team to support patient care needs. For example, podiatrists who used to work with patients independently now work closely with a range of team members – doctors, Diabetic Foot Screening nurses, dressing room nurses and wound care clinicians – to better manage diabetic foot ulcers and other foot-related pathologies.

The increasing complexity of patient issues calls for the continual re-defining and honing of Allied Health Professional roles, while differentiating them from those in tertiary settings. These challenges are merely bumps in the road for the Allied Health Services Department which has already overcome much in order to come into being and grow.


CULTIVATING A CULTURE OF CARE


Among the key initiatives that Mr Leong Yew Meng – NHGP’s Chief Executive Officer from December 2009 to September 2014 – embarked on during his tenure was to launch the “Way of Being” programme. It cultivated a people-centred culture in NHGP amongst staff and towards patients, imparting the tenets of leading by example and seeing the common humanity in each person. Mr Leong says, “The difference starts from us, inwardly. To see everyone we meet (be it a patient or co-worker) as an individual with different needs and challenges and to pause for a moment to understand their behaviour instead of being judgmental. This helps us take ownership and rise above our challenges to help them.”

His leadership was focused on people-centredness and communications to address staff morale issues arising from the high workload in the polyclinics. Mr Leong made the effort to deliver every orientation talk for new staff, to explain to them the culture and mission of NHGP, as well as to help them understand their relevance in their daily work. He often used the ‘Starfish Story’ to inspire staff to realise that every single effort, regardless how seemingly small, counted towards helping a patient.

Another event that Mr Leong remembers fondly was the Family Appreciation Day that he initiated in 2013. It was an event that he initiated to allow staff to show their appreciation to their loved ones, for their support towards their work. The response from staff was overwhelming and there were many touching moments when staff took the opportunity to express their gratitude to their family members. As part of the event, Mr Leong also initiated book prizes contributed by senior management to school-going children of junior staff.

“It was about our people and doing what we could to show that we value them,” he adds.

LEONG

YEW MENG

CHIEF EXECUTIVE

OFFICER, NHGP

2009-2014



was lending itself to chaos. Dr Chow describes the situation eloquently.

“As NHGP was simply a hirer of the dental service provided by the dentists, it was like running a restaurant while not having any control over its cooks. Everyone was left on their own and we grew used to having to fend for ourselves.”

Need for ChangeAfter Clustering in late 2000, the Dental Services Department, with dentists under SingHealth’s charge, came under NHGP’s Headquarters, with what was formerly known as Medical Affairs overseeing it. Dr Lew Yii Jen, Senior Director, Clinical Services, who was Assistant Director, Medical Affairs at the time, was tasked to manage the Dental Services Department.

Among the improvements he introduced were regular meetings with dental heads and focus groups among the dentists. These were welcomed.

“Dr Lew’s initiative targeted a key factor – the engagement quotient – of dentists in the organisation as a whole. Before this, the idea of being heard, that our feedback mattered and being able to participate in decisions was quite new to us,” shares Dr Peter Chow. By 2001, NHGP’s then Chief Executive Officer Dr Shanta Emmanuel saw a need to improve the arrangement further by appointing a Dental Head to take charge of the Dental Services Department. Dr Chow, former Dental Head in Jurong Polyclinic, was appointed to the role in June 2002.

Improvements ImplementedAn important starting point was manpower. To build up a pool of experienced dentists to anchor the staff and manage their attrition rate and low morale, NHGP first looked into factors that would make it more attractive for dentists to stay on for longer terms. This included designing a more appealing scheme for dental officers to want to continue to serve in NHG Polyclinics beyond their bond.

In addition, Dr Peter Chow and his team worked on raising the profile of NHGP as the employer of choice to draw emerging talent.

“Immediately after Clustering, SingHealth with the National Dental Centre under its care seemed like the natural choice for most dental officers to opt for in their postings to serve out their bond. We put in a lot of effort: going into the university to speak to dental students, conducting extensive training for dental officers posted to us and listening

08 The newly-renovated Dental Clinic with spacious and comfortable seats and modern consultation rooms

08

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SERVING OUR COMMUNITY68

The best healthcare takes place at home. As such, we engage, empower and equip our patients, their families and the community with knowledge and skills so that they can take charge of their own health and wellness.

“There are many providers in the community who could help look into our patients’ non-medical issues. As a primary care provider, our role is to help connect the dots, engaging suitable community partners to look into the different needs of our patients to complete the big picture of health.”

ADJUNCT

ASSOCIATE

PROFESSOR

CHONG PHUI-NAH

CHIEF EXECUTIVE

OFFICER, NHGP

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01 To keep our care services relevant to the evolving healthcare needs in the community, NHGP staff at the annual Primary Care Forum learn from the experiences and expertise of local and overseas experts such as Dr Margaret Chan, Director-General of the World Health Organization (WHO) who also visited Jurong Polyclinic on 3 April 2007

02 (Left to right) Dr Jason Cheah, Chief Executive Officer of NHGP (2005 to 2009), Mdm Kay Kuok, Chairman of National Healthcare Group, Dr Lim Chee Kong, former Head of Hougang Polyclinic and Dr Lim Suet Wun, then Group Chief Executive Officer of National Healthcare Group at the official re-opening of Hougang Polyclinic on 23 June 2009

03 Residents and staff staying active through line dancing at Ang Mo Kio Polyclinic Open House on 11 October 2003

04 Elderly residents enjoying simple exercises at Toa Payoh Polyclinic’s Open House on 11 October 2003

05 On 1 November 2003, Choa Chu Kang Polyclinic held its Open House and organised the “Healthy Lifestyle for You and Me” Active Kidz Contest to encourage young children to stay healthy by being more active

“All our polyclinics know the communities that they serve. They are aware of the demographics and disease patterns of the community that they are in.”

Involvement and Integration with Our CommunityNHGP establishes its role in providing primary care to the population together with the other organisations and healthcare agencies or partners. While NHGP empowers the population in their health journey, it also identifies and includes vulnerable populations in community health programmes.

DR WEE WEI KEONG

DIRECTOR, HEALTH

PROMOTION &

PREVENTIVE CARE,

NHGP

03 04 05


70

06 Yishun Polyclinic held its Open House for families with young children on 1 November 2003

07 Residents learning about the benefits of eating more fruits and vegetables at the booth manned by a nurse at Bukit Batok Polyclinic Open House on 11 October 2003

08 At Yishun Polyclinic, nurses were present at various booths to encourage patients to go for blood screening

09 A queue formed for a good reason as residents eagerly wait for their turn to get their blood pressure taken at Clementi Polyclinic Open House on 11 October 2003

10 Residents from Jurong West and Jurong Polyclinic’s Stroke Support Group members picking up tips on fall risk management and exercise for the elderly in 2012

right, back row) Dr Lim Wee Kiak, Member of Parliament (MP) for Nee Soon Group Representative Constituency (GRC), Mr K. Shanmugam, MP for Nee Soon GRC and Minister for Foreign Affairs and Law and Er. Dr Lee Bee Wah, MP for Nee Soon GRC witnessed the occasion as Dr Lew Yii Jen, Senior Director of Clinical Services at NHGP and Mr Jack Soh Tze Churn, Chairman, Publicity and Public Relations, exchanged the endorsed agreement

11 Primary Care Academy provided training and awareness to caregivers by giving them a peek into the visual conditions that the elderly face during its Know the Elderly Workshop in 2014

12 To further engage Nee Soon South residents with health-promoting activities, a Memorandum of Understanding was inked between Nee Soon South Division and NHGP in June 2014. (Left to

06

08

07

09



13 In April 2015, a dietitian shows Nee Soon South residents how to prepare a healthier dessert as part of a programme started through the MOU with Nee Soon South Division

NHGP launched two healthy cookbooks, Resipi Kasih Hidangan Sayang (Cooking with Love) and Suvaithu Paar Chellame (Taste it … My Darling) in 2005 and 2006 respectively. These cookbooks were the result of collaborations between NHGP and local radio stations. The Malay food recipe book, featuring healthier ways to prepare everyday favourites, was a collaborative effort with Warna 94.2FM station deejays while the Tamil-English recipe book was developed by staff, celebrities and radio listeners of Oli 96.8FM station

10

12

11

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IMPROVING CARE THROUGH TECHNOLOGY

CHAPTER SIX72

The Digitisation Journey Before planning began in 2000 to harness information technology to increase efficiency and bring an even higher standard to primary healthcare at NHGP, it was normal to see patient medical records in thick folders containing handwritten assessments and treatments on paper continuation sheets, numerous forms and letters.

Doctors, nurses and allied healthcare workers also had to wade through stacks of case sheets daily and manually fill in patients’ details or record parameters on the necessary but tedious forms for everything from requesting laboratory investigations to referral letters. To Dr Jonathan Phang, Deputy Director, Clinical Services, the initiative’s objectives of eventually going paperless seemed like “a beautiful dream on the distant horizon”. He co-chaired the IT Project Management Office that was a part of the committee spearheading the transition.

But it only took two years before the first fruits – the Patient Management Patient Accounting (PMPA) System – emerged. Through it, patients needed only to register once and their particulars and medical records would become accessible online among the nine polyclinics via a central database. And instead of needing to pay up to three times at three different service points, there would be only one consolidated bill at the end of each visit for the patient.

The one patient, one registration, one bill initiative was piloted in Choa Chu Kang Polyclinic in July 2002, before being launched in all the other polyclinics.

Tracing the path of digitisation that NHGP has taken and the many benefits it has brought.

01

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02 NHGP staff in discussion to improve IT developments and processes

01 Dr Jonathan Phang showing eNotes – the last module of the Electronic Medical Records (EMR) system – to former Health Minister, Mr Khaw Boon Wan

03 The new ceiling-suspended X-ray system with a height-adjustable examination table makes it easy for elderly and wheelchair-bound patients

02

03


A succession of developments slowly but surely rolled out in the years that followed. It started with common laboratory results shared online, then electronic orders for blood tests and X-rays, followed by electronic prescriptions for medication. In October 2009, Bukit Batok Polyclinic became the first primary healthcare institution in Singapore to go fully digital with its medical records. Within a span of 11 years, through persistence, diligence, attention to detail and innovative thinking, what had once been a dream became reality.

Along the way, the biggest challenge faced was in engaging stakeholders – doctors, clinicians, administrators and operations staff – to make the transition to full Electronic Medical Records (EMR) and then provide feedback for improvements. Dr Phang relates how the team came up with ways to get staff buy-in to the digitisation process over many meetings that would often stretch late into the night in order to meet the countless project deadlines.

“We carefully chose the EMR modules that were most mature and stable to implement first and also those

CHAPTER SIX74

where the benefits to patient care were high and with relatively less change required for clinicians. In each EMR module, we touted the benefits to patient care that clinicians would value. We kept it simple and clear in four main areas: online access to patient clinical information that is legible, clinical decision support for better patient care, an efficient process to help with the consultation process and a paperless environment. Once the departments began to implement the changes, the results began to speak for themselves.”

Achievements, Awards and AccoladesAmong the benefits achieved in making the digital switch are that records and test results can now be accessed simultaneously by any of the primary healthcare team including doctors, nurses and Allied Healthcare Professionals, seamlessly facilitating a

04

05

04 A tele-ophthalmology session in progress between doctor and patient

05 Self-payment kiosk


“We carefully chose the EMR modules that were most mature and stable to

implement first and also those where the benefits to patient care were high and with relatively less change required for clinicians.”


multi-disciplinary approach to caring for each patient. Discussions between various departments have taken on greater efficiency and time savings as they can now be conducted remotely via the online portal. Clinical decisions on the next steps in treatment or further tests can be expedited.

Staff can also be redeployed to take on direct patient care activities. The Outpatient Pharmacy Automation System (OPAS), an innovative collaboration between Tan Tock Seng Hospital, National University Hospital, National Healthcare Group (NHG) Pharmacy and Integrated Health Information Systems, automatically translates electronic prescriptions and picks the medications, reducing the need to fill prescriptions manually. In this way, the polyclinic pharmacist is freed up to focus on conducting the final check and on counselling the patient.

Pharmacy Technician Evelyn Soh, who works at Bukit Batok Polyclinic explains, “It is more fulfilling. Before, I would spend most of my time packing and sorting medicine; now I have more time to counsel patients on issues like food to avoid while taking medication, answer queries and allay any doubts patients may have.”

There is also the additional benefit of electronic alerts such as reminders for screening and decision support such as online charts guiding clinicians through evaluation processes on procedures like child immunisation. They all add up to safer practices for staff and a decline in the likelihood of human error.

For its IT achievements, NHGP received two awards from the Ministry of Health’s IT Excellence Awards 2014: the IT Excellence for Increasing Access to

DR JONATHAN

PHANG

DEPUTY DIRECTOR,

CLINICAL SERVICES,

NHGP



07

08

07 A patient and her caregiver participating in the Telecare programme

08 A patient and her caregiver in consultation with a Care Manager


CHAPTER SIX78

has reduced his clinic visits to two to three times a year. “With the Telecare programme, I feel like I am in control of my blood pressure; if it is not proper, then I will inform the doctor during my next visit. And by sending over my readings regularly, my doctor is able to refer to them and advise me to check on this and that.”

Self-registration booths were another innovation that has brought greater convenience for patients.

Ask Dr Phang about a learning point he took away from being involved in the lengthy task of digitising almost from ground zero and he

OPAS (Outpatient Pharmacy Automation System)What it is: Automated packer which sorts and packs medicine. Benefits: Instead of spending time and effort picking out and packing patients’ prescriptions, pharmacy technicians can now receive retraining to handle patient counselling while they dispense medication.

Electronic Consultation Notes (E-Notes)What it is: Digital medical records that doctors can access online to read and record diagnoses for patients. Besides patients’ medical records and test results, E-Notes also allows doctors to order lab tests and prescriptions. Benefits: With ready access to patient medical records on a common platform, this reduces medical errors and shortens consultation waiting time, as health attendants no longer need to deliver casenotes to the doctors’ rooms. E-Notes also allows NHGP to share patients’ medical records with hospitals.

Teleradiology services What it is: Digital imaging and transmission of such images as X-rays, CT and MRI scans to aid in diagnoses. Benefits: Since 2005, when NHGP was the first in Singapore to introduce teleradiology services in Ang Mo Kio Polyclinic, clinicians are able to access high-quality detailed reports at rapid turnaround times which are now a mere one hour. This is especially effective in cases requiring urgent care. Written records are automatically scanned into the system under the patient’s records, reducing space for the films and aiding accessibility among the multi-disciplinary healthcare team.

TECHNOLOGICAL TOOLS

09

09 Self-registration kiosks



replies after some thought, “Setting out on the journey, we knew that we may be headed for some rough seas in terms of overcoming our colleagues’ resistance to change, fear about IT hampering rather than aiding the consultation process and lofty expectations that the EMR system would solve all patient quality and safety issues.

“But always, the same encouraging thought kept me going: Think of the benefits IT will bring for our patients and staff. The success of the system has more than proved that in opening ourselves to pre-emptively set systems in place, it would not only allow us to prosper in the midst of pressure but enable us to stand up to the trials ahead.”

On the Horizon On the future of IT in primary healthcare, Dr Jonathan Phang says, “With issues arising from an ageing population and the burden of chronic diseases coupled with the multitude of tasks that clinicians in primary healthcare have to juggle in order to provide quality care to patients, transforming primary healthcare would mean transforming and evolving how we harness technology to even greater benefits. Making use of digitisation has not only saved us precious hours and reduced legwork, it aids us in clinical decision-making and enables us to keep up with the complexities and advancements in medical diagnosis and treatment. Most importantly, it relieves us of the daily non-essential tasks so that we can provide what is at the heart of healthcare – a caring touch while partnering patients in their journeys to healthfulness.”

12

10 Patients are able to manage their appointments through a mobile phone application

10


CHAPTER SIX76

Care award for its Telecare programme for patients with chronic illnesses and IT Excellence in Providing Quality of Care for OPAS in NHG Pharmacy. Dr Jonathan Phang, who was also honoured with the Champion for IT Excellence award, turned the spotlight on his team of IT champions.

“The team’s can-do spirit and unquenchable enthusiasm in the face of challenges were the driving force behind making our achievements today possible. It was the unflagging contributions of each of my fellow Operations colleagues, especially Yan Yan, Evelyn Low, Jing Xian, Christie and the iHIS team, particularly Ming Chu, Joanna Chia, Irene Kwek, Edwin Chew, Hafez Marie, Winston Woo, Christopher Chia, Duethy and Lee Poh Heng that have made this journey so rewarding.

“Our group of medical IT champions – especially Dr Evan Sim, Dr Simon Lee and Dr Manojkumar Kharbanda – were invaluable in looking at clinical care delivery and articulating how IT could be used to improve interprofessional collaboration and healthcare integration for continuity of care, patient engagement and empowerment, population management, evaluation and research. It was because of their passionate campaigning that our clinicians and clinic staff embraced IT and thrived using it as part of daily patient care.” He also lists the Telecare programme that was rolled out in 2014, as an IT innovation that he and his team are particularly proud of for the greater ease it brings to patients with stable chronic conditions who usually have to bear the costs and inconvenience of multiple visits to the polyclinics to monitor their health status.

“Now we can truly leverage technology to empower these patients. They can enjoy the convenience of care through home monitoring – submitting their health parameters online and having tele-consultations with nurse Care Managers to regularly check and discuss any health concerns – all within the comfort of home,” Dr Phang says, beaming with pride. With Telecare, 64-year-old Mr Shaik Hussein Bin Shaik Dawood, who has hypertension, monitors his blood pressure at home regularly. He submits his readings through an online portal. Once they are reviewed by a nurse, he has a tele-consultation with a Care Manager on the management of his condition. The programme

06

06 A Care Manager in teleconsultation with a patient

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OUR PATIENTS’ JOURNEY

Take a walk around our polyclinics of today to experience all the benefits that innovation brings, through the eyes of a patient.

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02 A user-friendly self-registration kiosk

01 Garden feature in Hougang Polyclinic


Appointment MakingWith the Appointment System (APS) launched in all nine polyclinics by November 2012, patients can now manage their time better with an estimated consultation appointment time. Whether it is to make a same-day or other advance appointments, members of the public can use any of three ways: call the Contact Centre hotline, log in through an online appointment system on the NHGP website or use NHGP’s smartphone app, miHealthCare.

RegistrationPatients arriving at the entrance of any of the nine polyclinics are now greeted by the warm, welcoming smiles of Patient Service Associates or Health Attendants, ushering them to neatly-lined kiosks where they are guided through the user-friendly self-registration. Within minutes, they are registered and can proceed to the waiting area outside their assigned consultation room.

EnvironmentMany of the polyclinics have spacious walkways and waiting areas, as well as cosy cafes for

02


82

snacks and drinks. With design features that incorporate small landscaped gardens, trees and shrubs lining the pebbled walkways within their premises, patients can experience nature’s healing surroundings at the polyclinics.

ConsultationAs the consultation room door swings open, patients are met with the warm greeting of a caring Family Physician in a well-lit, air-conditioned room. From the carefully designed table and placement of the doctor’s and patients’ chairs to the examination

couch, much thought has been put into making it conducive for the consultation process.

PharmacyMaking their way over to the pharmacy after consultation, patients now reap the benefits of the Outpatient Pharmacy Automated System (OPAS) in some polyclinics. It is a state-of-the-art machine which sorts and packs medications. Without the labour and time-intensive tasks of sorting and packing medications, pharmacists can devote more time to more important tasks such as counselling patients.

PaymentAs their visit draws to a close, payment is a breeze as patients can conveniently make payment at the self-payment kiosks. With easy-to-navigate infographics and elderly-friendly features such as larger font sizes, patients even have the option of paying using Medisave or through third-party payments or financial assistance schemes such as Medifund. The kiosks also accept payments using NETS, NETS Flashpay, NETS Cash Card and EZ-Link.

03 Well-designed and equipped consultation room

04 Pharmacies come with a retail shop for patients’ convenience

05 A self-payment kiosk

03 04 05


REVAMPING AND RENEWING


A key role that Dr Jason Cheah played as Chief Executive Officer of NHGP from November 2005 to December 2009 was in modernising the polyclinics.

It was under his leadership that Woodlands Polyclinic closed temporarily to undergo major renovations while Hougang, Jurong and Choa Chu Kang Polyclinics also underwent revamps. This created a more conducive and inviting environment while uplifting staff morale with updated surroundings. Besides infrastructure changes, the polyclinics were able to go “paper-less” through various technological innovations such as digitising processes.

“Being able to achieve Joint Commission International (JCI) accreditation was a milestone because it meant that NHGP could benchmark itself with international standards and be assured that our processes were on the right track and clinically sound. But beyond bringing renewal to hardware was the importance of revitalising heartware.

“After the clinics underwent a transformation, you could see in the faces of our staff, especially the pride that they took in their workplace and their work. I remember that I would regularly try to visit the polyclinics incognito. Often I would just sit at the waiting areas to observe from the patients’ as well as staff’s perspective what their experience was like, such as how things were handled on the ground. I recall one incident where I was able to witness how a laboratory technician – who had her hands full juggling patients, equipment and reports – spotted an elderly patient who looked like she was about to faint and ran over to her aid. She spoke calmly and reassuringly to the elderly patient while propping her up, then waited with her until the patient collected herself. She then assisted the patient to the laboratory room where there was space to rest and recover.

“It is such attention to care that may seem small but really does matter and should be encouraged, embraced and celebrated.”

DR JASON CHEAH

CHIEF EXECUTIVE

OFFICER, NHGP

2005-2009


84

Clementi Polyclinic, set up in 1980, is the oldest polyclinic to

come under NHGP management post-Clustering. Some of the improved fittings include new

flooring and furniture as well as flat-screen displays

CLEMENTI

“I would like to thank all the doctors, nurses and other staff. Whenever my elderly mother, sister or I visit Clementi Polyclinic, they never fail to be patient, polite and full of compassion. We especially appreciate the staff who have to walk around all day,

calling out patients’ names and guiding them. We always feel very grateful to them, especially when we enter the polyclinic. They

certainly deserve respect and appreciation.”JULIANA LIM

PATIENT OF CLEMENTI POLYCLINIC

ANG MO KIO


86

TOA PAYOH

Located in the heart of one of Singapore’s pioneer HDB towns, the Toa Payoh Polyclinic

has served residents since 1988. Opened in 2011, the Ageing-in-Place studio shows

elderly and their caregivers modifications and personal assistive devices to make their homes

safer and simpler to manage

BUKIT BATOK

Built in 1991, Bukit Batok Polyclinic houses Singapore’s first primary healthcare museum, Gallery of Memories,

which was set up on 1 October 2002. The museum features medical equipment, vaccination records,

handwritten prescription slips, nurse’s handbooks and photographs from earlier times when Maternity and

Child Health were the foremost concerns of the primary healthcare landscape

“Thanks to the doctor and the medical

team who treated me. I’m proud of the healthcare system we

have here, especially in Toa Payoh Polyclinic.”

LIM KWE TAIPATIENT OF TOA PAYOH POLYCLINIC

“Every time I need to see a doctor at Bukit Batok Polyclinic, I am

greeted by warm and friendly staff who are passionate about their

work. I feel like I am with family and relatives who are so welcoming.

Keep improving always.”LIANG KHOON

PATIENT OF BUKIT BATOK POLYCLINIC


88

WOODLANDS

CHOA CHU KANG

Re-opened in February 2008 after a major renovation since its set up in 1993, Woodlands Polyclinic houses the largest Dental Centre, featuring 12

individual consultation rooms with dental chairs for greater

privacy and comfort

“My dentist was very professional and caring in her dental assessment. I am

grateful for her excellent service during the dental treatment procedure.” ABDUL MAJID RIDZUAN BIN ABDULLAH @ NOEL DAVIES

PATIENT OF WOODLANDS POLYCLINIC



Ang Mo Kio Polyclinic was established in 1981.

It houses Singapore’s first Family Physician Clinic, in a primary healthcare setting, set up in 2005

JURONG

Built in 1988 and redeveloped in 2007,

Jurong Polyclinic has the largest patient attendance among all nine polyclinics,

seeing an average of 1,600 patients coming

through its doors every day

“I would like to thank my doctor because he is a people’s doctor. All my years of visits to Ang Mo Kio Polyclinic, I feel

that he is the best kampong-like doctor and is very friendly and informative. He

makes my day and I believe he brightens everyone else’s day too! Thanks, doctor,

you make your patients feel good.”HONG KEE LIM

PATIENT OF ANG MO KIO POLYCLINIC

“I would like to thank the management and staff because

Jurong Polyclinic is well-managed with a clean and brightly-lit

environment. The polyclinic is well organised and the waiting area for

patients is well planned.”MARGARET TAN

PATIENT OF JURONG POLYCLINIC

ANG MO KIO



HOUGANG

Hougang Polyclinic was built in 1991 and after

modernisation in 2008, it has elderly-friendly features like handrails and slip-resistant

flooring as well as designated wheelchair and baby stroller

parking spaces

BUKIT BATOK

“I have been visiting Hougang Polyclinic for a long time and the staff here are responsible

and helpful. I’ve since moved to Punggol but I still choose to have medical check-ups

in this polyclinic.”B. BUAN KAMIN

PATIENT OF HOUGANG POLYCLINIC



CHOA CHU KANG

YISHUN

Yishun Polyclinic, established in 1998, is the main primary healthcare provider in Yishun and Sembawang. In the event of an outbreak of

infectious diseases, Yishun Polyclinic’s Acute Cluster area can be easily converted

to segregate spaces and patients

Built in 1997, Choa Chu Kang Polyclinic is home to

the Primary Care Academy, launched in 2007 for the educating, training and

skills upgrading of primary healthcare professionals

in Singapore

“My doctor was empathetic in treating me tenderly and carefully and thoroughly examined me with

care. She also patiently explained my ailment and the appropriate treatment. She made me feel at ease and gave me a sense of relief. She doesn’t only treat patients physically, but also soothes

them mentally and psychologically. I have had the most fulfilling medical examination today at Choa

Chu Kang Polyclinic thanks to her.”

PHUA KIM YONG BENNYPATIENT OF CHOA CHU KANG POLYCLINIC

“I would like to thank the staff and management because Yishun Polyclinic is the best clinic I

have visited. Very systematic, clean, bright and comfortable. Staff also moved patients to less

busy clinics where possible. A very organised clinic. Well done. I wish other polyclinics can achieve this

standard as well. That will raise the service and standard of public clinics and hospitals. Thank you

very, very much. A very rare experience.”

NORMA S VARGASPATIENT OF YISHUN POLYCLINIC


BUILDING RELATIONSHIPS FOR OUR FUTURE

CHAPTER SEVEN90

The relationship between a Family Physician and his patient is such a special one that the best way to describe it would be like that of old friends. To me, it is about the trust, rapport, understanding, accountability and shared history that have been built over the years. And just like with an old friend, every time we meet, we don’t need to start from scratch. We simply start from where we last left off. From that common ground, consultations with the familiar Family Physician become warm encounters in which patients feel at ease to reveal their life details or simply to update the status of their health since their last visit.

It is this bond that is unique to Family Medicine and is what first drew me to this specialty. When I assumed the role of Chief Executive Officer on 1 October 2014, I knew that I would juggle being an administrator while continuing to practise and see patients. It’s a calling which I hold very close to my heart and the reason I became a doctor.

Choosing Family MedicineDuring my days as a houseman doing my hospital postings, I couldn’t make up my mind about which specialty to go into because I liked everything. So I thought that since I enjoyed the entire breadth of medicine, enrolling in the Master of Medicine in Family Medicine training programme seemed ideal.

When I was attached to a group practice as a trainee, I sat in during consultations and saw how my tutor at that time, a well-known GP, treated each of his patients as a friend, first and foremost. Over comfortable banter, his enquiry after his patients’ welfare would extend to their families. Amidst inside jokes, patients would hand over family photos,

Chief Executive Officer of

NHGP, Adjunct Associate

Professor Chong Phui-Nah,

discusses the importance

of building close ties with

patients, which is at the

heart of Family Medicine

and integral to NHGP’s

future initiatives.

01

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filling him in on their children’s latest shenanigans or upcoming holiday plans as easily as divulging their recent aches or unexplained pains. It was something that I hadn’t witnessed throughout all my medical school years in a hospital setting.

Perhaps in other settings like specialist clinics, there may be similar familiarity. But what struck me about this is that I was able to relate it to my close and familiar relationship with my own Family Physician and it inspired me to want a career that would be based on this exceptional bond. It is such a privilege to be able to share in the events of patients’ lives because to them, a Family Physician is first and foremost, a trusted friend.

Memorable MomentsWhile at Toa Payoh Polyclinic, I had a patient in her 50s who complained of symptoms like nausea and bloating; she had missed her period for three months. Looking at her presenting issues, I gently suggested that she take a urine pregnancy test, which turned out to be positive. She was in shock and was going through emotional upheaval ranging from disbelief to fear at facing impending motherhood at this late stage in her life with two grown children. I asked my clinic manager to temporarily stop the rest of my patient numbers so I could spend more time with her to advise her to see things positively and not rush into making a rash decision. Despite her initial misgivings, she eventually chose to keep the baby.

After she delivered, she brought her baby boy in to see me. I encouraged her to breastfeed. A few years later, she popped by to say hi. I remember how her face lit up as she shared, “It was the best

CHAPTER SEVEN92

decision we have ever made to keep the baby. He’s such a joy to the family!” I could not help but share in their joy.

They had initially been fearful of congenital issues with the child given the mother’s age, but the child was very healthy and well-adjusted and the whole family was delighted to have this bundle of joy enter their lives at such an unexpected time. It may not be the ideal situation for everyone but I am truly glad it worked out well for this family. It also reminded me again of the privilege of playing an important part in the lives of my patients, people who look to me for advice and allow me into their lives. It is something I take great pride in and I don’t take that privilege for granted.

Growing with PatientsAlso, as a life mission, it doesn’t get any better than being able to journey alongside the people you’re reaching out to as they travel through the seasons of their lives. The satisfaction I get is from being able to see patients and grow with them over this sojourn. From their active working lives, to having kids, then growing old, becoming grandparents and through their sunset years – it is really quite a phenomenal honour.

Looking AheadOn the subject of growing older together, I am mindful that as I steer NHGP into its next 15 years and beyond, the issues of an increasingly ageing population with more complex chronic conditions, coupled with the limited healthcare manpower resources, will be challenging. It will be more crucial than ever to allocate the right resources to meet patients’ needs.



01 The launch ceremony for NHGP’s 10th polyclinic, Pioneer Family Healthcare Centre – Your Community Polyclinic, with Adjunct Associate Professor Chong Phui-Nah second from left

02

04 05

03

02 The seven-storey Pioneer Family Healthcare Centre will be a future-ready centre designed to be a health-promoting classroom with an open rooftop and communal spaces for community engagement

03 Caring for the elderly community beyond clinical walls

04 A GP Clinic Assistant course for members of the public at the Primary Care Academy

05 Dr Amy Khor, Senior Minister of State for Health and Manpower (second from right), pointing to a model of the Pioneer Family Healthcare Centre at the groundbreaking ceremony held on 29 May 2015


“The issues of an increasingly ageing population with more

complex chronic conditions, coupled with the limited healthcare manpower resources, will be challenging. It will be more crucial than ever to allocate the right resources to meet patients’ needs.”


Thus we need to transform primary care and review our care delivery model. In our fast-paced society, the human touch is missing and patients have gotten used to taking a transactional approach to consulting a doctor, complaining when their expectations are not met. However, at the Family Physician Clinic where patients see their regular Family Physicians, patient satisfaction is usually high because of the strong doctor-patient relationship.

Being familiar with a patient’s background and family history, the Family Physician will better understand the patient’s illness beyond his presenting symptoms. This will help in making the right diagnosis and ultimately, coming up with an effective management plan for the patient. It is through this relationship and the trust that develops over time that Family Physicians are able to influence patients’ health choices and outcomes. This is consistent with the principles of Family Medicine, namely, to provide personal, preventive,

ADJUNCT

ASSOCIATE

PROFESSOR

CHONG PHUI-NAH

CHIEF EXECUTIVE

OFFICER, NHGP

06

06 Growing with our patients and their families to cater to their changing healthcare conditions and needs


CHAPTER SEVEN94

08 NHGP staff getting participants to join in the Exercise and Fall Prevention in the Elderly Forum at Toa Payoh South Community Centre in January 2012. The event saw 220 participants learning about safety measures and fall prevention

08

comprehensive, coordinated care as well as continuity of care. The next step is to empanel patients to teamlets, especially those with chronic diseases, rather than have them doctor-hopping. If a patient doctor-hops, there may be gaps in his medical history which may result in sub-optimal treatments. Each teamlet will comprise two doctors of whom at least one will be a Family Physician. They will work with a Care Manager – a nurse trained in chronic disease management – and a care co-ordinator who does the pre-consultation screening. An enrolled nurse may be added to the teamlet as it evolves.

Depending on the patients’ needs, Allied Healthcare Professionals – such as a dietitian and a podiatrist for diabetic patients or a psychologist and a physiotherapist for rehabilitation – may be included to help meet patients’ needs as and when required. Care delivery will be patient-centred rather than doctor-centred.

We need to allocate the right healthcare resources to meet patients’ needs at various stages of their illnesses. This will allow doctors to practise at the top of their licence and focus on the more complex cases while nurses help to co-manage patients with milder chronic conditions. Nurses will also have more time to counsel these patients. For this model of care delivery to work, patients must be persuaded to be empanelled to the teamlet led by the Family Physician. Not only will the long-standing relationship with the familiar and trusted members of the teamlet enhance the quality of care, patients will begin to feel more accountable for their own health. It will also empower patients and promote self-management.

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A pilot on transformation of care in the form of a teamlet is already in place at Toa Payoh Polyclinic. By mid-2016, this teamlet concept will be implemented as part of the clinical services in all nine polyclinics. The new Pioneer Family Healthcare Centre which is scheduled to open in 2017 will incorporate this teamlet approach in its care delivery right from the start.

As providing quality care cannot be a one-size-fits-all approach, we have to customise the way we provide care in order to meet the varying needs of each individual patient. For a start, we need to move away from our current mental model of every patient necessarily needing a physical face-to-face consult. Harnessing technology for Telecare will provide convenience and flexibility to patients. It will also allow clinicians more face-to-face consult time with patients who require it.

Another area for the future is the expansion of primary care capacity in the community. The new Pioneer Family Healthcare Centre is named to more aptly reflect the facility’s commitment and support to population health by enhancing the health of individuals and families in the community.

To do this well, it is essential to collaborate with GPs in the polyclinics’ vicinity and involve them in the care of patients with chronic diseases. This will also help to redistribute the higher chronic disease patient workload from the polyclinics to GPs. This is already in place at the Ang Mo Kio and Unity Family Medicine Clinics (FMCs) in Ang Mo Kio and Serangoon respectively. We recently opened a third FMC, Hougang FMC @ Ci Yuan Community Club, with solo GPs. This is an opportunity to reorganise

their practices and introduce the concept of care teams with nurses and allied health professionals to co-manage patients with chronic diseases.

As part of engaging the GPs, regular networking sessions as well as introducing an IT system platform for ease of information sharing are underway. We also provide training opportunities to GPs and their clinic assistants.

Finally, there has to be greater emphasis on Primary Care research. I was made in charge of starting research in NHGP from 2000 to 2003. In 2006, Dr Tang Wern Ee, Family Physician, Consultant, Family Medicine Development Division, set up the Clinical Research Unit (CRU) and we launched the first Singapore Primary Care Research Scientific Competition in conjunction

08 NHGP’s first batch of Family Medicine Residents who successfully completed the NHG-AHPL Family Medicine Residency Programme.

08

As part of their three-year traineeship, residents had to conduct clinical sessions in various Family Medicine Centres Resident Continuity Clinics (FMC-RCC)


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with our Primary Care Forum in 2012. Since then, it has been held annually with a year-on-year increase in the participation rate.

We hope to encourage and inspire more clinicians to embark on clinical and healthcare services research. Doing primary care research helps us to understand some of our patients and their diseases better as well as to assess the effectiveness of certain treatment regimes. This learning through research is a hallmark of a learning organisation which is constantly evolving to meet the changing healthcare needs of the population.

I am truly excited about what the future holds for NHGP and its role in transforming primary care in Singapore. It has taken us a while but I am grateful we are returning to the heart of Family Medicine. Patient-centric care stemming from the integral

mutual trust and concern of a doctor-patient relationship built over time. I recall an incident with a patient whom I had been following up for his chronic diseases for years.

I had diagnosed him with liver cancer during one visit and referred him to a hospital for evaluation and management. So I was really surprised when he turned up at my consultation room two weeks later. He said, “I went to see a surgeon as you advised and he explained to me the treatment plan. But I want to seek your opinion. What do you think I should do?” When I reflect on this incident, it humbles me greatly to know that beyond the advice that his surgeon would surely have provided him with, this patient trusted me enough to return specifically to seek my opinion and help for an important decision.

This reiterates the importance of the strong bond and trust between a patient and the Family Physician that is built over the years and how precious that trust is.

09 On 1 December 2013, Prime Minister Lee Hsien Loong, together with Ang Mo Kio Group Representation Constituency Advisers and grassroots leaders, visited Ang Mo Kio Family Medicine Clinic as part of the Active Agers Carnival 2013 and tour of Ang Mo Kio Town

10 NHGP and NHG Pharmacy research posters that received the Singapore Primary Care Research Award at the Primary Care Forum 2013

10

09



11 In line with the new care model, clinic assistants, who are usually the first point of service to patients, also require regular training and upgrading

12 Unity Family Medicine Clinic, a collaboration between NHG and Unity Healthcare

11

12


MILESTONES98

2000 Introduced Care Management for chronic patients

Implemented the Direct Access Scheme to allow patients direct referrals to NHG hospitals

Inception and inauguration of NHGP

Re-opened Clementi Polyclinic after upgrading work

2001 Launched NHGP’s Quality Journey to improve the overall delivery of its services

1980Clementi Polyclinic opened

1981Ang Mo Kio Polyclinic opened

1988Toa Payoh and Jurong Polyclinics opened

1991Bukit Batok and Hougang Polyclinics opened

1993Woodlands Polyclinic opened

1997Choa Chu Kang Polyclinic opened

1998Yishun Medical Clinic reopened as Yishun Polyclinic

2002 Introduced Podiatry Services in Toa Payoh and Ang Mo Kio Polyclinics

Implemented Patient Management Patient Accounting (PMPA) System across all nine polyclinics to allow access to a central repository of medical information

Formed the Dental Services Department

Opened the Gallery of Memories, Singapore’s first museum on primary healthcare

2003 Ang Mo Kio Polyclinic underwent major refurbishments to improve facilities

NHGP went through the SARS period, together with the rest of the nation, with staff rising to the challenge of keeping patients and staff safe

2004 Implemented the Business Intelligence System at all polyclinics

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Launched Clinical Research Unit to promote and develop quality research capability in doctors, nurses and pharmacy and diagnostics staff

Jurong Polyclinic re-opened after refurbishment works

Jurong Polyclinic hosted an official visit from World Health Organization (WHO) Director-General Dr Margaret Chan, the only healthcare institution stop during her two-day visit

Introduced the Advanced Practice Nurse’s role to partner doctors in co-managing patients

Introduced the SMS appointment reminder system to help patients remember and keep their appointments

Established Primary Care Academy to provide training and development for primary healthcare professionals

The Hypertension, Diabetes & Lipids Disorder Clinic, the first pharmacist-led chronic disease management clinic in Singapore, was piloted at Bukit Batok Polyclinic


2005 Started on the Electronic Medical Records journey

NHG Diagnostics introduced Singapore’s first teleradiology services at Ang Mo Kio Polyclinic. All polyclinics are now equipped with the service

Introduced the Singapore Footcare Centre to provide comprehensive foot screening and podiatry services to patients with diabetes

Established first Family Physician Clinic at Ang Mo Kio Polyclinic. Family Physician Clinics were later introduced to the rest of NHGP’s polyclinics as well

2006 Established first Physiotherapy Centre in Bukit Batok Polyclinic

A major step in its journey toward digitisation, with developments such as prescription orders, e-Laboratory results, NHG Aurora e-orders, nursing records and patient medical records, to make record keeping more intuitive, orderly and accessible

Launched the first Health for Life Centre at Bukit Batok Polyclinic

2007 Introduced the Family Medicine Competency Programme to upgrade the professional skills of our doctors in primary healthcare through hospital attachments and assessments

Introduced self-registration kiosks at all polyclinics to improve patient flow

Began collaborating with General Practitioners through the Adjunct Family Physician Scheme, to provide personalised care for chronic patients and mentor junior doctors in NHGP

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MILESTONES100

2008 Introduced the Ambulatory Anti-coagulation Clinic service, managed by trained pharmacists, in all polyclinics

NHG Diagnostics Centres at all polyclinics were equipped with Spirometry services for testing of lung functions

Opened the Health and Mind Clinic at Ang Mo Kio Polyclinic which enabled patients with common mental disorders such as anxiety, depression and insomnia to receive care at the primary healthcare level

Re-opened Woodlands Polyclinic after renovation work to improve facilities

The first International Conference on Healthcare Transformation: Primary Care Focus, which provided a platform for all healthcare professionals to share and explore pertinent issues in primary healthcare, was held in conjunction with the Singapore Disease Management Conference

NHGP also became the first primary healthcare provider outside of the United States of America to achieve Joint Commission International (JCI) accreditation

Primary Care Academy received accreditation as a Basic Cardiac Life Support training centre by the National Resuscitation Council (2008, 2012)

2009 Introduced Telecare services to enable patients to receive medical attention in the comfort of their home

Introduced Tele-Electrocardiography (ECG) to all NHG Diagnostics centres at all polyclinics, allowing doctors to review the digital ECG readings instantly on their monitors, thus improving turnaround time

The Singapore Disease Management and Primary Care Forum 2009 “Person-Centred Care: Making it a Reality” was held in conjunction with the 2009 Annual Scientific Conference

NHGP played a pivotal role in MOH’s Pandemic Preparedness Clinics strategy during the onset of the H1N1 pandemic flu. NHGP also initiated the “Extension of Medication” with home delivery services for medication

Bukit Batok Polyclinic completed its upgrading work and was the first primary healthcare institution to use E-Notes to record consultations

Introduced open access for patients from hospitals to endoscopy services at NHGP polyclinics; collaborated with Alexandra Hospital, National University Hospital, Khoo Teck Puat Hospital and NHG 1-Health

2010 Opened the Health and Mind Clinic at Jurong Polyclinic



Re-opened Choa Chu Kang Polyclinic after a major upgrading to become more elderly-friendly

2011 Launched four Family Medicine Centre – Resident Continuity Clinics at Bukit Batok, Hougang, Toa Payoh and Choa Chu Kang Polyclinics

Yishun Polyclinic began partnering Khoo Teck Puat Hospital’s specialist outpatient clinic to integrate follow-up care for discharged patients with dementia

Toa Payoh Polyclinic was upgraded for greater patient comfort by optimising natural ventilation and lighting

Set up Nephrology Evaluation Management Optimisation clinic with NUHS to combat the increasing trend of end stage renal disease in at-risk patients with diabetes

Singapore Footcare Centres and Podiatry Services first integrated to form core diabetic care teams at Bukit Batok and Woodlands Polyclinics

Choa Chu Kang Polyclinic received the BCA Green Mark (Gold Plus) Award for its green building features

2012Ang Mo Kio Polyclinic began partnering with Tan Tock Seng Hospital to integrate follow-up care for discharged patients with dementia

Launched Family Medicine Centre – Resident Continuity Clinic at Jurong and Woodlands Polyclinics

Collaborated with NHG Eye Institute in the Singapore Integrated Diabetic Retinal Photography Programme (SiDRP), where non-doctor staff can be trained to read DRP images

Successful digitisation of Tele-Electrocardiography reporting

Implemented the National Electronic Health Records System, to allow easy access to patients’ medical records for better continuity of care

Introduced mobile bone mineral densitometry service at Woodlands Polyclinic to care for elderly patients living in the north. The service is also available at Ang Mo Kio-Thye Hwa Kwan Hospital and Jurong Polyclinic for patients in the East, Central and West areas

NHG Family Medicine Residency Programme achieved accreditation by the Accreditation Council for Graduate Medical Education International (ACGME-I) and was re-accredited in 2013 and 2014

Attained the JCI accreditation for Primary Care Centres, reaffirming continuing efforts at better and safer care

Commissioned the first Singapore Primary Care Research Scientific Competition, in conjunction with the 2012 Primary Care Forum


MILESTONES102

NHGP received the 2012 Business Intelligence Asia Pacific Excellence Award

Yishun Polyclinic relocated to a temporary site to make way for the upcoming Yishun Community Hospital, as part of MOH’s Primary Care Masterplan

Awarded the bizSAFE Star by the Singapore Workplace and Health Council

2013 Choa Chu Kang Polyclinic began partnering with National University Hospital to integrate follow-up care for discharged patients with dementia

Launched Family Medicine Centre - Resident Continuity Clinic at Yishun Polyclinic

Launched first self-payment kiosk in February and full implementation at all polyclinics in August

Ang Mo Kio Polyclinic was equipped with biochemistry analysers, expanding from Choa Chu Kang and Toa Payoh Polyclinics

The Singapore Footcare Centre was relocated from Ang Mo Kio Hub to Hougang and Yishun Polyclinics and integrated with Podiatry Services to form core diabetic care teams

The first Family Medicine Academy at Bukit Batok Polyclinic was established by NHG, NHGP and Lee Kong Chian School of Medicine, to train medical undergraduates and doctors in

Family Medicine

Eight polyclinics were equipped with on-site ultrasound services: Hougang, Toa Payoh, Bukit Batok, Clementi, Ang Mo Kio, Choa Chu Kang, Yishun and Woodlands Polyclinics

NHG opened Ang Mo Kio Family Medicine Clinic (FMC) with strong support from NHGP. The FMC is a public-private partnership with General Practitioners to provide integrated and comprehensive healthcare to the community

Collaborated with nursing homes to improve the elderly’s access to subsidised medications and laboratory services

Piloted the Systematic Health Risk Profiling (SHARP) programme to offer screening for three common cancers to patients. Post-screening patients could also opt for treatment interventions at the polyclinics and participate in community-based lifestyle-modification and wellness programmes

Launched NHGP’s mobile application to help patients manage appointments and medications

A ceiling-suspended X-ray system was installed at Woodlands Polyclinic. The first Full Field Digital Mammography (FFDM) was installed at NHG Diagnostics at Jurong Polyclinic, and subsequently at four more polyclinics



2014 NHG opened Unity Family Medicine Clinic, with strong support from NHGP as part of the MOH Primary Care Masterplan

The Outpatient Pharmacy Automated System was piloted at Choa Chu Kang Polyclinic

Received the Singapore Human Resource Institute Awards for the categories of Employee Relations and People Management, Learning and Capital Development and Quality Work-Life Physical & Mental Well-Being

2015Garnered awards at the MOH Health IT Excellence Award 2014; IT Excellence in Increasing Access to Care (Telecare, NHGP), IT Excellence in Providing Quality of Care (Outpatient Pharmacy Automation System, NHG Pharmacy) and Champion for IT Excellence (Dr Jonathan Phang, Family Physician, Consultant)

The NHG Family Medicine Residency Programme achieved continued accreditation status from ACGME-I for three years. NHGP’s inaugural cohort of Family Medicine Residents graduated from this programme in 2014, eight of whom successfully completed the Master of Medicine in Family Medicine examination

Received the Management Partner award in recognition of good tripartite relationship, for unwavering support and contribution towards the membership growth of NHGP branch and the Healthcare Services Employees’ Union

Groundbreaking ceremony of NHGP’s 10th polyclinic, Pioneer Family Healthcare Centre

Supported the Games Medical Centre (GMC) to provide primary care services to the 28th SEA Games at the Sports Hub, Kallang

Launched Hougang Family Medicine Clinic @ Ci Yuan Community Club

Artist’s impression of Pioneer Family Healthcare Centre


ACKNOWLEDGEMENTS 104

Special thanks to the following from NHGP

Dr Doraisamy GowriRegional Director (North)

Primary Care Transformation Unit

Dr Lew Yii JenSenior Director, Clinical Services

Dr Wee Wei KeongDirector, Health Promotion & Prevention Care

Dr Kenneth LowDirector, Dental Services

Dr Jonathan PhangDeputy Director, Clinical Services

Dr Helen LeongFamily Physician, Senior Consultant

Dr Winnie SoonFamily Physician, Consultant

Dr Meenakshi Sundararaman Family Physician, Senior Staff, Toa Payoh Polyclinic

Dr Yuen Soo Hwa

Family Physician, Senior Staff, Woodlands Polyclinic

Dr Donna TanAssistant Director, Clinical Services

Chen Yee ChuiChief Nurse, Nursing Services

Jancy MatthewsDeputy Director, Nursing Services

Yeo Loo SeeDeputy Director, Nursing Services

David KokDirector, Finance

Chow Choon HarAssistant Manager, Nursing Services

Lee Ching LianSenior Nurse Clinician, Nursing Services

Ng Soh MuiSenior Nurse Clinician, Nursing Services

Carolyn ChanAdvanced Practice Nurse, Nursing Services

Angeline YeoAssistant Manager, Primary Care Academy

Evelyn Soh Pharmacy Technician, National Healthcare Group Pharmacy

We would like to thank the following for their contributions to the book

Dr Shanta Emmanuel

Dr Jason Cheah

Mr Leong Yew Meng

Dr Ling Sing Lin

Dr Razia Attaree

Dr Joseph Soon

Dr Elaine Tan

Associate Professor Wong Teck Yee

Dr Hwang Chi Hong

Editorial Advisory Committee

Adjunct Associate Professor Chong Phui-Nah

Chief Executive Officer, NHGP

Dr Peter Chow

Chief Operating Officer, NHGP

Editorial Team

Goh Geok Ngoh

Director, Corporate Planning & Communications, NHGP

Cynthia Chin

Cindy Chew

Jessica Sasayiah

Sabrina Lim

ThinkFarm Pte Ltd

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YEARS OF TRANSFORMING PRIMARY HEALTHCARE

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