Abstract
Introduction
SingHealth, the largest healthcare cluster in Singapore was formed in 2000 and comprised four public hospitals, five national specialty centers, three community hospitals and a network of eight polyclinics. SingHealth institutions provide the entire continuum of patient care from primary care, through secondary, tertiary care and quaternary, to community care. Through SingHealth’s strategic partnership in Academic Medicine with the Duke-NUS Graduate Medical School (jointly established by Duke University and the National University of Singapore since 2005), SingHealth Duke-NUS AMC was formed in 2011.1,2
Since its launch in June 2017, the SingHealth Duke-NUS Institute for Patient Safety & Quality (IPSQ) in Singapore has been active in integrating cluster-wide efforts in patient safety and quality within the SingHealth Duke-NUS AMC. IPSQ strives to have the patient safety and quality culture prevail across the cluster, regardless of care settings. IPSQ focuses on eliminating preventable error and harm, and improving patient outcomes by building and cultivating a strong patient safety culture. 3 This article shares some perspectives from the early experiences of our new institute.
IPSQ subscribes to the following culture attributes in the implementation of strong safety management system:
all healthcare workers (including front-line staff, physicians and administrators) take ownership and accept responsibility for the safety of themselves, their coworkers, patients and visitors; prioritization of safety above financial and operational goals; encouragement and reward of the identification, communication and resolution of safety issues; provision for organizational learning from adverse events; provision of appropriate resources, structure and accountability to maintain effective safety systems.
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Patient safety leadership
A culture where healthcare professionals strive for implementation of strong safety management systems requires strong leadership, which prioritizes safety above financial and operational goals; encourages the identification, communication and resolution of safety issues and provides appropriate resources, structure and accountability to maintain effective safety systems. The task for implementation of strong patient safety culture is to ensure that interventions known to be effective are applied reliably and consistently to all staff and patients who need them and aligned to the local culture, system and resources. 5
IPSQ emphasizes on three key leadership attributes for building local organization culture of patient safety. These are the “3Cs” for the leaders for building a proactive and generative patient safety culture, and promoting effective technical and adaptive changes in a contextual environment:
Communication – Leaders need to engage, encourage, empower and enable all healthcare staff and stakeholders with effective positive communication. Co-creation – Leaders need to facilitate co-planning, co-design, co-teaching and co-learning for co-implementation. These will optimize staff and stakeholders’ inherent enthusiasm and motivation, buy-ins and ownership to jointly produce a mutually valued outcome. Conflict Resolution – Leaders should expect conflict during implementation and be proactive in resolving them. Adaptive implementation in a contextual environment requires leaders to identify and help resolve conflicts that can occur amongst stakeholders, staff, caregivers and patients.
Patient safety and quality ecosystem
The strengthening of patient safety and quality culture requires a virtuous patient safety and quality ecosystem that takes time and constant efforts to develop. We believe while building this ecosystem, that it is necessary to concomitantly promote and synergize relevant contributing constituent cultures, including Speak Up Culture, Reporting Culture, Learning Culture, Patient Centric Culture, Support Culture, and Just Culture (Figure 1). Staff need to be able to work in a learning environment that provide quality care for patients and promote quality improvement in the system. They also need to feel safe to speak up and report unsafe practices, errors or adverse events; and for those staff who are involved they need to be supported, in a just culture environment which facilitates learning and accountability, without being traumatized or victimized as the second victim. 6
Patient safety and quality ecosystem and its constituent cultures vs. counter cultures.
Creating a virtuous ecosystem is challenging for all healthcare organizations as there are prevailing counter cultures such as the Blame Culture and Liability Fear Culture to contend with. To prevent counter cultures from festering further, the desired cultures of this virtuous ecosystem must be strongly inculcated, embedded, sustained and continually renewed in the healthcare institution for optimal safety and quality of care. This requires the leaders to invest in resources and infrastructure to build the ecosystem. Training programs for staff and teams to create awareness, promote and change individual and team behaviors congruent with the relevant cultures are important.
It is essential to share and spread the development of good culture within and beyond the healthcare cluster. For example, one of our institutions, KK Women’s & Children’s Hospital (KKH) has set up a strong Patient Safety and Risk Management Network comprising more than 100 Patient Safety Leads and Champions, mostly from middle level management to promote ground-up involvement. They have unwavering motivation and commitment towards patient safety and inspire fellow staff with their strong patient safety learning culture. They conduct Patient Safety Leads Walk Round, lead and participate in bimonthly sharing of patient safety initiatives. This network promotes cross-learning and collaboration; breaking silos amongst the departments and fosters a strong patient safety ecosystem.
Using this institution network as a best practice, IPSQ reviewed existing engagement process between institutions. IPSQ then started the SingHealth Patient Safety and Quality Improvement Networking Forum (PSQI Forum) – an engagement framework that fosters best practices sharing and opportunities for collaborations for all patient safety and quality professionals especially the middle management leaders. Regular dialogues help to cascade initiatives. The PSQI Forum provides a platform to generate robust sharing that guides strategies, developments and collaborations. This platform also helps to establish rapport and build trust among peers in SingHealth, bolstering the patient safety and quality ecosystem.
Seeding pervasive patient safety culture at all levels
IPSQ facilitates at all levels for organization culture of patient safety. At the top leadership there has to be a clear vision and leaders who walk the talk. Driven together with our corporate communications department, our patient safety vision is “Target Zero Harm”, a safety goal message that is in line with the Hippocratic Oath of “First, do no harm”. It is consistently broadcasted along with our SingHealth’s motto “Patients. At the heart of all we do”. And our academic mission of “improving patients’ lives”. Regular leadership walkabouts, focusing on and promoting patient safety (Leadership Patient Safety Walk Rounds (LPSWR)) are actively conducted and led by the top leadership.
At the middle levels, there should be spaces for champions and leads in patient safety to thrive and blossom. The model of strong Patient Safety and Risk Management Network of KKH is currently being shared at the cluster level as best practice.
On the ground, staff are encouraged and trained to speak up for patient safety. They are actively recognized with patient safety awards for good deeds and “catches” in patient safety. For example, the KKH Patient Safety Award, which is open to all staff, recognizes those who enhance patient safety through specific acts. Staff may raise an alert and be involved in corrective actions when necessary to salvage a situation resulting from a medical error. Patients are regarded as partners of care in patient safety, supported by the setup of a patient safety advocacy group comprising former and current patients and caregivers.
These engagements are embodied in our regular quarterly review of our Patient Safety Engagement Report (PASER), co-owned with our cluster’s Office of Risk Services. PASER provides a regular overview of patient safety indicators and engagement efforts across SingHealth institutions. It aims to strengthen commitment and accountability for patient safety, improvement efforts, as well as identify opportunities for cluster-wide sharing and learning as part of the learning framework within our AMC organizations. There are five categories with 13 various indicators for the current PASER. The five categories are LPSWR, Serious Reportable Events & Reportable Near Misses, Audits, Training Programs and Others (which include patient safety awards and patient safety forum participation as indicators).
PASER is neither aimed at encouraging competition between institutions nor be a tool for punitive actions. Rather, it seeks to identify existing and potential patient safety issues and to facilitate communication and engagement to categorize and resolve these matters at department, institutional or cluster levels. In highlighting problem areas and formulating learning points to address them, PASER also supports the organization’s goal of becoming a learning healthcare system.
Patient safety organizational strategies
Safety Culture has been identified as one of our pillars in cluster strategic map (Figure 2). Through cluster-wide collaboration with strategic partners, IPSQ together with our institutional stakeholders from SingHealth and Duke-NUS have identified early and co-created six strategies to embed a stronger patient safety and innovative quality culture for the AMC. These are: Developing Patient Safety & Quality Competencies, Providing Recognition for Staff in Patient Safety, Quality Improvement and Innovation (PSQI2), Strengthening Psychological Safety, Engaging Patients and Caregivers as Key Partners, Developing a Just Culture, as well as Building Resilience and Preventing Burnout.
A safety culture as a priority of the healthcare cluster strategy map.
One key aspect relates to recognition for staff. IPSQ introduced a PSQI2 Portfolio as one of the optional supplemental components of the SingHealth Duke-NUS Curriculum Vitae that can be reviewed for appraisal of staff. The portfolio enables staff to be able to highlight their PSQI2 activities and accomplishments as part of their career development process. The portfolio has been recognized and approved at the top leadership level of the cluster.
Framework for enhancing capability and capacity of patient safety and quality
IPSQ has developed a suite of programs aimed at upskilling and uplifting the Patient Safety, Quality and Innovation capabilities of staff under its Academic Medicine – Enhancing Performance, Improving Care (AM-EPIC) Framework (Figures 3 and 4). The AM-EPIC Framework is an education and professional development framework that consists of a portfolio of programs in six identified competency domains, namely Patient Safety & Quality, Risk Management, Innovation, Staff Resilience, Patient Centeredness and Advocacy, and Clinical Governance.
Framework for enhancing capability and capacity in patient safety and quality.
Enhancing capability and capacity in patient safety and quality.
The Institute builds capacity and capability in training and education and has currently appointed more than 50 staff as IPSQ faculty members with our train-the-trainers’ programs. These faculty members come from different institutions within the AMC and training backgrounds. They are empowered to pool their resources and expertise together to contribute towards patient safety and quality management in clinical services, research and education. IPSQ is thus able to harness their inherent self-motivation and unleash their talent potential while facilitating their career development process.
In response to the evolving needs of learners in the AMC, IPSQ strives to innovate existing programs and co-create new ones (Figure 5) to achieve effective learning outcomes, for example, a one-day blended learning QI program (incorporating e-learning with local scenarios) was co-developed with inter-professionals from the AMC, where the three-day QI curriculum was revamped to cater to learners with different learning needs.
Innovation and co-creation of programs.
Other program innovations have also been implemented in the pursuit of a common language and a harmonized curriculum. Using the TeamSTEPPS model, IPSQ has co-created with our institutions’ quality departments, a psychological safety program called TeamSPEAK®. TeamSPEAK® is a localized and structured program in strengthening staff’s psychological safety in speaking up for patient safety. The program creates awareness of speaking up for safety and understanding psychological safety, focuses on application of critical language CUS and strategies to build psychological safety and tap our organization memories, narratives and scenarios and also instill common understanding of encouragement to speak up. It propels the strategic journey in establishing a Speak Up Culture through an institutionalized train-the-trainer model, supported by local cases, shared language and blended learning for sustainability. TeamSPEAK® faculty are equipped to develop, teach and evaluate learning outcomes for the AMC. This integrated approach aims to build speaking up for patient safety impactful and sustainable (Figure 6).
Spreading TeamSPEAK® – a structured psychological safety program.
Infection prevention and control collaboration
IPSQ adopts an integrated approach in managing patient safety and quality and encourages interdisciplinary collaborations and coordination among our stakeholders and partners. The Cross Institutional Infection Control (CIIC) Audit Framework was set up to ensure high level of standards in infection prevention and control, and as many as 150 inter-professional CIIC Auditors from the stakeholder institutions have been appointed since 2016.
We standardize our audit parameters and formulation for Hand Hygiene Rate and Environmental Hygiene Index. As part of the efforts to drive the professional development track for the CIIC Auditors, a cluster-wide CIIC audit curriculum and a harmonized platform to capture cross-institution audit data for effective data management and reporting were developed. These CIIC Auditors are recognized and rewarded for their relentless commitment and achievements through the annual CIIC Auditor’s Appreciation event. These efforts have allowed our institutions to reach and maintain very high standards of hand hygiene and environmental hygiene (Figure 7).
Cluster hand hygiene compliance rate.
Root cause analysis to support organizational learning
Enhancing capability by staff to perform root cause analysis (RCA) effectively within our cluster facilitate organizational learning from accidents; IPSQ serves as a domain expert for RCA for serious adverse events and facilitates RCAs that are done within the cluster.
As part of a cluster-wide collaborative approach for enhancing sustainability and capacity, a harmonized RCA workshop was co-created with institutions’ RCA leads which guides common language, process and maintains standards as well as supports effective problem analysis and the design of effective solutions. The lessons from the RCA of the adverse events are distilled out to all the staff as regular IPSQ Patient Safety and Quality Bulletins.
Patient advocacy and engagement
Patient engagement is paramount in building a strong patient safety and innovative quality culture. In collaboration with the Patient Experience Office, IPSQ has set up a networking platform for patients, caregivers and healthcare professionals to share and convey ideas, best practices and healthcare journeys through the SingHealth Patient Advocacy Network (SPAN). SPAN plays an integral role in engaging our patients and caregivers as key partners and providing a safe platform for exchange of insights and learnings with healthcare professionals while working in tandem to achieve a common goal of enhancing patient experience for all.
Since its inception in 2017, SPAN led by two patient advocates who are cancer survivors from our cluster, has completed various impactful patient safety and related activities. These include simple glossary for healthcare team; patient and caregiver educational videos, patients and caregivers as partners video, serving as judging panel for SingHealth Hackathon; serving as members of quality, design and infrastructure project committees to shape design of new buildings and to enhance patient journey, speaking engagement at Quality and Innovation Day 2019 and hosting first SPAN Partners-in-Care Forum to share vision for patient advocacy. SPAN has also initiated the Patient Advocacy Communication Training under IPSQ AM-EPIC Framework, aimed at training effective patient advocates for patient safety and quality care in Singapore and the region.
Patient safety in the wider context – External collaborations
Good culture and system should be shared and spread across and outside the cluster for synergies. At the national level, IPSQ encourages and strongly supports participation by institutions of our cluster in projects of Singapore Healthcare Improvement Network (SHINe). 7 A strategic partnership between Institute for Healthcare Improvement (IHI) and Ministry of Health Singapore launched in November 2012 – SHINe has spearheaded a system-wide quality improvement initiative to enhance patient safety in all public sector healthcare institutions and many private institutions in Singapore. IPSQ shared SHINe’s ethos of “All Teach, All Learn, All Share”.
SHINe’s Large Scale Initiatives (LSI) established in November 2013 aimed to reduce harm by 30% in three years. The IHI faculty were instrumental in assisting the program start off, and within second year of the journey the work has taken on by a group passionate and committed local individuals from across Singapore healthcare sector with a total of seven faculty members from our cluster. SHINe, supported by 42 LSI Teams from 23 institutions in Singapore, has achieved and sustained remarkable successes. The emphasis is on leadership involvement, sustainability and scaling up of best practices. IPSQ helps run SHINe basic workshop on Human Factor on a regular basis.
Beyond national collaborations, our institute collaborates with external partners such as World Health Organization (WHO), Temasek Foundation International-Healthcare Executives in Asia Leadership, International Council of Nurses and agencies/official bodies in other countries, such as Myanmar Ministry of Health and Sports, in advocating for education and professional development in patient safety and quality to improve patient outcomes and deliver safe care, as well as sharing of best practices.
Our institutions had participated in previous WHO’s Global Patient Safety Challenge, for example, surgical safety checklist. 8 IPSQ is currently assisting WHO with the third Global Patient Safety Challenge – Medication Without Harm as part of contribution to global collaboration. IPSQ supports “Global Action on Patient Safety” resolution which was adopted by the 144th Session of the WHO Executive Board on 31 January 2019 and actively support World Patient Safety Day on 17 September, with introduction of safety pledges by staff in our cluster on that inaugural day – 17 September 2019 (Figure 8).
Patient safety advocate pledge.
Conclusion
IPSQ is proactive in integrating cluster-wide efforts in patient safety and quality within the SingHealth Duke-NUS AMC and beyond. Our cluster stood at 64% in the 2017 Patient Safety Index Assessment for Aggregated SingHealth Hospitals and the current aim is to bring that figure up to a higher level of proactive and generative culture.
This article shares the experience of the development of a patient and safety institute in Asia to promote a strong organization culture of patient safety. The key is building a virtuous patient safety and quality ecosystem which requires strong leadership commitment and effective communication. This entails co-creation of organizational strategies and co-development of a professional education framework to enhance capability and capacity for patient safety and quality.