aha
ISSUE 2: March-April 2019
MCI (P) 101/04/2018
Turning challenges into opportunities
Looking beyond tradition to think creatively, leveraging technology and tweaking processes for better patient outcomes
SHINING A LIGHT ON PRESSURE INJURIEs
10
UPCYCLING IT FORWARD
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CHAMPIONING A CHANGE FOR THE BETTER
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ontents
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COVER STORY Turning challenges into opportunities Constant improvement comes from asking the question, “How can we do better?”
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HEALTH HIGHLIGHTS Healthcare news and updates
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WHAT’S UP Community events, outreach efforts, and more
10 SPOTLIGHT Shining a light on pressure injuries Raising awareness of pressure injuries is a wholeof-hospital endeavour
24 5 THINGS ABOUT… Advance Care Planning Have you done your ACP? Here are five reasons why it matters 26 LIVE WELL CHAMPioning a change for the better Mr Tan Keng Boon went from indifferent diabetic to advocate and exemplar of CHAMP
14 EVERYDAY HEROES Upcycling it forward Many small acts of generosity add up to a lot and ensure comfort at the end of life 23 DAILY DOSE The DESMM Way The five pillars of living well with diabetes
THE KAIZEN SERIES 2 |
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In the last two issues, we have explored how Yishun Health’s culture of constant improvement and continuous refinements (kaizen) informs the way we design and enhance the way we work as an organisation. In the final instalment of the kaizen series, we highlight how this drives constructive and incremental improvements in patient care and safety.
PUBLISHER Yishun Health is a network of medical institutions and health facilities in the north of Singapore under the National Healthcare Group. It comprises Admiralty Medical Centre, Khoo Teck Puat Hospital and Yishun Community Hospital. It also Rechincludes community extensions such as arge Rest & Wellness Kampung. Recreatio (energy
in)
n
28 28 MAKAN TIME Bircher Muesli The fibre- and flavourfilled breakfast you can make in advance 30 MIND & HEALTH #RechargeMyJoy Like batteries, we need to physically and mentally recharge too!
EDITORIAL TEAM Deplete (energy
out)
Daily Deman ds
Hannah Wong Sabrina Ng Sharon Ng Albert Foo
EDITORIAL COMMITTEE
The editorial committee — made up of clinical, nursing, allied health, population health & community transformation, and administrative heads of department — advises aha’s direction. A/Prof Tan Kok Yang Angeline Tang Bastari Irwan Chia Kwee Lee Fatimah Moideen Kutty Shirley Heng
ktph.com.sg/aha aha@ktph.com.sg
PUBLISHING AGENT THINKFARM PTE LTD www.thinkfarm.sg
aha
ISSUE 2: March-April 2019
M A N AG I N G D I R E C T O R
Christopher Tay
E D I TO R I A L D I R E C TO R
Chua Kim Beng
C O N T R I B U T I N G E D I TO R
Sheralyn Tay
MCI (P) 101/04/2018
Turning challenges into opportunities
Looking beyond tradition to think creatively, leveraging technology and tweaking processes for better patient outcomes
SHINING A LIGHT ON PRESSURE INJURIEs
10
UPCYCLING IT FORWARD
14
CHAMPIONING A CHANGE FOR THE BETTER
E D I TO R
Dang Hui Ling
26
W
hy aha? The name aha holds much significance for us at Yishun Health. In part, it is a nod to our beginnings at Alexandra Hospital; it also stands for ‘Advocates for Health in Action’. Through these pages, we hope to empower you to take charge of your own health and discover those ‘aha!’ moments that lead to a healthier, happier you.
A R T D I R E C TO R
Regina Wong DESIGNER
Melissa Poon S E N I O R M A N AG E R , C L I E N T R E L AT I O N S H I P
Jessie Kek
C O N T R I B U TO R S
Eddie Teo, Justin Loh, Lily Lee aha is the official bi-monthly publication of Khoo Teck Puat Hospital (Co. Reg. No. 200717564H) and is produced by ThinkFarm Pte Ltd. All rights to this publication are reserved and no part may be reproduced without the expressed written consent of the publishers. While every effort has been made to ensure that the information in this newsletter is accurate and up to date, the editorial team will not be responsible for errors due to information received. Opinions expressed are that of the writers and do not necessarily represent the views and opinions of the publishers. Printed by Mainland Press Pte Ltd. MCI (P) 101/04/2018
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ealth Highlights
Budget 2019: Healthcare Roundup A range of healthcare subsidies will be introduced as part of the newly announced Merdeka Generation Package (MGP), which will benefit some 500,000 Singaporeans born in the 1950s.
T
he MGP aims to lower healthcare costs for Singaporeans and keep them active and healthy. Eligible seniors will be notified by April 2019, and will receive Merdeka Generation cards from June 2019. Here is what eligible Singaporeans can expect:
PAssion Silver card top-up A top-up of $100 to the PAssion Silver card can be used to pay for activities and facilities at community clubs, entry to public swimming pools, public transport, and more.
MediSave top-up From this year, eligible Merdeka Generation seniors will get a topup of $200 every year for five years to their MediSave accounts.
Additional MediShield Life premium subsidies for life Subsidies for seniors will start from 5% of MediShield Life premiums and increase to 10% after they reach the age of 75, an amount ranging from $31.50 to $918.
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CareShield Life participation incentive Seniors who join CareShield Life will get an extra $1,500 on top of the previously announced $2,500 when the scheme becomes available for existing cohorts in 2021.
Special Community Health Assist Scheme (CHAS) subsidies for life All Merdeka Generation seniors will receive CHAS subsidies regardless of income for common illnesses, chronic conditions, and dental procedures. In addition, there will be an additional 25% off subsidised bills at polyclinics and public specialist outpatient clinics.
hat’s Up
Recognition for Training Excellence K
hoo Teck Puat Hospital (KTPH) hosted the National University of Singapore Yong Loo Lin School of Medicine (NUSMed) Dean’s Appreciation Awards on 20 November 2018. The event honoured National Healthcare Group (NHG) physicians, medical faculty, junior doctors, and departments who demonstrated training excellence and mentorship to NUSMed undergraduates. Some 49 awards were presented in all. Yishun Health’s Department of Anaesthesia received the Clinical Training Excellence Awards. Three Yishun Health clinicians — Dr Anoop Thomas, Senior Staff Physician, and A/Prof Yip Chee Chew, Head
and Senior Consultant, both from Ophthalmology & Visual Sciences; and Dr Surej John, Consultant, Psychological Medicine — also received teaching excellence awards. A/Prof Chong Yap Seng, Senior Consultant, Department of Obstetrics & Gynaecology, National University Hospital, addressed the audience for the first time in his capacity as Dean of NUSMed. He thanked the faculty for their efforts in maintaining high levels of training and mentorship. This recognition underscores Yishun Health’s commitment to training and developing a new generation of medical professionals with high levels of clinical skill and a patientcentred ethos.
Senior Consultant Dr Lim Kim Seong (right) accepted the award on behalf of the Department of Anaesthesia
Receiving their awards from A/Prof Chong are (from left) Dr Anoop Thomas, A/Prof Yip Chee Chew and Dr Surej John
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hat’s Up
Better Support for Inpatient Dialysis T
Dr Lim Eng Kuang (seventh from left), Division Head of Renal Medicine, and the rest of his team hosted Yishun Health CEO Mrs Chew Kwee Tiang (fifth from left) during her visit to the newly opened Renal Centre
he new Renal Centre was officially opened on 21 January 2019 at KTPH Clinic B45. It will play a critical role in supporting and providing dialysis treatment during a patient’s inpatient stay, providing both haemodialysis (HD) and peritoneal dialysis (PD). The new Centre will be able to accommodate more patients, with two isolation rooms, 11 HD stations, and seven PD stations. The expanded facilities will enable the Renal Centre to carry out 26 HD treatments daily, a 30% increase.
Learn More About Occupational Therapy Y
ishun Health’s Occupational Therapists from Rehab Services set up an educational exhibition at the KTPH Main Lobby on 24 January 2019. The exhibition served to raise awareness about Occupational Therapy, and how it benefits patients and improves lives. Informative posters and engaging activity booths showcased the importance of leading a healthy and active life through meaningful day-to-day activities. These engaging interactions took the form of horticulture, Wii-Kinect, and art and crafts to highlight the importance of physical, cognitive and social activities. Passers-by and staff learnt what Occupational Therapists are trained to do: helping people develop, recover and maintain a meaningful life. This includes education,
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modifying the environment, and using tools and technologies to help
patients adapt and retrain their abilities.
Yishun Health’s Occupational Therapists came together to organise interactive and engaging activities for patients and the public
A Green Way of Life G
oing green has long been part of the Yishun Health ethos. In a nod to this, the first Green Conference was held on 18 January 2019. Organised by Yishun Health’s Green Committee, the conference served as a platform to exchange best practices and establish stronger partnerships to promote environmental sustainability within the healthcare sector. Mrs Chew Kwee Tiang, CEO, Yishun Health, who gave the opening speech, noted how Yishun Health has encouraged and maintained a sustainable environment over the years, and acknowledged the good work done by staff since 2010. Guest speakers touched on topics such as biophillic architecture, energy audit, and food waste reduction. For instance, Mr Jerry Ong, Vice President, CPG Architects (left), and Dr Nirmal Kishnani,
Tokens of appreciation were presented to Yishun Health’s Food & Beverage partners who took part in the No Plastic Straw movement
Associate Professor, Design & Environment, NUS — both of whom played a part in the building of KTPH — shared the green principles that went into the design process.
Cancer Patients are Never Alone O
n 27 January 2019, Yishun Health joined Nee Soon GRC at the launch of Never Alone, Singapore’s first constituency-based cancer support and awareness movement. It builds a network of
support and sees residents who are cancer survivors befriending and supporting neighbours going through a similar journey. All five Members of Parliament for Nee Soon GRC attended the event.
The event was attended by staff, service partners and suppliers, nursing homes, and healthcare partners from other institutions.
LEFT: Yishun Health nurses and dietitians set up booths to educate the public on cancer examination procedures, and the importance of healthy eating RIGHT: Doctors from Yishun Health’s General Surgery department (from left) — Dr Sim Hsien Lin, Dr Jerry Goo, Dr Tan Ming Yuan and Dr Tan Bo Chuan — addressed cancerrelated issues
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hat’s Up
Graduates with their GeriCare certificates and collar badges
Y
ishun Health conferred 56 GeriCare certificates to healthcare workers from our nursing home partners on 29 January 2019. Guest-of-Honour Ms Shirley Heng, Chief Nurse, Yishun Health, opened the GeriCare Graduation Ceremony at the KTPH Auditorium. At the joyous and meaningful event, she acknowledged the hard work and
Upskilling Nursing Home Partners tenacity of the graduating cohort, each of whom had shown dedication to the rigorous curriculum. Funded by the Ministry of Health, GeriCare@North upgrades the nursing skills of healthcare workers across eight nursing homes. The aim is to minimise hospital admissions and emergency transfers from nursing homes to hospitals.
Together with other nursing leaders, the programme is led by Dr James Low and Dr Laurence Tan, GeriCare’s Programme Director and Deputy Programme Director respectively. The nurses were provided preceptorship through a Telegeriatrics Nurse Training Course and the Advanced Palliative Care Course for Long-Term Care.
Living and Loving with ADHD O
n 25 January 2019, Yishun Health organised a talk for caregivers of children with Attention Deficit Hyperactivity Disorder (ADHD) so that they can be better equipped to manage and meet the needs of their charges, and improve parent-child communication. Dr Goh Kah Hong, Head and
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Consultant, Psychological Medicine, spoke about the effect of ADHD on a child, while Dr Chan Keen Loong, Senior Consultant, Psychological Medicine, and THRIVE Director, shared strategies for parents to communicate better with their ADHDstricken children. The session closed with a Q&A segment.
Dr Goh and Dr Chan (pictured) used case studies to illustrate behaviour patterns of children with ADHD, and shared strategies for better communication and management of the condition
TOP: Residents showcased the meaning of ‘community’ and the beauty and creativity that can arise from coming together to be active in body, mind and spirit BOTTOM: Prof Philip Choo sharing his thoughts with the audience during the panel discussion
Our Community of Care Y
ishun Health held its annual Regional Health System (RHS) Chinese New Year Lohei & Forum on 21 February 2019, during which Dr Wong Sweet Fun, Clinical Director, Population Health & Community Transformation (PHCT), recapped highlights of the past year. These included an enhanced community nursing programme, Self-Managed Autonomous Regional Teams, and the appointment of new PHCT nursing leadership: Ms Low Beng Hoi, Director of Nursing, and Ng Huoy Ling, Nurse Manager. She also highlighted the impact of teamwork in its outreach efforts and impact.
Two guest speakers were invited to share their perspectives on building enabled communities. Mr Cormac Russell, European Director, AssetBased Community Development (ABCD) Institute, shared that health is not a medical issue; rather, it is a social issue related to community resources. Dr Jean-Louis Lamboray, Co-Founder, The Constellation, talked about the importance of ‘doing nothing’, a challenge underscored by his own personal experience. When his 95-year-old father was discharged from hospital after a fall, it was difficult to refrain from stepping in to help with the dishes. But Dr Lamboray shared
that ‘doing nothing’ is sometimes critical in order to mobilise and strengthen the community. Dr Christina Tiong, CEO, Home Nursing Foundation, and Prof Phillip Choo, GCEO, NHG, joined the speakers to wrap up the forum with a panel session moderated by Dr Caroline Lim, author of the book, Building Enabled Communities. This spirit of camaraderie was then celebrated with a fun lo hei toss and lunch. Event participants also visited booths set up by Wellness Kampungs residents, who sold calligraphy pieces, handmade legacy blankets, bags, and sock toys.
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potlight
Dr Dawn Cen (left, Resident Physician, Orthopaedic Surgery), a member of the Pressure Injury Workgroup, with Roslind Leong (Staff Nurse), who takes on the role of Pressure Injury Audit Nurse for Ward B86
Shining a light on pressure injuries The result of intense or prolonged pressure on a localised area of skin, pressure injuries are sometimes overlooked. But a Yishun Health Workgroup is ensuring that pressure injury prevention and management becomes a standard component of overall care plans. 10 |
LEFT TO RIGHT: Dr Wishva Panagoda Kalinga (Resident Physician, Geriatric Medicine), Blesilda Ongsing Ramos (Principal Respiratory Therapist, Respiratory Therapy Services), and Mary Chan (Nurse Manager, Ward A52), who is Deputy Chairman for the Workgroup
THE KAIZEN SERIES PART 3 OF 3
W
hen it comes to bed sores or ulcers, there is a misconception that they only happen to those who are bedridden, and that the problem is largely unavoidable. However, there has been a shift in this thinking; research now shows that more can be done. As Dr Mansha Khemlani, Senior Consultant, Geriatric Medicine, KTPH, explains, even the terminology has evolved: ‘pressure injury’ is now recognised as a more accurate term. “Pressure injuries do not just develop in bedridden patients; hence, they are no longer referred to as bed sores. Before they even progress to ulcers, pressure injuries begin as non-blanchable redness; as such, the term ‘pressure ulcer’ has fallen out of favour,” she clarifies. Dr Mansha heads Yishun Health’s Pressure Injury Workgroup, which comprises doctors, nurses, physiotherapists, occupational therapists, podiatrists, dietitians, and respiratory therapists. Their goal is to raise awareness of the problem, train their peers in prevention and management, and equip caregivers with
the same skills. The workgroup was formed in May 2016 in response to a small but growing problem of pressure injuries. With an ageing population and rise in chronic diseases such as diabetes, cardiovascular disease, and stroke, pressure injuries have become more common. Recognising the problem and believing that steps had to be taken, Dr Mansha, a specialist in palliative care, took up the challenge.
LOOK AT THE WHOLE PICTURE Dr Mansha shares that disease management is more than tending to organ-specific problems. Comfort, quality of life, and other factors matter too. “The skin is the largest organ in the body. So even as we treat the heart, lungs or other organs, we must also consider the health of the skin,” she stresses. Pressure injuries are also not bound to a specific age group or disease, she adds, and should be taken into consideration, regardless of medical specialty. For nurses, professional training programmes keep them updated on the newest approaches to the management of pressure injuries, dressings, and medications. “We also look at various literature to standardise guidelines and update protocols according to the evidence,” says Dr Mansha. They hope to incorporate these into an e-learning module complemented by a hands-on component. Nurses also gave their input on how to improve clinical documentation to monitor pressure injuries, such as by using images instead of subjective descriptions. “This allows for better continuity of care, and a more accurate assessment of the state of the wound,” explains Dr Mansha. In addition to training for nurses, the workgroup raised awareness of the issue to doctors from the departments of General Medicine, Geriatric Medicine, and Surgery. This education of doctors is an important component of the work, reveals Dr Mansha, as pressure injuries go beyond nursing. “Historically, pressure injury prevention and management come under nursing. However, the practice of medicine has evolved to team-based care. Doctors also play a very important role because we make the decisions about devices to use, and these can potentially increase the risk of pressure injuries.” Subsequently, some less-known causes of pressure injuries began to be highlighted. For instance, one of the more unexpected causes are medical devices. “While these are needed for patient management and monitoring purposes, they can be a cause of pressure injury. This is a relatively new area in pressure injury management.
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potlight
LEFT TO RIGHT: Annuradhaa Ravi (Senior Physiotherapist, Rehab Services), Tang Qian Ci (Senior Occupational Therapist, Rehab Services), Yu Lee Hoon (Senior Nurse Clinician, Ward A62), and Ng Jia Lin (Senior Podiatrist, Podiatry)
LEFT TO RIGHT: Chen Yanyan (Nurse Clinician, ICU), Zheng De Xin (Nurse Clinician, Ward B66), and Magan Ho (Dietitian, Nutrition & Dietetics)
As doctors, we need to be aware that the devices we prescribe can have unintended consequences,” advises Dr Mansha. For example, oxygen masks can lead to pressure injuries behind the ears, while casts for broken bones can result in pressure injuries in diabetics, who are at risk of poor wound healing and sensory loss. Building awareness of the role they can play, she adds, doctors can help facilitate pressure injury measures and ensure that practices are in place by understanding some of the obstacles. “Nurses may not be able to turn a patient every two hours as prescribed because of pain, or someone with dementia may be confused and uncooperative. As doctors, being aware of the situation on the ground will help us better understand what we can do to support these practices,” advises Dr Mansha.
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POSITIVE PEER PRESSURE Over the last two years, the workgroup has garnered the buy-in and support of both colleagues and management. “Though it involves a lot of work, the workgroup finds it rewarding because it improves care and patients’ lives,” Dr Mansha reflects. As doctors, the duty of care goes beyond being disease specialists to being holistic healers, so she is heartened to see her colleagues come together to discuss and find solutions for problems, balancing sometimes competing goals. One example is the issue of casts among staff from the departments of Orthopaedics and Emergency Medicine. Simply being aware of the problem ensures that these patients are more closely monitored so that treatment times can be adjusted accordingly.
THE KAIZEN SERIES PART 3 OF 3
Underscoring the need for greater awareness, the workgroup has also held public education events each year to drive the message of pressure injury prevention to the community at large. In 2018, this took the form of two events. The first was the Pressure Injury Awareness Day at Kampung Admiralty, organised to educate and empower the public, especially caregivers, to spot signs of pressure injury and how to prevent them. Caregivers were invited to attend a public exhibition of informative health booths as well as a training session, where they were taught to use a sliding sheet and a wedge pillow. The second event was an in-depth training session for staff and community partners. Community health partners were invited to the STOP Pressure Injury seminar, which included four plenary sessions and three skills workshops. “Pressure injury is a common challenge for nursing homes,” notes Dr Mansha, “The seminar was aimed at bolstering the proficiency of our healthcare workers, particularly in the community care sector.” This work in raising awareness of pressure injuries has taken off, as seen in the growing rates of reporting. “More cases are being reported, including from the clinics and operating theatres, which was previously unheard of, suggesting a greater level of awareness,” asserts Dr Mansha. “All this is encouraging because it shows people are aware of the problem, are identifying and reporting it, which then allows us to actually do something about it.”
WHAT ARE PRESSURE INJURIES? A pressure injury is localised damage to the skin and the soft tissue under it. It usually occurs over a bony area or underneath a medical or other device. The injury occurs when there is intense and/ or prolonged pressure, or when this is combined with shear and friction. In its early stages, the skin appears red; in severe cases, open ulcers can develop. The risk and severity of pressure injuries may be increased if there are medical conditions such as diabetes, poor blood circulation, and by factors such as diet and age. Common pressure points on the body include the back of head and ears, shoulders, elbows, lower back and buttocks, hips, inner knees and heels.
LEFT TO RIGHT: Cheng Min (Executive, Clinical Quality, Clinical Services), Dr Mansha Khemlani, Mdm Yiap Pok Ling and Ms Velusamy Poomkothammal (Deputy Directors, Nursing), Chin Guey Fong (Senior Nurse Clinician, Inpatient Wards) and Meliza Lim (Nurse Clinican, Ward B56). Guey Fong and Meliza support the Pressure Injury Workgroup in the area of Nursing Quality
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veryday Heroes
Upcycling it forward While the end of life can be a dark and sorrowful time for patients and their families, small yet thoughtful gestures, good-hearted generosity, and a spirit of giving can give comfort to others and underscore the impact of paying it forward.
Edmund Lee and Nurse Clinician Sim Lai Kiow in their equipment storeroom
F
or the last 14 years, Nurse Clinician Sim Lai Kiow has worked with palliative patients, tending to their comfort and ensuring their dignity at the end of life. Wherever possible, she supports patients in their wish to spend their last days in the familiarity of their own homes. Apart from empowering caregivers with the confidence and skills to care for their loved ones, Lai Kiow also assesses the need for medical equipment, 14 |
such as adjustable beds, oxygen concentrators, and suction pumps. “These not only help the patient, but caregivers, too,� she points out. Beyond offering more comfort and dignity to patients at the end of life, the equipment goes a long way to support the caregiver and make it easier for them to carry out their caregiving duties. In some cases, appreciative families offer to donate medical equipment after their loved ones have passed on. At the same time,
some families cannot afford to buy or rent these items, while others do not qualify for subsidies to purchase them. Noticing these unmet needs, she started her own mini-programme to match equipment donors to those in need. For many years, she would request that patients’ families hold on to the equipment in their own homes while she looked for people who needed them and organised the transfer. Most families were willing to do so despite the inconvenience.
“Having the items lying around can be a painful reminder of their loss,” she says. In 2016, Lai Kiow decided to ask for help to continue operating her initiative, known today as Recycling Medical Equipment for End-of-Life Patients. With the support of former CEO Mr Liak Teng Lit and Yishun Health’s ABLE Studio, a basement storage space in Yishun Community Hospital (YCH) was set aside for her use, while the ABLE Studio offered logistical support. Edmund Lee, an Executive with ABLE Studio, explains that while Lai Kiow and her palliative care nurses identify patient donors and suitable needy recipients, his team acts as storekeepers and coordinators. The ABLE Studio keeps inventory, and maintains and cleans the equipment to ensure that they are fit for use. They also arrange for the logistics of receiving donated equipment, delivering them to patients, then collecting them when they are no longer needed. All this is done over and above their daily work of manning the retail store, fulfilling online orders, and administering the
All these contributions add up to a lot. It makes a big difference to help someone spend their last days at home, where it is more comfortable and familiar. SIM LAI KIOW NURSE CLINICIAN, KTPH paperwork for the various funding schemes. Despite this extra work, the effort is worthwhile, and Edmund sees it as a Corporate Social Responsibility project that benefits those in need. He reveals that some palliative care patients do not meet the criteria for funds, such as the Senior Mobility Fund (SMF). “The SMF is actually more for ageing-in-place and not meant for end-of-life care,” he
explains. “To qualify, beneficiaries must have a prognosis of more than three months, which is sadly not the case for this group.” And not everyone can afford the range of equipment, such as hospital bed, air mattress, oxygen concentrator, suction pump, wheelchair, commode, and more. “Families who come forward to donate these items have made a difference in helping some 100 patients and families in need over the last two years,” says Lai Kiow. Their donation is especially altruistic as, in most cases, donors willingly foot the transport bill in order to send the equipment to YCH. Supporting these efforts are three delivery partners — small business owners — who offer an affordable transport fee. She hopes to grow the initiative, such as through the donation of medical consumables (adult diapers, milk feeds, etc) to needy residents in nursing homes, and finding funds for more specialised servicing of equipment. “All these contributions add up to a lot. It makes a big difference to help someone spend their last days at home, where it is more comfortable and familiar,” shares Lai Kiow.
WANT TO CONTRIBUTE?
The ABLE Studio combines a retail pharmacy with space to display and demonstrate equipment for geriatric and rehabilitation care. Call 6602 2253 if you can contribute:
Lai Kiow and Edmund with their team: (from left) Daniel Sii (Staff Nurse), Saw Aung Thurak (Senior Pharmacy Assistant), and Hazeena Banu bte Shaik Alaudeen (Senior Staff Nurse)
Equipment: hospital beds, air mattresses, oxygen concentrators, suction pumps, wheelchairs, commodes Services: transportation, specialised repair skills for oxygen pumps, etc.
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Cover Story LEFT TO RIGHT: A/Prof Reyaz Moiz Singaporewalla (Senior Consultant, General Surgery), Ms Velusamy Poomkothammal (Deputy Director, Nursing), Guo Hui (Senior Nurse Manager, Inpatient Wards) and Dr Anil Dinkar Rao (Consultant, General Surgery) were part of the team that implemented the electronic-based protocol for calcium management
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THE KAIZEN SERIES PART 3 OF 3
Turning challenges into opportunities for better healthcare In the demanding healthcare sector, challenging the status quo is never easy. At Yishun Health, the engine of constant improvement is driven by a willingness to look beyond tradition, think creatively, leverage technology, and tweak workflow to enhance patient care.
H
ow can we do better? This is the unspoken question that underpins the culture of constant improvement. It is a form of positive discontent, a constructive aspect of dissatisfaction that inspires people to go beyond the complacency of ‘this is the way things have always been
done’. It is this mindset that motivates Yishun Health as an organisation and inspires its various safety, quality, and patient care initiatives. Often, such projects go beyond the core duties of staff, and require additional hours and effort to conceptualise, plan, test and deploy. It also means working around
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Cover Story
LEFT TO RIGHT: Dr Ester Yeoh, Dr Adeline Wee (Principal Clinical Pharmacist, Pharmacy), Buencamino Nastasha Duenas (Senior Staff Nurse, Ward B96), Chin Guey Fong (Senior Nurse Clinician, Inpatient Wards), Yu Yu Naing (Senior Executive, Clinical Services), and Sangeetha d/o Sodimani (Nurse Clinician, Ward B86) are part of a team of 12 that oversees inpatient diabetes management
established protocols and the needs of multiple stakeholders. But buoyed by the belief in patient-centred care, these endeavours — however complex and challenging — form an integral part of what it means to provide high-quality, affordable and hassle-free healthcare with science, love and wisdom. Take the issue of managing patients with diabetes. Dr Ester Yeoh, Consultant, Diabetes Centre, AdMC, and General Medicine, KTPH, points out that when patients with diabetes are hospitalised, there is a higher risk of fluctuations in blood sugar levels. In particular, hypoglycaemia (low blood sugar) can lead to longer hospital stays and an increased risk of death. “Hypoglycaemia is a common problem in hospitalised people with diabetes, particularly those who are frail, elderly, severely
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ill or have kidney impairment,” she reveals. This is because illness, changes in diet and appetite, as well as the timing of medication and meals, can lead to these fluctuations.
GETTING EVERYONE IN SYNC A team at KTPH led by Dr Yeoh — comprising doctors, pharmacists, nurse clinicians, and nurses, and supported by Clinical Services — was formed to reduce inpatient hypoglycaemia. This team, in line with the Singapore Healthcare Improvement Network (SHINe) Medication Safety Workgroup, aims to improve overall patient safety. Dr Yeoh says that the goal was to achieve a 30% reduction in hypoglycaemia among inpatients, particularly in preventable cases. Approximately three in 10 people
Certain diabetes medications must be given close to meal times, and if food delivery or medication rounds are delayed or out of sync, it can increase the risk of a hypoglycaemia event. DR ESTER YEOH CONSULTANT, DIABETES CENTRE, ADMC GENERAL MEDICINE, KTPH
THE KAIZEN SERIES PART 3 OF 3
who are hospitalised at Yishun Health have diabetes, she notes — not an inconsequential number. One of the first steps the team took was a hospital-wide education programme, including an e-learning module, to bridge knowledge gaps and ensure that all nurses and doctors, regardless of specialty, were familiar with inpatient diabetes management. Guidelines were put in place so that doctors and nurses can better adjust diabetes medications if patients needed to fast for certain procedures or scans, or transitioned to tube feeding. Meal intake charting was also improved to make it easier to assess how much a patient had eaten, and thereby assess the need to adjust diabetes medications. There were also road shows targeted at clinical staff, and pamphlets to educate patients and caregivers on how to recognise hypoglycaemia symptoms. “Selfmanagement is an important part of our mission of care; we ensure as much as possible that patients are actively involved in the management of their own disease,” Dr Yeoh says.
was easier said than done, as the Food Services department prepares and serves almost 3,000 meals a day. Nevertheless, the committed team there worked closely with the clinical team to develop a better coding system and process to match meal times to insulin administration. Today, food trays of patients who are on insulin are clearly labelled so that nurses can prioritise their delivery. “We use a colour coding system to clearly identify the type of insulin, and therefore how closely meals had to be taken in conjunction with it,” Dr Yeoh elaborates. Green labels indicate long-acting medications, while meals with red labels must be given in a timelier manner to patients. Piloted in 2014 in two wards in the surgical units, the project was slowly expanded to 11 wards, and will now be implemented hospital-wide. In the general and renal wards, there has been a decrease in hypoglycaemic events, notes Dr Yeoh, stressing the
need for continued vigilance and refinements to improve outcomes. “Clinical staff are more aware of processes to reduce hypoglycaemia, and are more empowered to speak up when concerned about patients with impending hypoglycaemia,” she adds.
TRANSDISCIPLINARY TEAMWORK Many improvement projects span medical disciplines and bring in expertise beyond the clinical. They require creativity, compassion and courage to step outside the norm. These take many forms, from redesigning processes and devices (see sidebar) to forming multidisciplinary task forces. One example of the latter is the Pressure Injury Workgroup, a hospital-wide effort to address, prevent and manage this underreported issue (turn to page 10 to read more about this). Another clinical initiative that illustrates the synergies that
MATCHING MEALS WITH MEDICATIONS One of the most important process improvements was the delivery of meals. “Certain diabetes medications must be given close to meal times, and if food delivery or medication rounds are delayed or out of sync, it can increase the risk of a hypoglycaemia event,” Dr Yeoh highlights. This meant roping in Yishun Health’s Food Services department. “They had an integral role to play and were actively involved in coming up with solutions to better synchronise the delivery of meals with the serving of medications,” she emphasises. This
Meals for patients on insulin are clearly labelled on the meal slip and placed on the top trays of the food trolley for prioritisation upon delivery to the wards
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Cover Story Knowing that her work makes life better for patients even after they have been discharged motivates her to continue tinkering with new gadgets and inventions. The Angie Cargo Pants (pictured below) comes with a special pocket to contain and conceal urine bags for those on an indwelling urinary catheter drainage. The Angie Headband keeps nasogastric intubation and feeding tubes (or NG tubes) neatly tucked out of sight along the hairline. After prototyping many versions of varying material and design, this is the final product (Hai Moy is holding one in the photo). The Angie NG Feeding Set brings added convenience to caregivers, putting together all the necessary tools needed to facilitate NG-tube feeding in a compact box.
NURSES: THE HEART OF INNOVATION
Working on the ground and close to patients, nurses are not only the backbone of patient care, but are also the ‘eyes’ and ‘ears’ on the ground. Attuned to patient needs, challenges, and the complexities and inconveniences they experience, nurses play an important role in driving many healthcare innovations. Their empathy and insights have been translated into many practical and important improvements. Advance Practice Nurse Toh Hai Moy (above) is a 40-year nursing veteran. Apart from improving the lives of patients through her nursing expertise, the prolific inventor has
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come up with a range of everyday devices and improvements that enhance patient comfort and quality of life. Known as Angie inventions — from a nickname that a patient once gave her — each piece is a response to an inconvenience that patients often encounter. Hai Moy tells a heartwarming story about the Angie Cargo Pants. “Many patients are embarrassed to go out because of the unsightly urine collection bag, so they tend to stay at home more, and that’s not good for their mental and physical health,” she recalls. “One elderly gentleman was so overjoyed when he bought the pants because he was no longer self-conscious about his catheter and was able to visit friends and relatives over the Chinese New Year.”
The Angie Potty, a urine measurement and specimen gadget, is a modification of the traditional ‘witches hat’ version, making it more sturdy, compact and easy to wash and sanitise. The receptacle can be lowered directly into the toilet bowl for ease of use and washed using the flush. It has clear markings for ease of reading and is made of durable plastic.
The full range of Angie products can be purchased at the ABLE Studio of KTPH and YCH.
THE KAIZEN SERIES PART 3 OF 3
It makes sure that all the right tests are done, in the right order and at the right time — a more streamlined and fool-proof process. This makes calcium management and replacement seamless, accessible and safer. A/PROF REYAZ MOIZ SINGAPOREWALLA SENIOR CONSULTANT, GENERAL SURGERY
arise from the coming together of multiple stakeholders is a new electronic-based protocol for calcium management after thyroid surgery. This improvement came about in early 2017 in a bid to reduce preventable errors, automate the calcium replacement protocol, and shorten the length of hospital stay. According to A/Prof Reyaz Moiz Singaporewalla, Senior Consultant, who spearheaded the project, it is also in line with the move towards a paperless work environment. A/Prof Reyaz, who runs the Endocrine Surgical Service within the Department of Surgery, specialises in minimally invasive general and endocrine surgery, such as the removal of the thyroid, parathyroid or adrenal glands. He explains that, after surgery to remove the thyroid and/or parathyroid glands, some patients may experience hypocalcaemia (low calcium levels). This is because these organs help the body regulate calcium levels. Hypocalcaemia can lead to muscle spasms, affecting the nerves and organs, leading to complications and longer hospital stays. As such, close monitoring of calcium levels is crucial after thyroid surgery. “More than 90% of patients require a standardised post-operative protocol that includes tracking their ionised calcium levels and calcium replacement therapy where needed,” A/Prof Reyaz shares.
DIGITISING FOR SAFETY To ensure greater consistency and continuity of care, as well as reduce the likelihood of human error, A/Prof Reyaz decided to digitise the process. Compared to the paperbased form in the operation notes, implementing the protocol in the
computerised case management system ensures that no steps are missed out. “It makes sure that all the right tests are done, in the right order, and at the right time — a more streamlined and fool-proof process. This makes calcium management and replacement seamless, accessible and safer,” he adds. Building on the idea, A/Prof Reyaz and his colleagues took the opportunity to refine some aspects of the protocol, which had been in place since 2011. Working with endocrinologists and pharmacists, they developed the clinical parameters and criteria for calcium monitoring and calcium replacement, including additional steps for safety. This included the need for an electrocardiogram prior to starting calcium infusion. Nurses also gave their input, redesigning workflow to make the protocol easy to deploy on the ground. The Clinical Informatics department then took all these inputs and converted them into a digital protocol within the case management system. “With the doses and processes all embedded in the system, we have greatly reduced errors and enhanced patient safety,” assures A/Prof Reyaz. Traditionally, patients in general hospitals in Singapore are warded for two to three days after total thyroidectomy (surgery to remove the thyroid gland) so as to monitor for symptoms of hypocalcaemia. “An audit of our service results showed that, in many cases, this was not needed and led to unnecessary occupation of acute hospital beds. We therefore prepared a paper protocol for calcium monitoring after total thyroidectomy, allowing us to discharge patients the very next
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Cover Story
morning if the discharge criteria were met,� he says. Now digitalised and incorporated into the hospital case management system, the protocol can be used across surgical and medical specialties to reduce human error. Since the project was implemented in July 2017, human errors from ordering the wrong blood tests, incorrect calcium dosage, and delays in implementing replacement have reduced from 20% in 2016 to zero. Reflecting on the effort taken to 22 |
develop this initiative, A/Prof Reyaz asserts that it underscores the commitment of all team members to come together and work beyond their core day-to-day functions to put patient safety first. These examples highlight not only the effort that goes into improving care, but also the teamwork involved when going the extra mile. It is testament to the spirit of collaboration and the integrated model that underpins Yishun Health’s patient-centric delivery of care.
With the doses and processes all embedded in the system, we have greatly reduced errors and enhanced patient safety. A/PROF REYAZ MOIZ SINGAPOREWALLA
aily Dose
The DESMM Way to Manage Diabetes
The DESMM method encompasses five pillars that cover key areas of diabetes management. With its focus on patient-centred care, Yishun Health advocates that people with diabetes be taught this method so that they can actively participate in their own daily care. DIET
D
Follow the My Healthy Plate plan: choose whole grains, lean meat, and fruits and vegetables for your meals. Keep to a diet that will maintain a healthy weight. Drink water whenever possible.
E EXERCISE Keep FITT: increase your physical activity by gradually increasing its Frequency, Intensity, Time and Type of activity. Such types of activity include cardio, resistance, and flexibility.
MEDICATION
Diet illustration: Health Promotion Board
Know your medicines to make them work better for you. Take them regularly as instructed, and let your doctor know if you don’t feel well after taking the medicines.
M
SUPPORT & STRESSORS
MONITORING
Commit to self-care — monitor blood glucose, blood pressure, weight, and skin (feet) hygiene. Keep them healthy. Visit your doctor regularly to check HbA1c (average blood glucose level over 2–3 months), eyes, feet, kidneys and cardiovascular health.
M
S
Stressors such as infections, emotional or mental stress, or lack of sleep can affect diabetes control. Seek help if you are unwell. Gather support from people around you, be it at home, at work, or in the community.
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Things About...
5 Things About Advance Care Planning
Advance Care Planning (ACP) is the act of thinking about, talking about, and documenting what matters to you and your treatment preferences when it comes to your own healthcare. Here are five reasons why ACP matters.
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A
dvance Care Planning is the act of discussing what is important to you in life, and hence what would be meaningful care for you as you age, become ill, deteriorate and approach the end of life. Here are five things you should know about ACP.
1
ACP IS FOR YOU, IF YOU ARE FOR IT
ACP is a voluntary discussion. If you understand your condition well, can make decisions, and are interested in having a say in the care you receive, an ACP will help facilitate your wishes to your family and medical team.
2
ACP IS NOT A DIRECTIVE, BUT A DISCUSSION
ACP is a discussion about what is important to you regarding your values and beliefs. We may discuss specific items of care that you want or do not want done for you; more importantly, your ACP should capture who you are as a person, what you need as a human being to live well, and what you would consider to be suffering.
3
ACP RELIEVES YOUR LOVED ONES OF MAKING DIFFICULT DECISIONS Your ACP can be as specific or broad as you need it to be. If your ACP is clear, it will relieve your loved ones of the burden of not knowing, worrying about what to do, or feeling guilty about making a wrong choice. Your ACP allows them to focus on being there with you.
4
CHOOSE A SUITABLE NOMINATED HEALTHCARE SPOKESPERSON (NHS)
Pick someone who knows you well, whom you can trust to carry out your wishes. You should also ensure that any loved one who may be involved in your care is on the same page and will respect your NHS’ decisions.
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CONTINUE THE CONVERSATION AND REVIEW YOUR ACP ACP is an ongoing discussion. It does not end when you sign the document. Keep the conversation going with your loved ones, and review your ACP with a certified ACP Facilitator if there is a change in your medical or life circumstances. At Yishun Health, we want to help our patients live well not just for the next five to 10 years, but to the very end. That journey begins with putting our patients at the centre, understanding their care goals, and delivering medical care that they value and find meaningful. The ACP is an important part of this.
HAVE YOU MADE ONE? To document an ACP, you may contact KTPH Mainline 6555 8000 or email ktph. advancecareplanning@ktph.com. sg to book an appointment. You and your NHS will need to be 21 years of age and above at the time of the documentation. Depending on the condition of your health, you may document one of three types of ACPs: • General ACP is for when you are healthy or have a stable chronic condition • Disease-specific ACP (DSACP) is for when you have a progressive, life-limiting chronic disease • Preferred Plan of Care (PPC) is for when you have a terminal condition and may pass away in one to two years
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ive Well
CHAMPioning a change for the better E
When he was diagnosed 10 years ago, Mr Tan Keng Boon was indifferent to having diabetes. A health coaching programme called CHAMP eased him into a healthy lifestyle that he has found easy to sustain.
TURN TO PAGE 23 TO LEARN DIABETES MANAGEMENT THE DESMM WAY 26 |
very day, Mr Tan Keng Boon, 60, hits the gym, goes for a jog or a swim, or a combination of these activities. This active lifestyle is new to the retiree, who previously “could not be bothered” despite having diabetes. “I did not make any special changes in my lifestyle and diet,” he admits. While he knew the risks, he did not fully realise the seriousness of the consequences. “I thought it was quite common.” When his diabetes got worse, he had no choice but to take medication. Over the years, his lack of action and the progression of the disease meant that his medication dosages kept increasing. By the middle of 2017, Mr Tan’s HbA1C (a measure of how well blood glucose levels are controlled; a figure of 6.5% or higher indicates diabetes) hit its peak at 8.2%. As such, his medication dosage was raised to 850mg three times a day. This made his wife, Mrs Melody Tan, even more concerned about his health. It was around this time that she learnt about CHAMP (see sidebar). The programme was looking for volunteers, so she applied and got the job. Mrs Tan then urged her husband to join the programme. “I was retired and had time on my hands, so I went to support her,” Mr Tan recalls. Learning about the simple changes he could make to manage his diabetes well, Mr Tan found the nudge he needed to make a change. “The programme was structured
and there was a clear way that emphasised the lifestyle changes I could make. I decided to just do it,” he says. Backed by this knowledge and the encouragement of his wife, he started to exercise and change his eating habits.
TURNING BACK THE TIDE After three months of regular exercise and changes to his diet, Mr Tan started to see a distinct improvement in his well-being. Most significantly, his HbA1C dropped to 6.2%. As his sugar control improved steadily, his medication dosage fell too. Today, he takes 250mg twice a day. Over the span of about a year, he also lost 4kg. Mr Tan knows he is lucky to have improved his health before developing complications from diabetes. His prior indifference to his condition has now been replaced by motivation. It just took a few steps; today, exercise has become a daily habit for him. Starting at a leisurely pace of 6km/h, he now jogs about 6km a day. Some days, Mrs Tan joins him for long walks around Yishun and Sembawang, in parks and along park connectors.
Mrs Tan has always prepared healthy meals, cooking at least two vegetable dishes. These days, Mr and Mrs Tan, together with their son and daughter, has upped the health ante, regularly eat brown rice in place of white rice. Occasionally, Mrs Tan packs a box of fresh crunchy vegetables for Mr Tan when he has to eat out. He has also swapped his sweetened coffee for kopi o kosong (black coffee with no sugar). His secret to this big change? Keeping an open mind and being adaptable. “It’s possible; it’s just a matter of really wanting to make a change,” he affirms. This attitude,
COACHING FOR HEALTH ACTION AND MANAGEMENT PROGRAMME (CHAMP) CHAMP is a community intervention programme that coaches residents in four simple, health-promoting actions that they can achieve in their daily lives: • Use the Healthy Eating Plate • Consume less free sugar • Substitute refined with whole grains • Increase physical activity Apart from education, CHAMP invites residents to experience lifestyle changes. Health action coaches guide them to make habits out of the four health-promoting actions. To join CHAMP (there are English and Mandarin sessions), call 6807 8107 (Monday–Friday, 9am–5pm) or email champ@ktph.com.sg.
support from Mrs Tan, and the coaching from CHAMP have all made a difference. Far from being indifferent, Mr Tan is now a champion of the CHAMP programme, setting a real-life example for others. He has been a speaker at the CHAMPion League, sharing his journey to wellness with others and motivating them to make lifestyle changes. “CHAMP helped me make changes to my unhealthy lifestyle. It was good to have a tool and concrete steps,” he adds. “Many people know the consequences, but they could not be bothered. If there is someone there to push and remind you, it makes a difference.” He also feels that being more targeted and having guidance outside of the clinical setting also helps. The initiative’s clear tips are easy to follow and integrate into daily life and, above all, the positive result is a true push factor. “When they see the improvement, it becomes the motivation to do better.” Mrs Tan is proud of what her husband has achieved. “I’m glad he was willing to change. And I’m grateful to CHAMP for guiding us,” she shares. She notes that his experience underscores the effectiveness of exercise and diet over medication. Like her role in supporting her husband in his endeavours, “it works hand in hand”. | 27
akan Time
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Bircher Muesli
cut & keep
Prepare this breakfast in advance for a nourishing and energy-packed start to the day. Recipe contributed by Chef Khor Soon Hoo Jason, Food Services, KTPH, in consultation with Nutrition and Dietetics, KTPH
INGREDIENTS Serves 2 • 1 cup raw quick-cooking or rolled oats • ½ cup low-fat yoghurt • ½ tbsp honey • 1 apple, peeled and diced • ½ cup blueberries • 2 medium strawberries, sliced • ½ cup walnuts
METHOD 1. Combine oats, yoghurt, honey and apple in a medium-sized bowl and mix well. Portion the mixture into two containers if desired. 2. Refrigerate for at least 3 hours, or overnight. 3. To serve, garnish with blueberries, strawberries and walnuts. Serve cold.
NUTRITIONAL INFORMATION (1 SERVING) Energy
516kcal
Carbohydrates
55g
Protein
13g
Fat
25g
• Saturated
3g
• Polyunsaturated
16.4g
• Monounsaturated
5.3g
Cholesterol
4mg
Fibre
8.8g
Sodium
50mg
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ind & Health
#RechargeMyJoy for better well-being We function like batteries! Learn why we need to ‘recharge’ ourselves regularly for optimal emotional and physical wellness. Demands and stresses of everyday living deplete the energy from our battery. If we don’t recharge consistently, we may soon find ourselves tired, unfocused, and running low on joy. We can recharge our energy and joy with both recreational (active) and restful (restorative) activities. Just like the powerbank, a portable device that recharges our devices on the go, we want to have a simple repertoire of activities to energise ourselves throughout the day!
Recharg (energy
in)
e
Rest Recreat & ion
Recharg (energy
in)
e
Rest Recreati& on
Deplete (energy
out)
Daily Deman ds
Deplete (energy
out)
Daily Deman ds
10 BENEFITS OF REST & RECREATION
REST Increases energy, concentration and focus
RECREATION Engages the mind, increases concentration and focus
Improves ability to cope with stress and adversity
Relieves stress and improves ability to cope with adversity
Promotes emotional and mental healing, and tranquility
Improves mood and reduces risk of depression
Enhances immunity and improves health
Increases satisfaction with life
Repairs and restores physical bodies
Improves physical health and strength
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SEARCH FOR JOY It is important that you make time for both restful and recreational activities to replenish your energy and joy. Find all 14 words that relate to recharging and enhancing our wellbeing in this puzzle.
N W B X U W Y Y F C R D L N B
E C N A L A B E H M L Y C E I
L N Y W S E N E R G Y A I B V
W K S J J A G U V K S H Y S O
R E V U P W N U X A M N S E E
E K R V R Q R I H E F E W D U
C T C A E V G U L P N U H E G
H S S B C V L D Y I K Z M C X
A E P R R F W H P U J Q C L H
R R Y E E Y L P H O B B Y U Y
G C Q A A V A E R F N S W T H
E X V K T H O E S Z J S Z T B
V N D M I W E L L N E S S E E
M B T K O B C H V Y Y O J R U
I H I U N O I T A R O T S E R
The hidden words are listed below:
• RECHARGE
• RECREATION
• RESTORATION
• HAPPINESS
• BALANCE
• BREAK
• DECLUTTER
• JOY
• REST
• ENERGY
• SELFCARE
• WELLNESS
• UNPLUG
• HOBBY
Hidden words can appear horizontally, vertically and diagonally in both directions.
YISHUN HEALTH HAPPINESS DAY 2019: #RECHARGEMYJOY Keep a look out for our Happiness Day activities — brought to you by our friendly Clinical Psychologists! Learn tips on how to ‘recharge’ your joy and energy. Date: 26 March 2019 Location: KTPH lobby
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