aha
ISSUE 5: September–OCTober 2019
BUILDING VALUE THROUGH RELATIONSHIPS
MCI (P) 065/04/2019
No matter how advanced medical technology gets, the human touch can make all the difference for our patients
THE HEALTHCARE DETECTIVES
AHA Sep-Oct19 cover.indd 2
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HEALING THROUGH GIVING BACK
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THE ‘KEY’ TO REMOVING KIDNEY TUMOURS
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ontents
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COVER STORY Value through the eyes of our patients Value-based care is underpinned by our desire to deepen engagement with patients, caregivers and communities
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HEALTH HIGHLIGHTS Healthcare news and updates
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WHAT’S UP Community events, outreach efforts, and more
12 SPOTLIGHT The healthcare detectives While they may work behind the scenes, medical laboratory professionals play a vital role in healthcare 16 EVERYDAY HEROES Healing through giving back Despite her own tragedies, this volunteer Patient Sitter is keen to bring comfort, care and companionship to her charges
THE VALUE SERIES
12 24 5 THINGS ABOUT… Colon cancer Essential facts about this disease, which sees about 2,000 new cases in Singapore annually 26 LIVE WELL Growing wellness — one plant at a time Meet two gentlemen running therapy sessions via their love of horticulture
Part 3 of 3 The final part of our three-part series on value-based care looks at how communication, active listening, and a person-centred approach build meaningful and empowering relationships to drive better care, improve outcomes, and add value to the patient experience.
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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 includes community extensions such as Wellness Kampung.
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EDITORIAL TEAM Hannah Wong Sabrina Ng Sharon Ng Albert Foo
28 MAKAN TIME Broccoli, mushrooms & tofu in egg white sauce Try this stir-fry recipe, which is filled with protein and fibre 30 DAILY DOSE The ‘key’ to removing kidney tumours Keyhole surgery for this condition offers patients numerous advantages, including faster recovery 31 MIND & HEALTH Colouring for calmness Practise mindfulness by colouring this illustration
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 Bastari Irwan Chia Kwee Lee Fatimah Moideen Kutty Shirley Heng Teresa Foong
ktph.com.sg/aha aha@ktph.com.sg
PUBLISHING AGENT THINKFARM PTE LTD www.thinkfarm.sg M A N AG I N G D I R E C TO R
Christopher Tay
aha
ISSUE 5: September–OCTober 2019
BUILDING VALUE THROUGH RELATIONSHIPS No matter how advanced medical technology gets, the human touch can make all the difference for our patients
H E A D, E D I TO R I A L
Chua Kim Beng
C O N T R I B U T I N G E D I TO R
Sheralyn Tay E D I TO R
Dang Hui Ling H E A D, C R E AT I V E MCI (P) 065/04/2019
Sean Lee
THE HEALTHCARE DETECTIVES
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HEALING THROUGH GIVING BACK
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THE ‘KEY’ TO REMOVING KIDNEY TUMOURS
W
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hy aha? The name aha holds much significance for us at Yishun Health. In part, it is a nod to our history; 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.
H E A D, 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
Justin Loh Lee Lily Vernon Wong
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) 065/04/2019
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ealth Highlights
MORE SUBSIDIES UNDER
CHAS
From 1 November 2019, all Singapore Citizens who have chronic disease can use the Community Health Assist Scheme (CHAS) for subsidies. Those who already qualify for CHAS will also receive bigger subsidies.
CHAS will be enhanced to make chronic care more affordable, thus enabling people to manage chronic disease in the community. • A new CHAS tier will be rolled out. The CHAS Green card covers all Singaporeans for simple and complex chronic conditions, regardless of income.
Existing subsidy
From 1 November 2019
Chronic Simple
NIL
Up to $28 subsidy per visit, capped at $112 per year
Chronic Complex
NIL
Up to $40 subsidy per visit, capped at $160 per year
• CHAS Orange cardholders will receive more subsidies for common and complex illnesses.
Existing subsidy
From 1 November 2019
Common Illnesses
Not applicable
Up to $10 subsidy per visit
Chronic Complex
Up to $75 subsidy per visit, capped at $300 per year
Up to $80 subsidy per visit, capped at $320 per year
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• CHAS Blue cardholders will receive more subsidies for complex chronic illnesses.
Chronic Complex
Existing subsidy
From 1 November 2019
Up to $120 subsidy per visit, capped at $480 per year
Up to $125 subsidy per visit, capped at $500 per year
• Merdeka Generation seniors will receive special subsidies for medical and dental care at GPs and dental clinics.
Merdeka Generation
Subsidies from 1 November 2019 onwards
Acute
Up to $23.50 subsidy per visit
Simple Chronic
Up to $85 subsidy per visit capped at $340 per year
Complex Chronic
Up to $130 subsidy per visit capped at $520 per year
Dental
Up to $16 to $261.50 subsidy per procedure
While every Singapore Citizen will be eligible for CHAS, the enrolment is still on an application basis. To enjoy these subsidies, households are required to submit an application. For existing CHAS cardholders, MOH will issue replacement cards for those who qualify for a higher CHAS tier by October 2019.
You can pick up a CHAS application form at any of the following locations: • Community Centre or Club (CC) • Community Development Council (CDC) • Public Hospital or Polyclinic
To download a form online, or for more information, visit www.chas.sg.
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hat’s Up
A Career of Committed Caring M
dm Chua Gek Choo, Director, Nursing, YCH, received the Exemplary Leader Award at the Public Sector Transformation Awards Ceremony on 19 July 2019. The award is conferred by the Public Service Division of the Prime Minister’s Office, and honours individuals and public agencies for work and organisational excellence. Mdm Chua, though small in stature, is well known for her energetic personality, dedication and tenacity in addressing challenges big and small. For over four decades, she has inspired those with whom she has worked across her many roles, including
Deputy Director of Nursing and Team Lead in KTPH’s Inpatient Planning Committee. “(Mdm Chua) has been an incredible pillar of strength for the nursing profession. Her honest and straightforward disposition makes it easy to converse and discuss issues and implement solutions,” said Ms Low Beng Hoi, Director, Nursing, Population Health & Community Transformation.
Recognition for Yishun Health’s Man of Ideas Also lauded at the 2019 Public Sector Transformation Awards was A/Prof Yip Chee Chew, Head and Senior Consultant, Department of
Ophthalmology & Visual Sciences (OVS), KTPH, and Medical Director, AdMC. He received the Exemplary Innovator Award. Beyond his clinical duties, A/Prof Yip is known for developing improved patientcare models and initiating qualityimprovement projects. He applies his 6-Sigma Lean Black Belt expertise towards collaborative efforts to improve patient care, increase productivity, and reduce healthcare costs. This award comes after his team’s win last year, when they received the Excel Innovation Project Award for the Community & Home Eye Screening Service.
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Enabling Employers Award S
ince 2006, Yishun Health has championed an inclusive workforce, hiring persons with disabilities. Over the years, we have strengthened our efforts to support and integrate such individuals into the workforce. Working with SG Enable, Yishun Health began participating in the School-To-Work programme in 2017. This initiative provides internship opportunities and
assists graduates from Special Education schools to transition into the workforce. This involves working with job coaches from MINDS to structure and customise training according to special needs. Apart from providing step-by-step pictorial guides, staff are also trained to interact and work with specialneeds graduates appropriately. Interns are also supported with
‘buddies’ and trained supervisors. On 26 July 2019, Yishun Health was accorded the Certificate of Recognition at the 5th Enabling Employers Awards for providing employment opportunities for people with intellectual disability (IQ 70 and below), autism, physical disability, or hearing/visual impairment. This is a biennial award given by SG Enable.
A Toast to Our Public Speakers! Y
ishun Health’s Toastmasters Club bagged a number of awards at Achievers Nite 2019. The event, organised by Toastmasters International Singapore, was held on 21 June 2019. The Club was conferred the Select Distinguished Club Award and its members garnered recognition as well. Vice President (Education) Syaiful Hakimnudin Bin Sa’adon, Radiographer, Diagnostic Radiology, was awarded the Distinguished Toastmaster Award. This is the highest award that Toastmasters International bestows. It recognises a superior level of achievement in both communication and leadership. Syaiful also won the Triple Crown Award, together with Tony Yang, Senior Manager, Facilities Management.
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hat’s Up
Patient Safety Comes First! 1
July 2019 marked the launch of Yishun Health’s inaugural Patient Safety Month. Organised by the Patient Safety Month Committee and supported by its various Workgroups, the campaign raises public awareness in four areas: pressure injuries, infection control, falls prevention, and medication safety. The campaign was also a timely reminder to staff about our safety commitment towards SAFE care: • Strive to uphold the highest standards in patient care • Advocate for patient safety every day • Fully support clinical quality projects that help us continue providing quality healthcare • Educate patients, caregivers and staff on ways to protect patients from harm caused by pressure injuries, poor hygiene practices, falls, and poor medication compliance
Speaking at the launch, Mrs Chew Kwee Tiang, CEO, Yishun Health, underscored the importance of the partnership between families and healthcare teams in ensuring patient safety.
A/Prof Pek Wee Yang, Chairman, Medical Board, and Mrs Chew (centre) at the launch of Patient Safety Month
Nurses Merit Award Ceremony S
Yishun Health’s seven Nurses’ Merit Award winners with (fourth from left onwards) Ms Shirley Heng, Chief Nurse, Yishun Health; Mrs Chew Kwee Tiang, CEO, Yishun Health; and Mdm Chua Gek Choo, Director, Nursing, Yishun Community Hospital
even Yishun Health nurses received the 2019 MOH Nurses’ Merit Award on 17 July 2019. This award — given out since 1976 — recognises individuals for their outstanding performance and contribution to the nursing profession. • Yu Lee Hoon, Nurse Manager, Inpatient Wards, KTPH • Joyce Lee, Nurse Manager, Cardiovascular Centre, KTPH • Fan Xiulan, Assistant Nurse Clinician, Peri-Ops, KTPH • Kathy Lam, Nurse Educator, Nursing Administration, YCH • Koh Pei Pei, Assistant Nurse Clinician, Ward A82, KTPH • Chan Hoi Sum, Nurse Manager, Ward B96, KTPH • Siti Nor Ilyana Binte Kamsol, Nurse Clinician, A&E Care Centre, KTPH
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In Partnership to Drive Community Learning S
ince 2017, KTPH has partnered National Silver Academy (NSA) to provide courses for patients and the public. The NSA is a network of post-secondary education institutions and community-based organisations offering a wide range of learning opportunities to seniors aged 50 and above at subsidised rates. These collaborations include the various Skills for LIfe diabetes programmes, and the Diabetes Empowerment Programme, run at AdMC by the Diabetes Centre. As part of NSA’s 3rd Anniversary Celebration, AdMC’s Diabetes Centre
was invited to receive a token of appreciation on 2 August 2019. Held at the National Library, the event was
graced by Guest-of-Honour Mdm Halimah Yacob, President of the Republic of Singapore.
Raising Awareness F of Acupuncture and Injury Management
The monthly acupuncture talks held at AdMC raised awareness of TCM for chronic illness and were conducted variously in English and Mandarin
rom March to June 2019, Admiralty Medical Centre (AdMC) hosted a series of monthly public talks on Traditional Chinese Medicine (TCM). The talks, held variously in both English and Mandarin, attracted more than 200 members of the public. On 8 June 2019, the series concluded with a session by acupuncturists from Yishun Health’s Sports Medicine Centre. Melissa Ong and Amanda Chua shared how acupuncture may help with digestion issues, diabetes, lower back pain, knee pain, as well as stroke rehabilitation. That same day, Amanda also spoke at a separate event at Kampung Admiralty, where she highlighted the use of acupuncture for knee and lower back pain. She was part of the Sports Medicine team who was present at Sembawang Community Sports Club’s Sports Fiesta. Amanda was joined by Dr Shauna Sim, Resident Physician, who gave a talk about keeping fit and preventing sports injuries.
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hat’s Up
‘Dream. Dare. Do.’ — An Inspiring Nurses’ Day Message
Ms Shirley Heng, Chief Nurse, Yishun Health, and Dr James Tan, HOD, Orthopaedic Surgery (Chairman of this year’s Nurses’ Day Committee) led the walk
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his year, Nurses’ Day at Yishun Health was commemorated under the theme of ‘Dream. Dare. Do.’ This call to action aimed to inspire nurses to rally their individual and collective strengths towards better, safer, and more accessible personcentred care. As part of pre-event activities, a Promenade Walk around Yishun Pond
and Laughter Yoga session were held on 25 July 2019. On 1 August 2019, the Nurses’ Day Committee, together with Yishun Health’s Nursing Directors, distributed gifts to all our nurses in the wards and clinics across KTPH and YCH. There was also a Nurses’ Day exhibition, held from 1–13 August 2019, which showcased personal reflections from our nurses.
A celebration was held on 2 August 2019 at the KTPH auditorium. Mrs Chew Kwee Tiang, CEO, Yishun Health, thanked the nurses for their contributions, particularly in supporting Yishun Health’s Unified Clinical Care Model. A/Prof Pek Wee Yang, CMB, also shared his aspirations for the nurses. Calling them the bedrock
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Ms Eileen Cheah, Assistant Director, Nursing (second from left), and Yvonne Yap, Nurse Manager (right), received their scholarships from Ms Mavis Khoo, Guest-of-Honour and Patron of KTPH (second from right)
and foundation of healthcare, he encouraged them to dream big, with the assurance that they would never dream alone. Together as Yishun Health, nurses and clinical professionals will continue to work closely as equal partners in care to create an environment with a strong culture of safety for all. During this celebration, the first two awards were given out under the Mavis Khoo Nursing Leaders Scholarship. Twelve Model Learner and two Top Student awards were also presented to nurses who have excelled in their studies, while six nurses received the Nurses’ Day Special ‘Dream. Dare. Do.’ Awards. This was followed by an entertaining line-up of performances from heads of departments, nurses, and nursing supervisors.
The clinical heads of departments let their hair down, putting up a dance performance to thank the nurses for their hard work over the past year
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potlight Malcolm Albert Hey, Senior Medical Technologist, prepares urine specimens for analysis in the Urine and Body Fluid Analysis section of the core laboratory
The Healthcare Detectives
Blood, body fluids, and biopsied tissues hold a wealth of information on what is going on inside your body. Working to extract this ‘evidence’ are medical laboratory professionals who work behind the scenes, playing a vital role in the diagnosis, treatment, management and prevention of disease.
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lthough most diagnostic tests do not take place in front of patients, laboratory science professionals are key members of a modern healthcare team who are vital in providing safe and quality patient care. It is estimated that some 65–70% of clinical decisions are made based on the results of laboratory tests. Each day, medical laboratory professionals make use of state-ofthe-art technology to help doctors and nurses piece together the observations in samples into a complete picture of a patient’s health. This allows treatment and diagnosis to be based on evidence rather than guesswork.
Wee Guan Lim, Senior Medical Technologist, prepares quality control material before patient sample testing in the Special Chemistry section
BLOODY TALES Many modern diagnostic tests are performed using blood samples. Haematology is the study of diseases related to the blood. A commonly requested haematological blood test is the full blood count (FBC), which provides an overview of the quantity and quality of various blood cells in circulation. Even the size, shape and contents of blood cells are measured and scrutinised. Interestingly, all these analyses can take place using just one millilitre of blood. Another test is the peripheral blood smear, which provides a ‘snapshot’ of the cellular components in blood. This allows laboratory scientists to study the appearance of red blood cells, white blood cells, and platelets with the enhancement of special stains under both conventional and digital microscopy. Biochemistry tests are among the most commonly requested diagnostic tests in a patient’s healthcare journey. Routine kidney and liver function screening panels are used for detection of disease states, while cholesterol and lipid panels are often used in screening for cardiac and vascular risk factors. The detection and measurement of glycated haemoglobin (haemoglobin molecule that has been irreversibly attached to a glucose molecule) have changed how diabetic patients are diagnosed and monitored in recent years.
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potlight
Karen Lee, Senior Medical Technologist from Microbiology, examines the agar culture plates for clues to identify the microorganisms responsible for infections
Due to the sheer quantity of requests for such tests every day at Yishun Health, total laboratory automation has been implemented in the biochemistry laboratory to maximise efficiency and accuracy while reducing the incidence of errors.
WHEN WASTE IS ALSO USEFUL Another common test is the urine test. Though we may consider it a waste product, it is far from wasted
in the hands and under the scientific eye of laboratory technologists. Urine testing goes back to ancient times, when urine was tasted for the presence of sugar and visually inspected for colour and clarity. These days, urine testing is carried out using dipsticks that have been designed to detect up to 10 different chemical analytes, such as glucose, bilirubin and even bacterial by-products. Colour and clarity of the urine samples are defined objectively by
colour and turbidity detectors, while cells and sediments in the urine samples are accurately identified and counted by fluorescence flow cytometry. The presence of atypical cells and sediments in urine can aid in the diagnosis of infections and other urinary tract disorders.
ESSENTIAL FLUIDS Aside from blood and urine, laboratory science professionals also perform diagnostic tests on body fluids from various sites,
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WHAT’S IN A NAME? At Yishun Health’s Laboratory Medicine Department, a team of more than 90 staff work in a variety of specialty roles and functions 24 hours a day, seven days a week. Medical technologist: This is a medical laboratory scientist who performs diagnostic analysis on patient specimens sent to clinical laboratories. A medical technologist can choose to train as a generalist in various core laboratory specialties, such as clinical biochemistry, haematology and transfusion services, or specialise in a specific field of laboratory medicine, such as microbiology.
“There is a patient at the end of every sample. We take pride in knowing that every accurate and reliable result we generate intangibly enhances a patient’s quality of life.” WEE GUAN LIM SENIOR MEDICAL TECHNOLOGIST
such as peritoneal space, knee joints, and even cerebrospinal fluid. The observation of crystals, abnormal cells and unexpected microorganisms in these fluids can be diagnostic of disorders such as malignancy, inflammation and infection.
QUALITY IS KING Medical laboratory science has progressed in tandem with improvement in quality processes. Quality management in laboratory
Cytotechnologist: Like a cell ‘detective’, a cytotechnologist is specially trained to examine human cells under microscopy and detect cancer, pre-cancer states, and other abnormalities. They work with clinicians and pathologists to provide accurate observations of the cell samples collected. Histotechnologist: This is a medical laboratory scientist who is trained in the specific preparation of tissue samples removed from a patient. The tissue samples have to be specially prepared before they are examined under a microscope by pathologists for evidence of disease, such as cancer. Phlebotomist: Deploying empathy and skilled hands, a phlebotomist draws blood from patients for clinical testing. Phlebotomists are well versed in the quality requirements of the laboratory, and ensure the specimens they collect meet these requirements. Laboratory information systems (LIS) officer: An IT specialist who maintains the laboratory information system that supports data flow and laboratory automation. With increased reliance on IT solutions for patient management, the job of the LIS officer is often not confined within the walls of the laboratory. The LIS officer also works with hospital information system administrators and vendor specialists to ensure secure and continuous IT support for the other medical laboratory professionals.
testing has always been tightly regulated to ensure patient safety. Standard operating procedures (SOPs) are in place for every step of the Total Testing Process, from verifying correct specimen collection to ensuring optimal performance of laboratory analysers and timely release of test results to the doctors. Daily quality control checks and participation in international proficiency testing programmes are also implemented to ensure laboratory standards
are on par with laboratories all over the world. Yishun Health’s Department of Laboratory Medicine is also accredited by the College of American Pathologists for its compliance with established performance standards. “There is a patient at the end of every sample. We take pride in knowing that every accurate and reliable result we generate intangibly enhances a patient’s quality of life,” assures Senior Medical Technologist Wee Guan Lim.
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veryday Heroes
Healing through giving back Having been a caregiver to family members and overcoming cancer, Mdm Kalsom binte Abdullah knows all too well the stresses and strains of taking care of the chronically ill. As a volunteer, she channels her experience of those dark times to bring comfort, care and companionship to her charges.
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t least once a week, Mdm Kalsom can be found in the Dementia Ward of Yishun Community Hospital (YCH), sitting with patients to ensure their safety. As a volunteer Patient Sitter, she keeps an eye on patients, talks to them, and joins them in bedside activities. She began volunteering in January 2018, a few months after her husband passed away. He had been ill for a long time, and she was his sole caregiver. Not only did he have heart trouble — he underwent major heart surgery in 2005 — he had also been on dialysis for many years due to kidney failure.
“By sharing my story, I hope that caregivers know they are not forgotten and left on their own. There is support around if only they are willing to open up and communicate.”
DEDICATION IN SPITE OF ILLNESS Although caring for her husband was challenging, Mdm Kalsom continued to be dedicated towards his care, even after she was diagnosed with breast cancer in 2010. With the same fortitude that marked her role as caregiver, she journeyed back to health while continuing to meet her husband’s needs, which grew even more complex as the years went by. Towards the end of his life, he developed dementia, suffered multiple heart attacks, and was frequently hospitalised for long stretches, which made taking care of him ever more strenuous. While Mdm Kalsom could hardly be faulted in her caregiving duties, the burden of care took its toll. When her husband passed away in August 2017, her grief was immense. As is common with caregivers, she questioned her decisions about his care, and wondered whether she could have done things differently. Fortunately, she found a way to process her emotions and celebrate her husband’s memory through
volunteering as a Patient Sitter. By offering companionship and keeping an eye on patients, she allows nurses to focus care and attention on the patients who need a little more help.
HONOURING HER HUSBAND “Volunteering fills the gap and is a way to honour my husband,” she says. Although she is still healing from her loss, she feels happier when she is able to help others and remember him through caregiving. Mdm Kalsom offers more than just a gentle manner and empathy —
her experience as a caregiver for her husband makes her particularly well suited for the role of Patient Sitter. In fact, even before becoming a caregiver for her husband, she had already played that role for her grandfather, who died of cancer, and an aunt with advanced-stage dementia. She understands patients’ needs, feelings and worries, and connects well with them. She has even stayed in touch with a patient who has since been discharged from YCH. This former patientturned-friend still reaches out to Mdm Kalsom whenever she has an appointment at KTPH. These selfless acts of service are fulfilling for Mdm Kalsom, despite her own difficulties, such as problems walking due to knee pain. To encourage other caregivers, Mdm Kalsom shared her story at Yishun Health’s ‘Active Ageing for Caregivers’ seminar. She hopes that it will serve as a reminder to caregivers that support is available, and that self-care is important. “Caregivers often feel alone and lost; by sharing my story, I hope that they know they are not forgotten and left on their own. There is support around if only they are willing to open up and communicate,” she advises. Mdm Kalsom’s story is a beacon of hope to caregivers. Although she still has challenges in her life, she is not bitter and has maintained a cheerful and calm outlook on life. These experiences have made her a stronger person, she asserts, while her volunteer work is simply an act of compassion that comes naturally. “When I see someone in need of help, my heart goes out to them. It is only human to reach out and try to ease their suffering.” | 17
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Cover Story
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THE VALUE SERIES
PART 3 OF 3
Value through
the eyes of our patients Our efforts to drive value-based care lie not only in process improvements, enhanced clinical models, and transdisciplinary services. More importantly, it is underpinned by our desire to deepen our engagement with patients, caregivers and communities.
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s we move towards a more holistic understanding of what ‘good’ healthcare means, the goal of medicine becomes more than undergoing surgery or putting a cast on a setting bone; it also means expanding the idea of medical success from purely clinical aims to consider other outcomes. For example, beyond achieving a safe and uneventful surgery for the patient, other factors need to be assessed by the care team: Will the
patient be able to recover his or her independence after surgery? Will the surgery lead to a long and painful hospital stay and recovery? Can the treatment lead to an improved state of health? In other words, does the immediate goal of treatment have long-term benefits to a patient’s quality of life? This is the value-based care approach. Apart from clinical goals, it is important to consider what happens after a hospital stay or medical treatment.
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Cover Story
ADDING VALUE TO CRITICAL CARE To enhance and optimise surgical and critical care, this approach has been adopted at Yishun Health’s surgical intensive care unit (SICU). According to Dr Kumaresh Venkatesan, Director of the Surgical Intensive Care Unit, Senior Consultant, Department of Anaesthesia, patients and their families go through high levels of stress during these periods that stem not only from the medical crisis, but also from being in the ICU. While the critical care environment of the SICU is one fraught with complexity, time pressures and serious illness, this does not make functional and qualityof-life outcomes any less important, he emphasises.
The challenge is that ICU patients are seriously ill and unable to communicate with their loved ones and medical team on how they wish to be cared for. For patients without an Advance Care Plan, it can become even more challenging when critical medical decisions need to be made in a timely manner that is aligned with the patients’ preferences. “There is usually a lot of anxiety and questions about outcomes and prognosis,” Dr Kumaresh says. To help the family make informed decisions, the SICU team does more than critical care. It often engages family members to learn about the patient’s wishes and beliefs. The team is led by Anaesthesiologist Intensivists — anaesthesiologists
who are specially trained in critical and intensive care — who work with intensive care nurses, surgeons, infectious disease specialists, dietitians, physiotherapists and respiratory therapists to coordinate multidisciplinary care for patients. Dr Kumaresh is one of five such specialists at Yishun Health. His role is to address a patient’s needs during critical care, and work with the patient and his family to develop care plans from the surgical stage and beyond. “We want to bridge an important gap between medical outcomes and quality-of-life outcomes that are meaningful for a patient. This helps us to plan a course for the patient with the goals of successful completion of surgery and recovery in the ICU,” he explains.
“After we have handled the immediate issue, it is important to step back and take a broader look. We also need to consider longerterm needs and outcomes for the patients outside of the ICU.” DR KUMARESH VENKATESAN DIRECTOR, SURGICAL INTENSIVE CARE UNIT; SENIOR CONSULTANT, DEPARTMENT OF ANAESTHESIA
Dr Kumaresh meets with the patient’s family to gain better insights into his preferences and to help the family make decisions according to their loved one’s wishes
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THE VALUE SERIES
PART 3 OF 3
CONNECTIONS THAT MATTER
SAYING “I DO” IN THE ICU
When 69-year-old Mr Lim was warded in the ICU in late July 2019 for pneumonia, he knew he was nearing the end of his journey. He had been cared for at KTPH for over nine years for his chronic diseases. Unfortunately, the prognosis was not good when he was admitted this time. His last wish was to see his daughter get married. Learning of this request, Pamela Foong, Assistant Nurse Clinician, worked with the family to organise a solemnisation ceremony in Mr Lim’s ICU room. Strict rules about infection control typically apply in the ICU. However, to make allowances for this event, the ICU’s nurses and doctors requested for help from several departments to garner the necessary approvals and special concessions. A comprehensive infection control plan was also implemented. To ensure Mr Lim would be well enough for the special day, the ICU team took extra care to monitor his condition and motivate him to keep his spirits up. On 13 August, Mr Lim and his family witnessed a simple but beautifully poignant ceremony. Mr Lim passed away a few days after, with his final wish fulfilled. Expressing appreciation to the ICU team and the various departments that had cared for Mr Lim over the past nine years, the Lim family wrote a short note of thanks, remarking that the elder Lim “passed on peacefully with no regrets”. How we care for our patients and their families, beyond the medical aspects, matters to them. This episode is an affirming nod to our staff, who have gone beyond the call of duty to show empathy and love, touching the lives of those who pass through our hospital.
To do this, he sits down with the patient’s family over several sessions to gain better insights into his preferences and to help the family make decisions according to their loved one’s wishes. Treatment, if any, should be about meeting goals that are important to the patient while also addressing the concerns of the family members — such as cost of treatment. It is not about medicalising every issue, emphasises Dr Kumaresh. “How we bring value to patients is to avoid unnecessary and unwanted treatment, especially if it only brings about transient improvement.” Dr Kumaresh points out that, in some cases — particularly for the very elderly and/or chronically ill — invasive surgery or treatments may not have curative value beyond
the short term. Instead, they may cause longer-term stress and pain to the patient, and increase the medical cost borne by the family. “After we have handled the immediate issue, it is important to step back and take a broader look. We also need to consider longer-term needs and outcomes for the patients outside of the ICU,” he adds [see box story]. For instance, in life-limiting illness, the SICU team members may activate their palliative care colleagues to initiate interventions for comfort and pain management. “As intensivists, we recognise that there is a need to look beyond medical crisis and episodic care to take a more holistic and relationship-based approach,” he shares.
One Yishun Health programme that illustrates going beyond treating isolated acute episodes to take a more long-term view of health is the Ageing-In-Place Community Care Team (AIP-CCT). One of their goals is to address the root cause of hospitalisation for patients with three or more admissions to KTPH over a one-year period. Community nurses identify not just medical issues, but other factors that contribute to readmissions. They may train caregivers, educate patients on medication compliance, and encourage healthier habits. Allied health professionals may also be called in to share dietary tips and teach simple rehabilitative exercises, as well as help improve the home environment to reduce fall risks, enhance mobility, and increase comfort for the patients. Kimberly Lim, Senior Staff Nurse, AIP-CCT, explains, “We ensure that patients receive care and support so that they can manage well at home and prevent unnecessary hospital visits.” After all, 70% of health determinants are actually modifiable and can be addressed via holistic post-discharge care. Mdm Teo Nee Moi is a patient under Kimberly’s care. The 78-year-old broke her arm in a fall about two years ago, which led to a long hospital stay. The elderly lady was subsequently readmitted several times as her fracture site became infected. She even stopped eating regular meals for almost a year due to early stage dementia, resulting in extreme fluctuations in her blood sugar. “It was a very anxious period for my mother and the family,” shares her daughter, Ms Yenn Teo. “She lost confidence in herself after the fall and was in very low spirits.” | 21
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Cover Story
Under the AIP-CCT programme, Ms Teo saw a remarkable improvement in her mother’s wellbeing. Over time, with advice from a dietitian and friendly persuasion from Kimberly, Mdm Teo was encouraged to eat more regular and healthier meals to manage her blood sugar and dizzy spells. Grab bars were also recommended and installed in the home to prevent future falls. “The monthly home visits are a relief for the family, and my parents are always so happy when it is time for Kimberly to visit,” observes Ms Teo. In the past, the family was often unsure of what to do for dizzy spells or vomiting besides seeing their neighbourhood general practitioner. “Having someone to turn to for advice between medical appointments is very reassuring,” says Ms Teo.
A quick call to Kimberly for advice usually resolves episodic issues and prevents them from getting worse. Kimberly also provides advice on medication and arranges delivery of medication when needed, bringing convenience to the family. It also helps that these episodic issues and changes are updated on Mdm Teo’s file so that her specialists are also kept in the loop. These efforts not only demedicalise care but, more importantly, build trust and rapport. It is this connection between the healthcare provider and patient that drives compliance and healthier habits.
A RELATIONSHIP OF TRUST For patients, this connection is the crux of ‘value’ in their perception of value-based healthcare. Taking into
consideration a patient’s personhood can lay the foundation to a trusted and long-standing doctor-patient relationship, especially in the face of a serious medical condition. Take Mr Wong Foo Phang, 72, who was diagnosed with Stage Three colorectal cancer in 2007 during Yishun Health’s early days as Alexandra Hospital. His surgeon is A/Prof Tan Kok Yang, Deputy CMB (Service Development), Yishun Health, and Head of Surgery, KTPH. Mr Wong recalls that he was devastated by the diagnosis. “I kept asking, ‘Why me?’ No one else in my family had cancer. It was hard to accept,” he admits. He had surgery to remove the cancerous growths, and stayed in hospital for over a month, during which he suffered several post-surgery complications and needed multiple surgeries.
Kimberly Lim, Senior Staff Nurse, AIP-CCT (left) not only makes home visits, but is available in between medical appointments to answer queries from patients and their caregivers
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THE VALUE SERIES
PART 3 OF 3
“Patient-centric care is seeing beyond the pathology and treatments to see each patient as a person.” A/PROF TAN KOK YANG DEPUTY CMB (SERVICE DEVELOPMENT), YISHUN HEALTH; HEAD OF SURGERY, KTPH
“I could not eat and became very thin and weak,” he shares. Despite the many crises and challenges that arose during his hospital stay, one thing stood out for him: A/Prof Tan’s professionalism and dedication to his care. Even when Mr Wong raised complaints, he saw that A/Prof Tan listened, empathised, and was sincere during their interactions. In fact, Mr Wong’s strongest memories of that period were not about their conversations about medical care; instead, they were the occasions when A/Prof Tan efficiently tended to problems or when he noticed Mr Wong’s poor appetite. Mr Wong also remembers their casual chats about his scooter and their favourite hawker food. He appreciates that A/Prof Tan is not just a doctor who is dedicated to treating his condition, but is someone who cares about him as a whole
person. “His manner touched me,” affirms Mr Wong. “A/Prof Tan observes and takes an interest in me. I have developed every confidence in him.” It is for this reason that, for the last nine years, Mr Wong — who lives in Tiong Bahru — still makes the one-and-ahalf-hour journey to see A/Prof Tan for follow-up appointments at KTPH.
VALUE: PUTTING PEOPLE FIRST Building relationships and empathetic communication are intangible ingredients that make a big difference in improving care delivery and enhancing the patient experience. It is why Yishun Health’s value-based care model comprises not only metrics for clinical, functional, experience and cost — all these factors are underpinned by empathy. It is by knowing what matters
to patients that drives good clinical processes and relevant services programmes that lead to successful long-term outcomes. This approach shifts the dynamic from a paternalistic doctor-patient relationship to a partnership based on understanding. As Hippocrates once noted, “It is more important to know what sort of person has a disease, than to know what sort of disease a person has.” This insight helps healthcare providers design meaningful treatment that respects a patient’s experience and autonomy. This brings value to patients and truly puts them in the centre of care. As A/Prof Tan sums up, “A good outcome is about more than a single cutting-edge technology or medical specialty. Patient-centric care is seeing beyond the pathology and treatments to see each patient as a person.” | 23
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Things About...
5 Things About...
Colon Cancer Colon cancer is one of the most common types of cancer in Singapore among those aged 50 and above. However, younger adults can get it, too. Here’s what you need to know to about this alarming trend. In consultation with Dr Surendra Kumar Mantoo, Senior Consultant, General Surgery, KTPH
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COLON CANCER CAN HAPPEN IN YOUNGER ADULTS
BE SERIOUS ABOUT SYMPTOMS; YOUNGER-ONSET COLON CANCER OFTEN GOES UNDETECTED
While it most often affects people aged 50 years and above, colon cancer can also occur at a younger ages. At KTPH, patients below 50 years of age constitute 12% of all patients diagnosed with colorectal cancer. Extrapolate this to the 2,000 new colorectal cancer cases being diagnosed every year in Singapore, and it is estimated that about 240 patients under 50 are diagnosed with colon cancer annually.
Evidence shows that colorectal cancer in younger people tends to be more advanced as the symptoms are dismissed for a non-specific disease. This means it is important to be on the lookout for common symptoms of colorectal cancer, such as rectal bleeding, change in bowel habits, unintentional weight loss, and abdominal pains. Not all symptoms point to cancer, but it is important to find a cause. Early consultation with a doctor and tests such as a colonoscopy can pick up colorectal polyps, which can be removed to prevent cancer. When diagnosed at an early stage, colorectal cancer has a higher chance of cure.
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STAY ACTIVE AND EAT HEALTHY
Smoking and being overweight and physically inactive increase the risk of getting colorectal cancer at any age. Diets high in red (beef, pork or lamb) and processed meats (hot dogs and some luncheon meats), and heavy alcohol consumption are also associated with an increased risk of colorectal cancer. Eat a healthy, plant-focused diet, and engage in moderate physical activity at least 30 minutes every day. These habits are helpful in promoting good health, preventing cancers, and reducing the risk of other chronic diseases.
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KNOW YOUR FAMILY HISTORY
Having colorectal cancer in the family increases the risk of getting it. About 5–10% of people who develop colorectal cancer have inherited gene defects that can cause familial cancer symptoms and lead to them getting the disease. In general, colorectal cancer screening should begin at the age of 50 for people at average risk; but if you have a family history of colorectal polyps and cancers, Crohn’s disease or ulcerative colitis, start screening for colorectal cancer earlier.
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THE GLOBAL TREND OF YOUNGER-ONSET COLON CANCER MAY RISE An American-based study shows that, if current trends persist — by 2030 — the incidence rate of newly diagnosed patients aged 20 and 34 will almost double, and will increase by 46% among people aged 35–49. Singapore may see a similar trend if steps are not taken to address the issue.
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ive Well
GROWING WELLNESS — ONE PLANT AT A TIME Mr Hur Tze Huan and Mr Low Lum Soon have turned their love for all things lush and green into a meaningful activity for patients at YCH. Each week, they run a horticultural therapy session that engages the muscles and minds of patients through movement and mindful activity. Mr Hur Tze Huan (right) and Mr Low Lum Soon lead the horticultural therapy sessions at YCH
B
onding over their love for plants and gardens, Mr Hur and Mr Low met while volunteering at Yishun Health’s rooftop gardens. Mr Hur, 79, who first started volunteering at the KTPH rooftop gardens almost 10 years ago, is a trained agriculturist who has been working around plants his whole life. These days, he has a particular fondness for growing flowers, particularly scented ones, which offer him a little challenge. Mr Low, 70, a retired building maintenance engineer, inherited his love for plants from his mother. He, too, enjoys more complex gardening tasks, especially the skill and attention needed to grow vegetables. His engineering background comes in handy when it comes to planning and building structures and irrigation systems. Three years ago, they took their role as gardening volunteers further and began running horticultural therapy sessions for patients in the wards once to twice a week. In August 2019, the activity reached a milestone when it conducted its 200th session. These hour-long sessions begin with a light seatedexercise routine accompanied by music and singing. This is followed by an educational segment on a featured plant. With pictures and
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props, Mr Hur introduces the plant, its uses and benefits. Patients and their caregivers are then given a chance to see, feel and smell the plant itself. Next, small pots are distributed for participants to plant seedlings that they can keep and care for. Each session can accommodate up to 12 patients, together with their caregivers and volunteers who act as facilitators.
AN IDEA TAKES ROOT The idea for this activity came from Mr Hur. He had lived in New York City for a year to be with family. One day, on a visit to the New York Botanical Garden, he chanced upon a professional course on horticulture therapy and decided to sign up for it. The course widened his perspective on plants. “I learnt that plants not only fill the stomach, but can also benefit the mind,” he shares. This idea was greatly underscored during one of his practical sessions, where he had to sit in on a horticultural therapy session for children at a medical centre’s cancer ward. That day, the children were introduced to cherry tomato seedlings — each child planted some in a pot to take home. After the session, one of the mothers approached them, crying. “I thought something was wrong, but she told us, ‘I’m not crying because I’m sad; I’m just so happy today because, since my boy got cancer six months ago, I have not seen him smile. Today is the first day I saw him smile.’”
The idea that a simple activity can offer so much joy and happiness to people who are sick and suffering resonated with Mr Hur. When he returned to Singapore, he shared this story with Mr Low. Inspired, they proposed introducing horticultural therapy to patients. “Horticultural therapy is well defined, and its benefits have been well documented by a lot of scientific research,” explains Mr Hur. Studies have found that horticultural therapy supports recovery, betters pain control, and improves mood, resulting in shorter hospital stays. By bringing the ‘garden’ into the ward, the activity extends its reach beyond the able-bodied to those who are recuperating from illness and are less mobile.
LEAVING NO ONE OUT Mr Hur’s certification in horticultural therapy goes beyond bringing wellness to others. “It has also added interest to my life,
giving me something to look forward to,” he reveals. This meaningful activity has allowed them to contribute in more ways than one. From planning lessons and developing educational material to briefing new volunteers and guiding participants, all this preparation work keeps their minds active. There is also a social wellness aspect. The benefits are mutual as everyone involved gets a chance to interact and engage with each other. “Group therapy and interaction are essential elements of the session,” Mr Hur advises. “Through gardening and blossoming friendships, we lift each other up.” Mr Low reflects that turning a hobby into a community service makes what he does in his spare time more fruitful. “Volunteering is the best way to do this because we can also give back and contribute to society. Even as retirees, by finding new purpose beyond ourselves, we can definitely go further.”
Group therapy and interaction are essential elements of the session. Through gardening and blossoming friendships, we lift each other up. | 27
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akan Time
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cut & keep
Broccoli, Mushrooms & Tofu in Egg White Sauce
Crunchy and savoury, this quick stir-fry is a well-balanced dish filled with protein and fibre. Recipe contributed by Chef Terry Wan Sau Aun, Food Services, KTPH, in consultation with Nutrition and Dietetics, KTPH
INGREDIENTS Serves 4 • • • • • • • •
240g broccoli, cut into florets 60g shitake mushroom, stems removed and sliced 60g white shimeji mushroom, broken into small clusters 20g carrot, sliced 60g silken tofu, cubed 200ml vegetable stock 10g egg white ½ tsp corn starch, dissolved with a little water
NUTRITIONAL INFORMATION (1 SERVING) Energy
45kcal
METHOD
Carbohydrates
2g
1. Bring a pot of water to boil and blanch the broccoli, mushrooms, carrot and tofu. Drain and plate the broccoli and tofu. Set aside the mushrooms and carrots for the sauce. 2. For the sauce, bring the vegetable stock to a boil, then add in the mushrooms and carrots. 3. Swirl in the corn starch solution. 4. Gently stir the sauce and gradually add the egg white into the thickened stock. Season to taste. 5. Remove from heat and pour the sauce over the broccoli and tofu.
Protein
5g
Fat
1g
• Saturated
0.1g
• Polyunsaturated
0.4g
• Monounsaturated
0.1g
Cholesterol
0g
Fibre
3g
Sodium
216g
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aily Dose
THE ‘KEY ’ TO REMOVING KIDNEY TUMOURS
Using a keyhole technique to remove kidney tumours — rather than making a large incision to take out the entire kidney — helps patients recover faster from surgery and maintains a higher level of kidney function. In consultation with Dr Shum Cheuk Fan, Consultant, Urology, KTPH
K
idney or renal cell cancer is a disease in which malignant cells form in the kidney. It is the ninth most common cancer in Singapore, and the number of diagnoses has been rising in recent years. This is partly due to an ageing population, higher incidence of chronic disease, as well as better rates of screening.
The good news is that more cases of kidney cancer are being discovered at an earlier stage. This greatly increases the chances of survival. Traditional surgery for kidney cancer involves removing the whole kidney via a large incision made in the torso. In some cases, only part of the affected kidney is removed.
KTPH’s Urology Department now offers a less invasive method, which uses laparoscopic (keyhole) surgery to remove only the affected part of the kidney. The technique requires advanced laparoscopic skills, and is recognised as one of the most challenging urological operations. In 2018, 16 such surgeries were conducted at KTPH.
ADVANTAGES OF LAPAROSCOPIC SURGERY:
• Good outcomes Studies show that kidney-sparing surgery (removing the tumour and a margin of normal tissue) is as effective as removing the entire kidney • Kidney function is preserved Patients are less likely to develop kidney failure and cardiovascular problems, improving overall survival rates • Better recovery Patients experience less post-operative pain and scarring, and recover faster
• More benefits Patients with only one kidney are also excellent candidates for this surgery, as it is able to preserve their remaining kidney function
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Colouring
ind & Health The repetitive motion required in order to colour a picture produces a calming effect akin to meditation. Here’s an illustration — taken from our Annual Report — for you to do just that.
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