A policy ethnography study of a Singapore regional health system on its governance adaptations and associated challenges as a project organisation to implement Healthier Singapore.

Objectives: Project organisations reflect a modern and non-bureaucratic form of organising public-sector activities, which promises innovation, entrepreneurship, and order and control to bring about change. This study seeks to investigate the project organisation Singapore Health Services (SingHealth) Region Health System (RHS)'s approach to implementing the Healthier Singapore (HSG) strategy, including models of governance and perceptions of RHS leads, identify the challenges facing the RHS, and to draw insights into the conditions necessary for using project organisation as a policy tool in policy implementation. Study design: We adopted a policy ethnography approach to answering the research question. Methods: The approach involved: (1) non-participant observation with fieldnotes taken during meetings, events, programme activities, and conferences concerning SingHealth and HSG implementation; (2) analysis of 52 organisational documents; and (3) interviews with 21 senior SingHealth leaders from the RHS Executive Committee, involved in envisioning and overseeing the production of RHS projects to align with the HSG strategy (March to September 2022). Results: Evidence demonstrates the presence of multiple governance and interactive governance in HSG implementation, including legitimising the RHS as the project organisation; engaging the private corporations; incorporating the citizens; and working with non-governmental organisations. However, the RHS faced many challenges, ranging from governance, workforce, financing, IT infrastructure and care models, problem definition, primary care and legacy issues, knowledge management, and being pandemic-informed in its delivery. Conclusion: The RHS will need to address these challenges through the necessary constitutive, directive, and operational actions, and interactive governance to enhance its institutional capacity to implement the HSG Strategy.

Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore.

The need to develop holistic public health approaches that go beyond treating the biological causes of ill health, to addressing the social determinants of health, have been highlighted in the global health agenda. Social prescribing, where care professionals link individuals to community resources that tackle social needs have gained increasing traction worldwide. In Singapore, SingHealth Community Hospitals introduced social prescribing in July 2019 to manage the complex health and social needs of the aging populace. Faced with the paucity of evidence on the effectiveness of social prescribing and its implementation, implementers had to contextualise the theory of social prescribing to patients' needs and setting of practice. Using an iterative approach, the implementation team constantly reviewed and adapted practices, work processes and outcome measurement tools based on data and stakeholder feedback to address implementation challenges. As social prescribing continues to scale in Singapore and take root in the Western Pacific region, agile implementation and continued evaluation of programmes to build an evidence pool will help to guide best practices. The aim of this paper is to review the implementation of a social prescribing programme from the exploratory phase to full implementation, and draw lessons learned in the process.

Developing population health research priorities in Asian city state: Results from a multi-step participatory community engagement.

OBJECTIVES: To identify a broad range of research priorities to inform the studies seeking to improve population health outcomes based on the engagement of diverse stakeholders. METHODS: A multi-step, participatory and mixed-methods approach was adopted to solicit and structure the investigative themes from diverse stakeholders. The priority setting exercise involved four key phases: (1) feedback from community leadership; (2) interim ranking survey and focus group discussions during the population health symposium; (3) individual in-depth interviews with stakeholders in the community; and (4) synthesis of the research priorities from the multistep process. RESULTS: Diverse stakeholders in Singapore, comprising community partnership leaders, health care and social service providers, users of population health services, patients and caregivers, participated in the research priority setting exercise. Initial 14 priorities were identified from six community leadership feedback, 42 survey responses, two focus groups (n = 16) and 95 in-depth interviews. The final integrated research agenda identified six priorities: empower residents and patients to take charge of their health; improve care transition and management through relationship building and communication; enhance health-social care interface; improve respite care services for long-term caregivers; develop primary care as a driving force for care integration; and capacity building for service providers. Selected research questions in each priority area were also generated to develop novel models of care, foster collaboration, implement optimal services and enhance understanding of the end users' care needs. CONCLUSIONS: This study illuminates that greater community engagement in research priority setting for population health can facilitate the formulation of evidence-based research agendas that matter to the care providers and service users in the community. The outcomes derived from this exercise will help focus researchers' efforts through which meaningful gains can be made for population health.

ValuedCare program: a population health model for the delivery of evidence-based care across care continuum for hip fracture patients in Eastern Singapore.

BACKGROUND: To test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital. METHODS: The ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months. RESULTS: VC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs). CONCLUSION: The implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system.

Evidence-based decision-making on medical technologies in China, Japan, and Singapore.

OBJECTIVE: To review the use of evidence in the market approval process, reimbursement, and price control mechanisms for medicines and medical devices in China, Japan, and Singapore. METHODOLOGY: Documentary reviews relevant to public health policy and management by government authorities. RESULTS: Drug regulatory authorities play a vital role in the market authorization process of medical technologies. The approval criteria in the three countries are similar to those of the US Food and Drug Administration and many other countries, whose core measures are efficacy, safety, and quality, along with risk-based analyses in China and Singapore. All established the national drug list (Japan) or lists (China and Singapore) for reimbursement. Although Japan reimburses any drugs listed, China and Singapore selectively reimburse regarding the types of the list. The cost-effectiveness is utilized for prioritization of new drugs listed in Singapore. Japan controls the price by government, whereas Singapore keeps market liberalism, and China maintains a mixture of both. CONCLUSION: All three countries have established their own mechanisms, but cost-effectiveness requirements have not been fully introduced yet, partially applied to the reimbursement processes in Singapore.

Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study.

OBJECTIVE: To describe an outbreak of severe acute respiratory syndrome (SARS) in a tertiary hospital in Singapore, linked to an index patient with atypical presentation, and the lessons learnt from it. DESIGN: Descriptive study. SETTING: A tertiary hospital in Singapore. PARTICIPANTS: Patients, healthcare workers, and visitors who contracted SARS in Singapore General Hospital. MAIN OUTCOME MEASURES: Probable SARS as defined by the World Health Organization. RESULTS: The index patient presented with gastrointestinal bleeding, initially without changes to his chest radiograph. Altogether 24 healthcare workers, 15 patients, and 12 family members and visitors were infected. The incubation period ranged from three to eight days. Only 13 patients were isolated on their dates of onset. CONCLUSIONS: Atypical presentation of SARS infection must be taken into consideration when managing patients with a history of contact with SARS patients. The main gap in the containment strategy in this outbreak was the failure to identify the index patient as someone who had been discharged from a ward in another hospital that managed probable SARS cases. Strict infection control measures, a good surveillance system, early introduction of isolation procedures, and vigilant healthcare professionals are essential for controlling outbreaks.