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What counts for quality care?

How do you gauge what makes for quality care at a healthcare institution? Is it by measuring improvements in wait time? Counting the number of research papers published? Or is it by asking patients how often they were shown courtesy and respect?

Quality care is measured using all those metrics but it is also determined by whether patients choose to be cared for by an institution, according to Chief Quality Officer of the National Cancer Centre Singapore (NCCS), Dr Terence Tan.

“We want our patients to choose NCCS not only for the excellent clinical care we provide but also the excellent experience they get when they are treated here,” said Dr Tan, who is also Senior Consultant in the Division of Radiation Oncology at NCCS subspecialising in head and neck cancers and uro-oncology.

The challenges of measuring quality

In 2016, NCCS embarked on its first two-year quality plan to support the institution’s Four Quality Priorities; safety, courtesy, show and efficiency. At NCCS safety is defined as not putting patients at risk of harm, courtesy is treating patients with care and respect, show is doing the best for patients and efficiency is smooth delivery of care.

A key challenge, when formulating the quality plan, was getting buy-in from different departments to identify meaningful key performance indicators (KPIs).

“The biggest obstacle we faced when formulating the quality plan was that people were afraid that they would fail to meet their KPIs,” recalled Dr Tan. “There was a tendency to choose KPIs or set targets that were easy to meet, but that does not help us improve the quality of care.”

To get around this challenge, Dr Tan and his team explained that KPIs and targets can help teams to monitor their efforts and progress as they work towards the goal of providing the best possible care for patients.

Very soon, departments saw the value of the plan and were willing to push their targets higher and higher with each successive two-year plan, with scores in safety, courtesy, show and efficacy significantly improving over the years.

Just smile and communicate

National Cancer Centre Singapore nurses are all smiles at a 2019 Nurses’ Day celebration.

In 2018, in response to an institution directed challenge, NCCS nurses chose to work on improving the patient experience by providing clearer explanations using the S.M.I.L.E communication framework. First conceptualised by Dr Tan in 2016, S.M.I.L.E is based on the belief that good communication forms the basis of good staff-patient interaction.

S.M.I.L.E provides a guide for conversations to ensure a positive experience for patients when attended to in NCCS. The adoption of this framework soon showed an increase in scores to the question, “How often did staff explain things in a way you could understand?” in patient feedback forms for NCCS nurses.

Seeing how a simple communication framework could improve patient experience prompted Dr Tan and his Quality Management team to make “Clear Explanation” a KPI in 2019 for all NCCS Allied Health Professionals, while NCCS doctors were taught the S.M.I.L.E communication framework. “Clear Explanation” scores across NCCS improved from 2018 to 2021 from 80% to 96% improvement for nurses’, 71% to 84% for allied health professionals and 81% to 96% for doctors in the same period.

Quality in action

Earlier this year, a patient wrote a commendation for a nurse who attended to her during a chemotherapy session at the NCCS Ambulatory Unit. When she first arrived, the nurse asked the patient if she wanted her dressing changed. The patient was certain that the nurse had familiarised herself with her case before she arrived because the patient had experienced an issue with her dressing at her last visit.

The attention to detail continued when the nurse asked the patient about her past sessions. After the patient shared that she had previously felt very drowsy during the administration of a support drug to reduce allergic reactions to chemotherapy, the nurse made sure that the support drug was administered slowly so that the patient did not experience a sudden drop in energy levels. The nurse also helped her with a request for medication and a COVID-19 booster appointment.

“The service and nursing care provided was above expectation and patient-centric,” shared the patient.

Maintaining standards of quality at the new NCCS


Nurses at the National Cancer Centre Singapore put patients at the heart of all they do.

NCCS is slated to move its operations to a new, much larger purpose-designed building at the end of 2022. The new space will provide opportunities to improve patient experience, but it also comes with the challenge of maintaining quality care in a new and larger setting.

“The foundation for quality care in the new NCCS building is being planned and built while we are still in our old premises,” said Dr Tan. “What we have established for quality must be ingrained, transported to the new building and improved even further.”

This can be achieved by coordinating a well-planned move so that staff, equipment and processes are in place for services to begin and be provided in the same safe, professional and efficient manner as it is now. The move will be supported by audits and data collection which will be shared with department heads and leadership for action.

Patients are at the heart of all we do

When asked what his vision is for the future of quality care at NCCS, Dr Tan is quick to answer.

“The new NCCS building will be many times larger than our current floor space, but we shouldn’t just be a bigger version of what we are now. We need to be bigger and better than what we are now. For that to happen, we must collectively focus our efforts to be truly patient-centric at every point of the care journey,” declared Dr Tan.