Thursday 14 August 2025 | 14:05-15:05 

Format: Presentation

Stream: Safety

Part 1: Design for Safety and Quality – from Conceptualisation to Actualisation

Woodlands Health Campus is the newest healthcare development in Singapore, contributing to overall healthcare capacity growth. Officially opened in July 2024, it is also the very first to integrate acute, ambulatory, intermediate and long-term care facilities, embracing the challenge to develop new models of care, promote person-centricity, and enhance safety and quality. As one the rare large-scale healthcare developments designed and built in the worldwide pandemic, the experience in rapid improvement to improve safety and resilience will also offer great learnings.

This session will outline Woodlands Health Campus planning journey in creating a new paradigm of design for safety and quality through end-to-end collaborative and participatory approach, in innovating new models of care, transforming care deliver and enabling process improvement.

Key session outcomes:

1. Understand the design and methodology of the SINERGIAPS trial, including its patient-centered audit and feedback approach.
2. Identify strategies to engage patients and healthcare professionals in improving patient safety in primary care settings.
3. Apply implementation science principles, such as the CFIR framework, to evaluate and enhance the real-world adoption of safety interventions.

Yan Yan Woodlands Health; Singapore

Part 2: Enhancing Patient Safety in Primary Care: Evaluating the Impact of SINERGIAPS Through a Hybrid Randomised Clinical Trial

This session will present the SINERGIAPS trial, a patient-centered intervention aimed at improving safety in primary healthcare. We will explore how SINERGIAPS leverages patient-reported outcomes and experiences to drive meaningful improvements in patient safety culture and reduce avoidable hospitalizations. Attendees will learn about the trial’s innovative audit and feedback approach, the use of the PREOS-PC questionnaire, and its integration with educational resources for healthcare teams. Additionally, we will discuss the study’s implementation framework, offering insights into real-world challenges and facilitators. Delegates will gain practical knowledge on engaging patients and healthcare professionals in safety improvement initiatives and explore the broader implications for healthcare systems globally. This session is ideal for anyone interested in advancing patient safety, implementation science, and fostering patient and family engagement in care.

Key session outcomes:

1. Understand the impact of built environment on safety and quality, and as an important part of the overall health system.
2. Appreciate the participatory design approach Woodlands Health Campus has taken in planning and design for safety and quality.
3. Learn about the experience in developing and putting in place a safety system for hospital opening.

Jose M Valderas National University Health System; Singapore

 

 

Thursday 14 August 2025 | 15:35-16:05 

Format: Presentation

Stream: Safety

Part 1: Stories from the little red dot: A data driven approach to tackling Alert Fatigue in Electronic Medical Records

Singapore is currently transitioning to New Generation Electronic Medical Record (NGEMR), a unified system for all public healthcare institutions. During this transition, clinical decision support tools that were originally developed for individual institution was migrated in bulk to all institutions. This was causing frustration for users as they did not integrate well with clinical workflows and contributed to alert fatigue.

This presentation captures the Quality Improvement (QI) journey undertaken by the National University Health System (NUHS) in Singapore to transform its Clinical Decision Support system, focusing on our top firing Best Practice Advisories that contributed to the majority of alert fatigue. The goal was to enhance alert efficacy, reduce alert fatigue, and improve user experience by making it easier to do the right thing.

1. Improve the effectiveness of clinical alerts by evaluating their quality, minimising alert fatigue, and implementing targeted improvements.
2. Optimize Clinical Decision Support (CDS) systems using quality improvement methods, data-driven insights, and strong governance frameworks.
3. Drive sustainable CDS enhancements through stakeholder engagement, process standardisation, and adaptable implementation strategies informed by real-world experience.

Key session outcomes:

Jishana Farhad Abdul Naseer National University Health Systems; Singapore
Lim Er Luen National University Health Systems; Singapore

Part 2: Implementing Cost-Effective Pharmacogenetics Service for Improving Patient Safety

Pharmacogenetics uses a person’s genetic information to inform if they may be under-dosed (i.e. therapeutic failure), overdosed (i.e. toxicity) or are at risk of adverse drug reactions. It is an important clinical tool for improving patient safety. Data from Singapore showed that about 30% of adverse drug reactions (ADRs) admitted to a major acute care hospital in Singapore were caused by at least one drug with a clinical annotation in the Pharmacogenomics KnowledgeBase (PharmGKB). Furthermore, the SG10K_Health study further revealed that 26.8% of Singaporeans carry a genetic variant that raises the risk of life-threatening side effects to at least one medication. This session will describe the processes for implementing a pharmacogenetic service across multiple acute care hospitals in Singapore, share the lessons learnt and discuss approaches to improve the cost-effectiveness of such a service, including identifying the subgroups of patients who will experience the greatest benefits.

Key session outcomes:

1. Improve the effectiveness of clinical alerts by evaluating their quality, minimising alert fatigue, and implementing targeted improvements.
2. Optimize Clinical Decision Support (CDS) systems using quality improvement methods, data-driven insights, and strong governance frameworks.
3. Drive sustainable CDS enhancements through stakeholder engagement, process standardisation, and adaptable implementation strategies informed by real-world experience.

Wee Hwee Lin Saw Swee Hock School of Public Health; Singapore

Thursday 14 August 2025 | 15:35-16:05 

Format: Presentation

Stream: Change

Part 1: Revolutionizing Hospital Operations: Unlocking Capacity and Elevating Patient Care through Lean Redesign of Inpatient Flow

Discover a groundbreaking approach to transforming hospital operations by shifting from traditional push systems to dynamic pull systems that enable seamless, continuous patient flow from the Emergency Department to admission and discharge. This transformative concept tackles the root causes of bottlenecks, revealing how batching decisions and tasks in clinical settings creates “idle time” for patients and constrains hospital capacity. Learn how patients who remain hospitalized beyond medical readiness contribute to delays and perpetuate outdated push systems, extending length of stay (LOS) and reducing bed availability. By applying A3 Lean and Six Sigma principles, this approach integrates stakeholder engagement, operational redesign, and data-driven strategies to revolutionize hospital flow. This presentation showcases how Lean methods streamline discharges, reduce LOS, and deliver measurable financial gains—all while enhancing the patient experience. Join us to explore a sustainable transformation that redefines hospital efficiency and sets a new standard for patient-centered care.

1. Transform hospital flow with Lean principles by mastering push vs. pull systems, eliminating bottlenecks, and addressing delays such as discharge inefficiencies.
2. Drive system-wide change using the A3 Framework and data-driven strategies, engaging stakeholders to reimagine processes and implement sustainable, high-impact solutions.
3. Build a foundation for lasting improvement by leveraging staff, patient, process, and technology insights to design effective, scalable, and enduring transformation initiatives.

Key session outcomes:

Danna Qunibi University of Texas Southwestern Medical Center; USA
Lauren Lazar University of Texas Southwestern Medical Center; USA

Part 2: Mastering Quality for Healthcare 2.0 : Developing Robust Quality Improvement Capabilities across a Healthcare Cluster

Join this illuminating session to explore the transformative journey of the National University Health System (NUHS) in Singapore as they systematically built Quality Improvement (QI) capacity and capability across their healthcare institutions. From 2019 to 2024, NUHS embarked on an ambitious initiative to cultivate a culture of excellence throughout its hospitals and primary care services by leveraging the Institute for Healthcare Improvement (IHI) Model for Improvement and lean principles.National University Hospital and Ng Teng Fong General Hospital led this initiative, training 25% of the cluster’s staff to proficiently apply the framework and leading to over 800 successful improvement projects from 2019 to 2024. This session will share key strategies, challenges, and successes, providing practical insights for leaders, clinicians, and healthcare professionals looking to scale QI efforts within their organizations. Discover how fostering widespread QI proficiency can drive sustainable change and enhance care outcomes.

Key session outcomes:

1. Understand how to scale QI capacity across diverse healthcare settings using the IHI Model for Improvement.
2. Explore key strategies for engaging staff and leadership in large-scale QI training initiatives.
3. Gain insights into overcoming challenges and measuring the impact of QI efforts on patient outcomes and organizational performance.

Bhuvaneshwari Mohankumar National University Health System; Singapore
Hwang Chi Hong Ng Teng Fong General Hospital; Singapore

 

Thursday 14 August 2025 | 14:05-15:05 

Format: Presentation

Stream: Populations

Part 1: Scaling Hospital-at-Home: Ensuring Quality and Safety during Growth

This session explores how hospital-at-home programmes can scale rapidly while maintaining high standards of quality and safety. Singapore will present its journey in evolution and scaling of hospital-at-home locally, alongside strategies for balancing growth with patient safety and operational efficiency. Melbourne will share insights from their use of a digital algorithm embedded in their electronic health record for real-time identification of patients suitable for hospital-at-home and impact on patient uptake and outcomes. The discussion will focus on practical strategies to ensure safe, high-quality care while supporting programme expansion.

Key session outcomes:

1. Apply strategies for scaling hospital-at-home programs while ensuring safety and quality.
2. Draw from international case studies to inform their own hospital-at-home initiatives.
3. Understand how patient-reported measures shape care models and operational decisions.

Stephanie Ko National University Hospital; Singapore
Seok Ming Lim Royal Melbourne Hospital; Australia

Part 2: Innovating to Build a Culture of @Home Care: Redesign Ideas and Lessons Learned

Health systems must deliver high quality consumer outcomes and experiences but are under pressure from rising demand and increasing capital costs. Turning toward innovative @home care delivery models is one way health services can meet these challenges now and into the future. Eastern Health (Melbourne, Australia) has progressed on a journey toward a culture that places high value on @home care over recent years. This session will present a series of change ideas and lessons learned that have driven sustained growth in @home care (both admitted and non-admitted), reduced clinically avoidable readmissions and a delivered strategically aligned organisation that promotes @home care. Delegates will hear what has worked – clinician empowerment, pathway development, digital enablement and sector partnerships – and will also learn from some ideas that did not do as planned.

Key session outcomes:

1. Reflect on the strategic importance of @home care in their health service context
2. Take away concepts/improvement initiatives that will support enhanced care outside of the ward environment
3. Consider examples of service redesign that build @home capacity to address capital costs, while maintaining high quality patient outcomes and experiences.

James Campbell Eastern Health; Australia
Penny Gaskell Eastern Health; Australia

 

Thursday 14 August 2025 | 14:05-15:05 

Format: Presentation

Stream: People 

Part 1: Enabling Value-Based Care: Strategies to Improve Adoption of Patient Reported Outcome Measures (PROMs)

This session will explore an innovative approach to scaling the adoption of Patient Reported Outcome Measures (PROMs) in healthcare, focusing on Tan Tock Seng Hospital’s (TTSH) multi-pronged strategy. By utilising IT enablers such as Robotic Process Automation (RPA), alongside comprehensive patient and clinician education, the project successfully increased PROMs adoption, improved patient participation, and generated substantial cost savings. Attendees will learn practical methods for driving PROMs adoption in the healthcare setting, with insights into overcoming barriers and fostering a culture of value-based care.

Key session outcomes:

1. Learn systemic change management strategies used to drive PROMs adoption
2. Explore methods of patient and clinician education that drive increased engagement with PROMs.
3. Gain insights on the benefits of involving and empower patients to take an active role in their healthcare journey through PROMs.
4. Understand how to leverage IT enablers to automate and scale the implementation of PROMs.

Chan Lai Gwen Tan Tock Seng Hospital; Singapore

Part 2: Volunteer-Powered Care: Revolutionising Rehabilitation in Tan Tock Seng Hospital Integrated Care Hub

This presentation showcases the innovative volunteer programs at TTSH Integrated Care Hub (ICH), an inpatient rehabilitation facility. Despite staff capacity constraints, volunteers bridge gaps in direct patient assistance and social support, enhancing patients’ recovery. Our programs include Therapeutic Program Assistance (e.g. Adaptive Sports; Vista Fiesta), Direct Patient Support (e.g. Patient Engagement), and Specialized Programs, supported by over 400 volunteers who contributed 6,000+ hours over a 6-month period. Our Para-Nursing program, a Singapore first, has attracted diverse volunteers, including migrant domestic workers. Volunteers receive the necessary skills training and buddy-guidance, ensuring a nurturing environment for them to practice skills and gain confidence. They also acquire transferable skills, benefiting their own communities. This presentation highlights effective volunteer integration into healthcare settings; innovative program development and management; and lessons learned for the plans forward. Explore how volunteerism can transform patient care and foster a supportive ecosystem.

Key session outcomes:

1. Gain insights into the effective volunteer integration into healthcare settings
2. Learn about innovative volunteer development and management
3.Reflect on how volunteerism can transform patient care and foster a supportive ecosystem.

Hayley Chau Tan Tock Seng Hospital; Singapore
Wee Fong Chi Tan Tock Seng Hospital; Singapore

 

 

Woodlands Health; Singapore

Speaker bio to follow. 

Thursday 14 August 2025 | 14:05-15:05 

Format: Presentation

Stream: Change

Part 1: Rapid Respiratory Recognition and Response: Building Capacity for Primary Healthcare Providers (4R Project)

This project will trial the integration of High-Velocity Therapy (HVT) in eight primary healthcare facilities to evaluate its feasibility, safety, and effectiveness in managing pediatric respiratory distress. The study includes a novel teleconsultation feature where primary healthcare providers can receive real-time guidance from pediatric specialists during HVT administration, enhancing decision-making and adherence to clinical protocols. Key Objectives

• Evaluate Patient Outcomes: Use objective measures like respiratory rate (RR) and SF ratio (SpO₂/FiO₂) scores to monitor the effectiveness of HVT in stabilizing children with respiratory distress.


• Enhance Provider Support: Implement teleconsultation for on-demand specialist input to guide frontline providers in using HVT effectively.


• Optimize Protocols: Assess adherence to standardized protocols and identify areas for improvement to ensure safe and effective implementation in primary healthcare.


• Reduce Mortality and Deterioration: Analyze the impact of HVT on patient stabilization and outcomes before referral to hospitals.

Key session outcomes:

1. Identify the role of High Velocity Therapy (HVT) in managing pediatric respiratory distress in primary healthcare settings, including its clinical benefits and indications.
2. Discuss practical steps to adopt HVT and teleconsultation in their healthcare environments to address similar challenges.
3. Evaluate the impact of teleconsultation on enhancing provider confidence and protocol adherence, and its role in improving patient stabilization outcomes.Apply evidence-based strategies to integrate innovative therapies like HVT into resource-limited settings, ensuring safety, feasibility, and sustainability.

Tartila Tartila Dr. Cipto Mangunkusumo National Referral Hospital; Indonesia

Part 2: Innovations in Respiratory Care

Discover the cutting-edge advancements shaping the future of respiratory care in this dynamic session. We will explore how Tele-NIV empowers healthcare professionals and patients through remote monitoring, reducing ICU readmissions and enhancing outcomes. Learn how different machine learning models predict ICU readmissions, enabling proactive interventions and resource optimization. Dive into the importance of integration of ventilator parameters into EMRs, unlocking real-time data for improved decision-making and patient safety. Finally, uncovers the power of digitalized workflows and competency in transforming healthcare efficiency and staff training, making it available anywhere and everywhere for healthcare professionals. This session offers actionable insights for clinicians, administrators, and innovators looking to stay ahead in respiratory care.

Key session outcomes:

1. Understand the benefits and implementation of Tele-NIV in reducing hospital readmissions and improving patient outcomes.
2. Explore strategies for digitalizing competencies and workflows to improve healthcare staff training and operational efficiency.
3. Recognize the value of integrating ventilator parameters into EMRs to enhance respiratory care efficiency and accuracy.

Ong Wei Jun Dan Ng Teng Fong General Hospital; Singapore

Thursday 14 August 2025 | 10:40-12:10 

Format: Presentation

Stream: People

Part 1: A Public Hospital’s Ten-year Value Driven Care Journey Towards Sustainable Healthcare

The Changi General Hospital (CGH) Value journey which started almost a decade ago has seen tremendous progression in our approach towards delivering care that matters to our patients; from standardised care pathways to optimisation of care bundles. In this ever-evolving healthcare landscape where our patients are becoming older, frailer and have more co-morbidities, there is a need for a more innovative and sustainable approach in how we deliver care to ensure that our patients not only get well, but also stay well and continue to live well when they return home. Building on the successes and learning from the challenges of our journey thus far, we developed a robust SPORE (Significance, Prioritisation, Ownership, Resourcing and Enable) framework coupled with mindset building to inculcate value-consciousness in both staff and patients. The Mission-Method-People formula is the core fuel driving all value improvement activities across CGH and partners, to achieve sustainable excellence for our population across the care continuum.

Key session outcomes:

1. Shifting mindsets towards value-based healthcare
2. Identifying improvement opportunities and overcoming challenges sustainably
3. Practical applications of improvement methodology to drive value improvement activities

Jansen Koh Changi General Hospital; Singapore
Ang Woo Boon Changi General Hospital; Singapore
Lim Fang Ming Changi General Hospital; Singapore

Part 2: Driving Sustainable and Cost-Effective Healthcare in Singapore

Traditionally, healthcare cost containment and sustainability have been viewed as the domain of public policy and payors, while private providers are often perceived as drivers of increased utilisation and expenditure. IHH Healthcare Singapore (IHH SG) believes that sustainable healthcare requires shared responsibility across all stakeholders, including private providers.

This presentation outlines our efforts to contribute meaningfully to this agenda. Key initiatives include reducing costs associated with suboptimal care, implementing systems to track value-based outcomes, and optimising procurement strategies to lower the cost of care. We will also share our experience working with payors to enhance case management.

Beyond institutional initiatives, IHH SG supports the national agenda on preventive care and population health through active participation in Healthier SG. This includes managing chronic diseases at the community level and proactive health promotion through workplace outreach and partnerships with corporate human resources to support employee health and well-being.

Through these initiatives, IHH SG demonstrates that private healthcare providers can play a critical role in achieving both high-quality care and cost sustainability—contributing to a more resilient and patient-centered healthcare ecosystem.

Key session outcomes:

1. Advance cost-effective, high-quality care by reducing suboptimal care, tracking value-based outcomes, and optimizing procurement to improve affordability in private healthcare.
2. Strengthen payer-provider collaboration through enhanced case management and shared responsibility for sustainable healthcare financing.
3. Promote preventive care and population health by supporting national initiatives like Healthier SG and engaging in community outreach and corporate wellness partnerships.

Peter Chow IHH; Singapore

Part 3: Engaging & Empowering patients to drive sustainable change: Patient as partner and resource


Patients can play a significant role in influencing and contributing to lasting improvements in healthcare systems, this session explores actionable strategies and share experience to:

• Engage patients with kidney disease as active partners and a resource in their care.


• Leverage patient experience and insights to enhance quality and safety in healthcare.


• A process of engagement, participation, knowledge/informed/enablement to empowerment and partnership.

SF Lui Hong Kong Kidney Foundation; Hong Kong
Bill Wang Hong Kong Kidney Foundation; Hong Kong

Thursday 14 August 2025 | 10:40-12:10 

Format: Session

Stream: People

Part 1: Person-Centred Improvement through ESTHER Network Singapore: Making What Matters To Our Patients A Reality

This talk showcases ESTHER Network Singapore’s innovative approach to person-centred improvement, which not only starts with our patients (or Esthers) but actively involves them in the design and implementation of person-centred care improvement for meaningful and sustainable change in health and social care delivery. The session unveils the ESTHER person-centred care philosophy and our nine-year journey of co-creation through real-world examples. Learn how we foster cross-sector synergy, bridging gaps between patients, health and social care providers and key stakeholders. We’ll share our approach to measuring what matters to patients and candidly discuss challenges and lessons learned. Through compelling real-world case studies and patient stories, we demonstrate that person-centred improvement is not just an ideal, but an achievable and necessary reality. Join us to explore how the person-centred improvement approach can drive meaningful and sustainable change in health and social care.

Key session outcomes:

1. Understand ESTHER Network Singapore’s key principles of person-centred care improvement and co-creation.
2, Identify strategies for meaningful patient engagement and cross sector collaboration in health and social care initiatives.
3. Gain practical insights from real-world examples, challenges and lessons gleaned over nine years of person-centred care improvement.

Joy Tan Meiling Singapore General Hospital; Singapore

Part 2: Southcentral Foundation’s Journey with Co-Creating Healthcare with the Alaska Native Community?

25 years ago, Alaska Native people chose to assume responsibility for their own health care, breaking away from a federally-run system that did not meet the needs of the community. Southcentral Foundation (SCF), an Alaska Native-owned and operated system, now provides health care and related services to approximately 70,000 Alaska Native and American Indian people in southern Alaska. SCF’s relationship-based Nuka System of Care was built from the ground up by and for the community it serves, creating a system where patients are active partners in their care. This has led to greatly improved quality of care for the community, as well as increased customer and employee satisfaction. This session will cover how SCF worked with the Native community to transform the health care system, how it maintains the system according to the community’s values, and how the system has led to improved health outcomes for the community.

Key session outcomes:

1. Describe how SCF worked with the Alaska Native community to transform the health care system
2. Identify the key elements of SCF’s relationship-based system of care
3. Analyze how SCF’s transformed system supported the Alaska Native community in achieving better health outcomes

Doug Eby Southcentral Foundation; USA 
Gerard Asselin Southcentral Foundation; USA 

Part 3: Accelerating Value-Based Healthcare in the National Healthcare Group – Our Story

This session will feature our journey and lessons learned over the past two decades on Value-Based Healthcare processes and ground up initiatives, from patients to populations. For the medical workstream, we will showcase Asthma as an example, taking a National, Cluster and Institutional lens, with integrated care pathways (ICPs) and how we improved the country’s mortality and DALYs (Disability Adjusted Life Years). We will share key quality improvement efforts within and across settings and systems. Current challenges to care and future directions will be explored. For the Surgical workstream, we will share in detail our Enhanced Recovery After Surgery (ERAS) programme, and how it has helped reduce complications, length of stay and costs for patients and the system. By sustaining and scaling ERAS across different surgical subspecialties, ERAS is a Value based care enabler for improved surgical outcomes with cost reductions. For the Finance workstream, we will share how we are using Financing as a lever to bend the cost curve. This would include varying financing of patient care by care settings to incentivize care shifts, focusing on specific population segments such as high utilizers who consume disproportionately higher cost of care, and analyzing variations in Top Diagnosis Related Groups (DRGs).

Key session outcomes: 

1. Gain insights from implemented practices to adopt into their own practice settings.
2. Understand how Value based healthcare is instituted in a cluster hospital network, with end-to-end integration and evaluation.
3. Participants will be able to understand challenges and solutions in PROM adoption and implementation within an Electronic Medical Record System (EMR).
4. Use an evidence-based approach to identify variations at practice level and scaling of best practice approaches.
5. Understand how financing can be used to complement clinical care transformation and integration.

John Abisheganaden Tan Tock Seng Hospital; Singapore
How Kwang Yeong Tan Tock Seng Hospital; Singapore

 

Thursday 14 August 2025 | 10:40-11:10 

Format: Session

Stream: Safety

Part 1: How Human Factors and Ergonomics Can Improve Patient Safety – Case studies from Hong Kong Public Hospitals

Human factors and ergonomics studies humans and their interaction with the surroundings to improve human performance. With the complex work environment in healthcare settings, human factors and ergonomics help improve the design of different aspects of the sociotechnical system by understand the capabilities and limitations to eventually improve patient safety, prevent incidents and enhance patient experience. This presentation shares real case examples in public hospitals of Hong Kong how human factors and ergonomics can be applied to improve system design and monitor effectiveness of improvement actions for sustainability. These examples include modification of mental models, modification of product and environmental design and standardisation of safety practices.

Key session outcomes:

1. Understand what human factors and ergonomics is
2. Understand how human factors and ergonomics can help improve the sociotechnical system and improve patient safety
3. Learn from real cases how human factors and ergonomics can be applied in healthcare settings

Andy Kwok Hospital Authority; Hong Kong

Part 2: Psychological Safety for Sustainable Quality in Healthcare: Empowering Speaking Up, Engendering Civility & Enhancing Trust

In healthcare, sustainable quality hinges on open communication, yet fear of speaking up often undermines trust, leading to errors and missed opportunities for improvement. High-reliability organizations struggle to progress through the four stages of psychological safety, particularly in fostering open dialogue and providing constructive feedback. This session introduces TeamSPEAK™, an initiative by Singapore’s largest healthcare cluster dedicated to promoting psychological safety and fostering open communication. This comprehensive approach enhances effective communication, reinforces positive change, and advances the organization through the stages of psychological safety. Coupled with TeamGRACE™, a locally developed program promoting professional behavior, civility, and communication among staff to achieve positive workplace culture and improve trust. We aim to cultivate an environment where transparent communication not only enhances safety but also drives continuous improvement and sustainable quality in patient care. Join us to discover practical strategies and real-world examples of how fostering psychological safety can transform healthcare environments, improve team dynamics, and lead to sustainable quality improvements.

Key session outcomes: 

1. Understand the four stages of psychological safety and their impact on team dynamics.
2. Acquire practical skills to promote psychological safety within teams.
3. Develop strategies to foster a psychologically safe environment that supports sustainable quality improvement.

Alvin Chang KK Women’s and Children’s Hospital; Singapore
Pang Nguk Lan KK Women’s and Children’s Hospital; Singapore

 

Part 3: Getting through Fear of Blame to Reporting and System Learning – Our Journey in Increasing Near-Miss Reporting

Tan Tock Seng Hospital is one of the largest tertiary hospitals in Singapore. Over the years, we worked on promoting a culture where hospital staff can share information openly and are given fair treatment when an incident happens. We established a second victim support program where staff involved in a serious adverse event are provided support based on a tiered model. The fear of blame is a common barrier to incident reporting. A Good Catch Program was co-created with frontline staff to recognise people who prevented errors from causing harm. We have achieved a sustained increase in near miss reporting. This enabled us to be more pro-active in system gap identification and closure before patients are harmed. This session is for healthcare practitioners at every level seeking to understand how to improve safety culture and near miss reporting.

Key session outcomes: 

1. Understand how a Just Culture tool can be used jointly with the Decision Tree for Determining Culpability of Unsafe Acts, to ensure balanced accountability for staff and organization whilst allowing the need for an open and honest reporting environment.
2. Appreciate how a Just Culture tool helps the supervisors to evaluate the incident without bias or judgment and provide fair treatment to staff, whilst learning from the incident and fixing the underlying system issues to provide a safe environment for patients.
3.Understand how an organization can provide a formal support structure to staff following an adverse event. Understand how the implementation of a Good Catch Program and error communication contribute to system improvement through learning from near miss reporting

Tan Hui Ling Tan Tock Seng Hospital; Singapore