Data Sources for Healthcare Regulation in Singapore

1. Data Sources for Healthcare Regulation in Singapore Sharing at the 27th EPSO Conference 11th April 2019

2. Singapore’s healthcare system serves public health and well-being • MOH’s Vision: • Championing a healthy nation with our people – to live well, live long, and with peace of mind • MOH’s Mission is to: • Promote good health and reduce illness • Ensure that Singaporeans have access to good and affordable healthcare that is appropriate to needs; and • Pursue medical excellence

3. Care across the continuum is delivered via a mix of public and private channels Health Promotion Acute Care Long term care Primary Care Intermediate Care Individual & Community Responsibility Supported by the Health Promotion Board Private Hospitals (~ 20% of inpatient beds) VWO-owned Community Hospitals (~60%) VWO-owned Nursing Homes (66%) Private commercial operators (33%) GPs and Private Sector Group Practices (~ 80% of patients) Restructured Hospitals & National Centres (~ 80% of inpatient beds) Govt-owned Community Hospitals (~40% & growing) Family Medicine Clinics (public private partnerships) Polyclinics (~ 20% of patients) Vanguard Health (1% by 2020) Government starting to have more influence/ presence in primary care and ILTC sectors Government owned or delivered Privately owned or delivered

4. Our overall regulatory approach is layered and risk based • First, we regulate drugs and devices under the  Health Products Act and Misuse of Drugs Act. • Next, we regulate the healthcare professionals providing care via the professional registration acts e.g. Medical Registration Act, Dental Registration Act, Nurses and Midwives Registration Act, Allied Health Professional Acts. • Where there are clear patient safety risks, we regulate the services and premises where care is provided.   • Finally, for all other care-related harm, criminal law protects the public. Criminal Law Premises & Services Professionals Medicines & Medical Devices

5. With a Comprehensive Licensing Strategy • Policy Development and Engagement • Licensees are educated through continuous engagement on the sectoral compliance status, good practices, key issues and policy updates. • A consultative approach is adopted in creation of regulatory standards and guidelines. • Monitoring and Controlling • Premises-based licensing regime based on PHMC Act. • The tenure of licences are determined by the compliance rate assessed through inspections (new/routine) or audits (ad-hoc/compliance). • Enforcement and Prosecution • Based on various sources of information e.g. complaints, whistle-blowers, inspection findings, errant licensees can be taken to task under the regulatory ambit of the PHMCA or referrals to professional bodies. • Prosecution through courts lead to monetary fines or jail sentences of licensees. 3 2 1 Premises & Services

6. We operate on a premises-based licensing regime today Number of Licensed Healthcare Institutions* • Legislation in the past was not sufficient to regulate: • More private hospitals, and the corporatisation of government hospitals; • Medical clinics providing alternative care e.g. Sanatronic clinics. • Therefore, there was a need for a stronger regulatory measure: • In 1980, the Private Hospitals and Medical Clinics Act (PHMCA) was enacted to provide governance and oversight over private hospitals, clinics, laboratories and healthcare establishments. • Today, a total of 4,602 licensees are regulated under the PHMCA. *correct as at 30 Dec 2018

7. But, our operating context is changing… AGEING ADVANCING 1 2 population Medical technologies • Personalised medicine via genetics and Precision Medicine • Novel, state-of-the-art and high cost drugs, devices, treatments and vaccines (e.g. Proton Beam Therapy) FEWER working-age adults Persons aged 20-64 years per elderly aged 65 years & over 2X 5X longer hospital stays > Likely to be hospitalized Tech companies’ interest in the healthcare sector have led to the influx of state-of-the art medical equipment and novel treatments. compared to those 20-54 yrs INCREASING 3 incidence of chronic diseases due to urban lifestyles • undetected, • untreated or • poorly managed, Chronic disease can reduce patients’ quality of life and increase the care and cost burden on families RISING 4 healthcare costs $11b 2016 $4.7b 2012 >2X government expenditure on healthcare Driven by the ageing population and Government’s shift to bear a greater proportion of healthcare costs

8. … And, as a Ministry, we are making 3 key shifts – Moving: • Beyond Hospital to Community • Transforming primary care • Developing aged care in the community • Integrating care across continuum • Growing need for new care models into the community and coordinated team-based care across healthcare settings • Better governance for safe, good quality care and appropriate care- What is the Impact? 1 • Beyond Quality to Value • Ensuring appropriate care & treatments • Making healthcare delivery more productive 2 • Emerging Technology • Cell and Tissue Therapy • Genetic Testing • Artificial Intelligence • 3D Organ Printing? • Others? • Examples of New Models of Care • Telemedicine • Precision Medicine • Models that Support Ageing • Mobile Medicine • Mobile Health Screening • Home Care • Beyond Healthcare to Health • Moving upstream to health; war on diabetes • Ageing actively 3

9. As such, we are also updating our primary premises/services regulation • NEW Healthcare Services(HCS) Bill: • To safeguardpatient safety and welfare, while enabling the development of new and innovative healthcare services that benefit patients • To strengthen regulatory clarity • To enhance governance of licensed entities • To ensure continuity of care and accountability • Services-based licensing regime • Private Hospitals & Medical Clinics Act (PHMCA): (established 1980) • To provide for the control, licensing and inspection of private hospitals, medical clinics, clinical laboratories and healthcare establishments, and for purposes connected therewith. • The Act functions on a premises-based licensing regime to ensure patient safety at premises delivering healthcare. Proposed date of enactment of HCS Bill: 2019 (licensing will occur after an adequate ‘sunrise’ period) OUTDATED

10. As such, we are also updating our primary premises/services regulation Private Hospitals & Medical Clinics Act (PHMCA): (established 1980) NEW Healthcare Services(HCS) Bill: • services-based: not tied to entities possessing a ‘brick and mortar premises’ • flexible and modular: can accommodate various business models • Only 4 license categories • No provisions for the licensing of healthcare services delivered outside of fixed premises OUTDATED Non-premise based services? e.g. Telemedicine, Mobile Medical, Ambulance A Flexible and Encompassing Services-Based Licensing Regime

11. A key component of our regulatory approach is a risk-based approach What? Varying license tenure and inspection frequency based on the risk profile of a licensee (e.g. inspecting low risk clinics at most once every 5 years). Why? More efficient use of resources by focusing efforts on higher risk licensees who are more likely to result in lapses in patient safety Reduce regulatory burden for licensees who have lower risk. How? Collecting data on potential risk factors of licensees. Analyzing data to obtain predicted risk profiles of licensees

12. Our Approach to Risk Profiling today consists of global and individual risk

13. These risks are mainly determined by compliance history Global Risk of Service • Global risk of service based on broad analysis of: • Degree of Service Complexity • Historical Compliance of Service Providers • Acuity of Patients • Volatility of Risk Factors (prevalent for long term care service providers) • Individual Risk Profile of each licensee based on historical compliance records • Risk assessed during each inspection computed based on risk tagging of each inspection requirement. • Current risk computed based on 2 past inspections. Individual Risk Profile of Licensee

14. However, there is a lot more data available to us when constructing risk profiles Individual Risk Profile Financial Info Incident Reporting Facilities and Equipment Info Quality Indicators Staffing Info Inspection/ Audit/ Enforcement & Complaints Capacity & Utilisation Info • Falls • Medication Errors • Surgical Errors • Address Data within the Ministry of Health • Compliance Status during Inspection/Audit • Enforcement against HCI • Number and Nature of Complaints • MOH funding • Participation in MOH Financial Schemes Financial Scheme Audits • Financial Health (e.g. Operating Margin) • Staff Turnover Ratio/Employee Attrition Rate • Care Staff Ratio • No. of Beds • Bed Occupancy Rate • Admissions • Attendances • Average Length of Stay • Return to ED /Readmission Rates • Mortality Rates • Near Misses • Infection Control Indicators (e.g. MRSA Rates) • Pressure Ulcer Rates • Waiting Time • Fire Safety Certs • NEA Radiology Licences • MOM Autoclave Licences • Foreign Worker Levy Payment Default • CPF Payment Default • Internal financial audits from MOHH Data from other Governmental Agencies • Accreditation Status (e.g. SAC-SINGLAS for labs) • Contraventions/offences from other professional boards/agencies (e.g. HPA offences, disciplinary records)

15. Moving forward, we plan to use these sources of data to inform our regulatory efforts • Business Intelligence • Developing dashboards to allow real-time monitoring and analysis of risk factors and outcomes of healthcare institutions. • Business Analytics • Enhancing individual risk profiling by developing a predictive model of risk, based on the different sources of available data. 1 Gathering historical data from different sources across MOH and other government agencies 2 Merging datasets to develop dataset for analysis 3 Using statistical tools and methods to build and test models for predicting risk

16. Some key challenges we foresee… • Completeness of data: • Given the variety of healthcare institutions we license, not all data collected might be complete (e.g. not all HCIs are registered with ACRA and submit their financials, Private Hospitals do not report indicators on utilization to MOH) • We do not have a complete picture of patient feedback (we collect some feedback for Public Hospitals, but not for most of the other sectors). • Contextualization of Data: • Given the differences in operating models of each healthcare institution, indicators might not have the same scale or magnitude in predicting risk of different institutions (e.g. need to adjust for casemix when considering certain quality indicators - hospital specializing in cardiac surgery is might have more cardiac surgical issues than a general hospital due to increased volume, rather than increased risk) • Timeliness of data: • In order to maximize the effectiveness of our regulatory regime, we need real-time information on our licensed healthcare institutions. However, most indicators and data sources are usually collected with significant time gaps (6 months – 1 year) • Sensitivity of data: • Healthcare institutions might not be willing to report information (e.g. quality indicators, patient feedback) if they know it will be used to inform regulatory efforts.

17. Some Questions for Discussion What types of data do your agencies use to determine the level of safety and quality of care provided by regulated healthcare institutions? How are these types of data collected? Have you faced any challenges in collecting this data? How useful is the data in helping determining the level of safety and quality of care provided by regulated healthcare institutions? What types of tools have you used to operationalize the collection and analysis of this data?

18. Thank you!