People

COVID 19 had an unprecedented toll on healthcare workers all over the world [2,10,11]. The people who ensure the AMC functions efficiently and effectively, are the staff…..every single one of the multi-disciplinary staff during COVID 19. It was critical to ensure their development continues. The building of their capacity and inculcating their capabilities, must be relevant and applicable in the current as well as the post-COVID 19 world. Training and continuing education is important and must be customized. It has to be linked to their ability to learn, unlearn and relearn. The ability to learn is a standard, but unlearning can be challenging. Some staff may hang on to old practices and are unable to let go of these. This is where mindset change and adaptation comes in. How do we get their buy-in? How do we prove the new method is better than the old? How do we combine the traditional with new technology? One good example would be the cutting down of face to face training. With that, medical officers, residents and nurses training sessions have gone virtual. We invested in electronic (E- learning) and online learning in a big way. Didactic and interactive sessions were delivered via Zoom, or other similar platforms [12,13]. Simulation in the sim-lab was converted to computer-based simulation [12].  We also had to ramp up the development of our Virtual and Augmented Reality (VR and AR) applications faster than expected. We very quickly sourced for funds to hasten the completion of our Innovation Arcade at our simulation centre (The SingHealth Duke NUS Institute of Medical Simulation), in preparation for the  VR, AR, mixed reality (MR)  and serious games applications. We applied for the Learning Technology Adoption Grant (LTAG), from SkillsFuture, Singapore and are working on 14 different serious gaming projects with appointed vendor companies [14]. SkillsFuture is a national movement providing Singaporeans with the opportunity to develop their fullest potential throughout life, regardless of their starting point. The skills, passion and contributions of every individual will drive Singapore’s next phase of development towards an advanced economy and inclusive society. These projects cut across various disciplines, whilst some are inter-disciplinary. All these projects have bearing on our patient care, workflow as well as staff training. Our staff are the subject matter experts in these applications and will champion their use for training and education.

To be able to embark on these projects and ride the latest bandwagon of digital transformation, we have to ensure our people are exposed to the latest developments. We created the awareness by telecasting webinars and virtual seminars on relevant themes. Training sessions are made readily available and accessible. These sessions are provided for all the relevant staff. Empowerment courses are also converted to virtual training format and the numbers of participants increased significantly during the COVID-19 pandemic, despite the heavy workload that we were facing. The focus on mastery of skills and knowledge is important. This, we feel, is a step in the right direction to be able to function in the VUCA (vulnerable, uncertain, complex and ambiguous) world, post COVID-19. Staff motivations must never be taken for granted [15]. That is why messaging and reinforcements must be conducted regularly. This can be through the AMC’s intranet, screen–savers on all computers, posters, email blasts and flyers. This customized faculty development concepts will ensure our future ready workforce is up-to-date, competent, resilient and relevant.

Support for all these relevant changes must come from the leadership and management. In fact they are the ones leading in the AMC’s thrust, mission and vision. Leaders who walk the ground, get involved and are aware of the issues will have a deeper understanding of any situation and this means any policies they craft, are likely to be more practical and responsive. Leaders have the ability to inculcate inclusivity. At our AMC, the Chief Executive Officer session with all the staff is termed as “The Family Meeting”. At the session during the COVID 19 pandemic, attendances increased, with many enthusiastic feedback and questions. Sharing the future directions and main thrusts, reassuring the staff, supporting and empowering them through positive attitude, care and concern can have strong impact on employees. The importance of collegiality and camaraderie across any hierarchy must never be under-estimated. This way the staffare encouraged to bring up constructive ideas and feedback, as this is the way to enhance and improve our performance at the AMC [7].

Being able to embark on all these exciting new developments and projects will not be relevant if our staff are not motivated and unwell. This is why during COVID 19, the AMC had invested and rolled out even more activities and resources related to staff psychological wellness, mindfulness and “Joy At Work” (JAW) initiatives. Mindfulness training during COVID 19 has helped the staff at the AMC in a variety of ways [3,7].  It helps to increase attention span and this was certainly useful with the longer hours at work in modular teams. It helped build and strengthen relationships between all levels of staff and across disciplines as well. This facilitated work processes such as when the Emergency Department (ED) staff made admissions; there were lower incidence of bed blocks. Discussions were collegial. The Infectious Diseases consultant on call took consultations readily and provided collaboratively discussions and advice with the ED staff on admissions to isolation wards, high dependency beds and intensive care units for infection-related diagnoses. The positive attitude demonstrated more gratitude, care and concern for each other. Peer support was enhanced. Wellness ambassadors were appointed and taglines such as “ Its OK to not be Ok” were publicized. Counselling was made available 24 hours a day to any staff who needed this or wanted to talk on any issues [7]. Mindfulness can also help in promoting the more conscious practice of Medicine. A happy and satisfied staff will deliver compassionate care and this is the gateway to patient satisfaction [16]. We cannot have our staff painstakingly creating processes from the vantage point of the patient and not see joy in their own work, come alive.

During the pandemic, there was an opportunity for institutions to review their various KPIs (key performance indicators) and manpower needs. With the new norms, some parameters may have to be altered. For example, due to the donning and doffing of PPE when managing certain groups of patients, more time will be required. This means the average time spent per patient will increase and thus, productivity will be altered as well. Allocation ratios of doctors and nurses in the different areas will also change. COVID 19 also provided an opportunity for the level of trust between individual employees and the AMC to be stepped up. The demonstration of care and concern for the safety of staff must come across clearly. This defines another important compact of the institution. Showcase of gratitude and appreciation for each other is important. With these happening at all levels, instead of post-traumatic stress manifestations, staff are now in the phase we term, “post traumatic growth and development”, since the COVID-19 pandemic started. This way the AMC continues to heighten our capabilities and capacity of our staff as they continue to thrive. In fact the pandemic brought out the best in them. Without the physically and psychologically healthy workforce, the delivery of excellent healthcare will be difficult [7].

Change is hard, challenging and difficult, but when people come together, we can accomplish the impossible. The future will see healthcare staff embracing more global learning, shared knowledge, best practices and the setting up of more communities of practice. This may lead to more standardization and less unscientific variations of care [17,18].

Patients

During COVID 19, there were changes encountered with the AMC’s patients profile and case mix. This was mostly due to the changes observed during the various phases, as the pandemic spanned out.  As we move into a more stabilized state of the COVID-19 pandemic in Singapore, many of the changes that have taken place related to patient care will continue [19]. This includesa higher utilization of telehealth and teleconsultation. This can increase productivity and save time for the healthcare providers as well as the patients. In fact, where appropriate the family members can even join in. Of course, not all cases are suited for teleconsult, thus the more appropriate cases and diagnoses were selected: eg. follow up for chronic diseases and primary care type  cases [20]. Video-consults and video calls were also used appropriately.The full potential of telehealthcan be summarized as follows:

1. For on demand virtual urgent care. This can be for lower acuity emergency visits
2. Virtual clinic type consultations: for primary care cases, chronic illnesses follow up or for specialist outpatient clinics consultations
3. Virtual home care service. This can cover “virtual visitations” with communications over the computer or smart mobile devices.
4. Remote monitoring is also possible when there is cooperation of the parties involved. Digital engagement tools can also be used for education of the public. This is also where telehealth can provide oversight to many aspects of care such as patient controlled analgesia for cancer patients

It will be more challenging to break bad news or manage complex complications virtually. Thus, some aspects of face to face care must still continue.

At SingHealth, an e-learning telehealth course was made available online and for all staff who complete the modules, CME (continuing medical education) points were awarded. Moving on, this has now become the basic fundamental course for Telehealth certification for staff using tele-consultation. This course covered the definition of telehealth and teleconsultation, detailsof the requirements, maintaining confidentiality during tele-consults and even charging mechanisms for primary care physicians utilizing this modality. With the wider use and greater numbers of practitioners subscribing to it, the cost will become more reasonable and thus the service can be offered at lower costs to patients [21].

At the frontline, patient screening evolved and workflow processes were updated. New areas were created to manage infectious patients in negative pressure environment. Senior physicians help reminded the residents and medical officers of the potential blind-spots for other diagnoses, in the midst of their focus in not wanting to miss out diagnosing COVID 19. Besides training and educating staff, patients also went through the ‘journey of change’. They were learning to use their mobile phones for video consults, testing their hands at various mobile applications the AMC had implemented. Some of these applications were derived from our regular hackathons, where new ideas were generated. There werealways staff on hand as well as IT (information technology) ambassadors to assist patients who were not tech-savvy to negotiate these new applications. They were assisted and their queries were sorted out and clarified, to help them leverage technology in this new age. This also aligns with the Singapore’s government initiatives to make the country a ‘smart nation’[22]. In fact during and post COVID 19, the majority of correspondences with patients eg. appointment dates and changes,were via mobile devices. SMSes (Short Message Service) will continue to be used for reminders. Traditional and manual  resources were still made available for those who really are not able to cope with new technology.

Places

The post COVID-19 world of healthcare will never be the same as before. There is no going back to what we were used to. The infection control changes, potential risks from new and emerging infectious diseases and some of the technological developments we are all so used to now, will continue on this trajectory. However, the other healthcare trends such as the ageing population, more chronic illnesses and their related complications, higher incidence of cancers and thus immunosuppression, as well as the more complex presentations in our patients will also continue.

The AMC’s facilities and work processes will continue to evolve, as it has since SARS. The negative pressure facilities in the ED continues to be added. With the new ED under construction, forward planning has been done to ensure sufficient space and facilities, eg. separate ports can be converted to negative pressure areas as deemed necessary by demand. These flexibilities will help in handling upsurge in future outbreaks or pandemics management. Whilst planning all these, the patient flow must continue to remain as seamless as possible. The main objectives of the work flow and processes in the ED must ensure that:

1. The ED must not allow over-crowding. Innovative distancing measures will have to be implemented
2. The ED must not become a reservoir of nosocomial infections
3. The ED work flow must ensure safety of the patients as well as the staff working there and
4. The timing to manage patients, especially acutely ill and critical patients must not be compromised.

The Infectious Diseases wards and facilities too underwent upgrading during COVID 19. The number of isolation wards and roomshave increased up to some 30 % of our total bed capacity. At the peak of the COVID 19 pandemic, a 5 level multi-storey carpark near the AMC was closed to the public and converted into a consultation and management area for foreign workers from the dormitories. This was termed as our FSA (Fever Screening Area). The ample space, across 5 levels enabled us to use the areas for consultation ( cubicles were constructed), waiting areas for swab results and waiting areas for COVID + patients awaiting admission to negative pressure isolation rooms in the main hospital building. Staffwere seconded to work in this area, with full PPE (personal protective equipment). Before new work areas such as these are opened, we organized insitu simulation to study the workflow processesto realize latent threats. At the same time we did a failure mode effect analyses, to establish best practices.

One of the large open carparks on the AMC campus was cleared and 50 container wards were built quickly. These were all negative pressure rooms for high risk patients. This certainly provided additional bed space for the institution. This was one of our achievements during COVID 19; completion of the building within 30 days.  Besides these initiatives, we also have the negative pressure isolation tent available in case it needed to be deployed into any particular area of work, quickly [23] (Figure 2).