[AVBC 2025] Integrated Discharge Program for End-to-End Patient Journey in National University Hospital
Care Process & Redesign
Appropriate & Value-based Care Conference
National University Health System
28 November 2025
To enhance visibility and recognition of multidisciplinary collaboration essential to streamlining patient care both within. Multipronged interventions, including system changes, multi-disciplinary team engagement, and education, were rolled out.
Year Submitted: 2025
Published Date: 28 November 2025
Tags: Care Process ＆ Redesign, Workflow Redesign, Quality Improvement, Value Based Care, Discharge Planning
About this Content
Aims
To enhance visibility and recognition of multidisciplinary collaboration essential to streamlining patient care both within the hospital and across care settings.
Background
Delivering optimal healthcare from admission to discharge has become increasingly complex, requiring close collaboration among healthcare providers across diverse settings. Without robust oversight, fragmented communication can result in inappropriate care, such as unnecessary investigations or low-value treatments.
Methods
A visibility dashboard was set up to monitor outcome measures for the Department of Medicine in 2023 to understand current trends, identify areas to improve, and monitor the progress of various interventions. Data is extracted from the NUHS Value Driven Outcomes database.
Results
Improved rate of several indicators was observed since the program implementation. The co-signing rate of discharge summary increased from 51% in 2022 before implementation to 68% in 2024. The rate of appropriateness of clinical narrative against lab tests increased from 40% in 2022 to 55% in 2024. On average, there was a reduction in medications by -0.6 in 2022 to -0.9 in 2024 on discharge.
Conclusion
Multipronged interventions, including system changes, multi-disciplinary team engagement, and education, were rolled out. By emphasizing best practices, quality outcomes, and patient-centered care, the program enhances visibility and recognition of multidisciplinary collaboration.
Lessons Learnt
Challenges in delivering optimal healthcare require a proactive, system-wide approach that emphasizes clear care pathways, effective communication, and planning throughout the care continuum.
Keywords
healthcare, discharge, patient care, multidisciplinary, communication, interventions
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National University Health System |
Organization(s) Involved | National University Health System, National University Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Healthcare Administration |
Applicable Specialty or Discipline | General Medicine |
Project Lead(s) | Htet Htet Aung |
Project Member(s) | Chua Chun En |
Connect with this contributor!
Htet Htet Aung - htet_aung@nuhs.edu.sg