[AVBC 2025] One Care Team (OCT) Model
Care Process & Redesign
Workforce Transformation
Appropriate & Value-based Care Conference
National Healthcare Group
20 November 2025
To sustain effective multidisciplinary teams by redefining the role of experienced ward nurses and empowering them to. PNLs are key to fostering collaboration, anticipatory care, and mentorship.
Year Submitted: 2025
Published Date: 20 November 2025
Tags: Care Process ＆ Redesign, Workforce Transformation, Quality Improvement, Workflow Redesign, Access To Care, Referral Rate, Length Of Stay, Value Based Care, Discharge Planning, Patient Satisfaction, Job Redesign, Multi-Disciplinary
About this Content
Aims
To sustain effective multidisciplinary teams by redefining the role of experienced ward nurses and empowering them to co-lead clinical huddles and multidisciplinary discussions.
Background
Nurses have always been central to patient care, but increasing complexity in healthcare has fragmented traditional communication models. The One Care Team (OCT) model addresses this by enhancing patient-centred, right-sited care while optimizing resource allocation.
Methods
All ward-based healthcare professionals are part of OCT. Principal Nurse Leaders (PNLs) are trained in clinical assessment and act as the main liaison in the mornings and early afternoons. They review care plans, initiate early family engagement/updates, expedite or defer services appropriately, and coordinate MD discussions, especially for complex cases.
Results
In 2024, the average length-of-stay decreased by 0.7 days compared to 2023. Early discharges (before noon) increased to 31% compared to a control ward (22%). Patient and caregiver satisfaction improved. Medication-related interventions rose by 288%, and clinical suggestions/escalations increased by 290% compared to the control ward.
Conclusion
PNLs are key to fostering collaboration, anticipatory care, and mentorship. Together with administrative and operational leaders, One Care Team enhances care quality, system efficiency, and team accountability.
Lessons Learnt
The implementation of the One Care Team model without additional manpower through streamlined workflows and added nursing oversight can lead to improved patient and caregiver experiences.
Keywords
Multidisciplinary, Nursing, Patient Care, Resource Allocation, Workflow
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Nursing |
Applicable Specialty or Discipline | General Medicine |
Project Lead(s) | Lee Yin Yee |
Project Member(s) | Liu Wan Zhen |
Connect with this contributor!
Lee Yin Yee - yinyee.lee@nhghealth.com.sg