Are we asking the right questions?
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A decade ago, National University Health System (NUHS) began asking a simple question:
How do we know if our care is truly improving patients' lives?
Healthcare has long measured what it does for patients. Value-Driven Outcomes (VDO) asked a different question: what difference did it make?
Good care had never been the question.
The question was whether outcomes could be measured, compared and improved.
In 2015, NUHS became the first healthcare cluster in Singapore to pioneer VDO.
VDO is a framework that measures both outcomes and costs to understand what creates value for patients.
The idea was straightforward, yet powerful.
Measure what matters. Learn what works. Improve what does not.
A decade of impact
More than 300,000 patients benefited.
18,225 hospital days reduced.
793 emergency readmissions avoided.
654 fewer return-to-operating-theatre cases.
456 complications prevented.
More than 75 VDO conditions implemented.
The questions that changed care
VDO began not with answers, but with uncomfortable questions. Questions that challenged assumptions about value, quality and improvement.
Many wondered whether value-based healthcare was about reducing costs, questioning clinical judgement or comparing clinicians against one another.
The reality was almost the opposite.
AVBC became a way to make outcomes visible, learn from variation and understand how care could become better for every patient.
NUHS asked a sharper question:
Were we achieving outcomes that mattered most to patients, and were those outcomes being measured in a way that could drive improvement in care?
From VDO to Appropriate and Value-Based Care (AVBC)
VDO began as a way to measure outcomes and understand value. Over time, it became something bigger: a way to challenge assumptions, learn from variation and continuously improve care. The shift was not from caring to caring more. It was from doing our best to knowing whether we were making a meaningful difference.
Good care was the starting point. Value became the goal.
Total knee replacement
When does recovery start?
Recovery is shaped by more than what happens in the operating theatre. Through prehabilitation, anaemia optimisation and enhanced recovery protocols, clinicians were redesigning the patient journey before the first incision was even made.
Today, many patients are discharged within one to two days, compared to approximately four to five days previously. Earlier mobilisation, better pain control and enhanced pre-op preparation help patients recover faster and return home sooner.
“The real success isn't that patients leave hospital earlier. The real success is that they recover sooner, regain their independence faster, and return to the activities that matter most to them.”
– Adj Asst Prof Amritpal Singh, Head of Division & Senior Consultant, Division of Hip & Knee Surgery, Department of Orthopaedic Surgery, Ng Teng Fong General Hospital (NTFGH) and Senior Consultant, Division of Hip & Knee Surgery, Department of Orthopaedic Surgery, National University Hospital (NUH)
PCI Same-Day Discharge
How much care is enough?
More isn't always better. It was once routine to keep patients in hospital overnight for observation after Percutaneous Coronary Intervention (PCI). A nurse-led pathway challenged that assumption, showing that ensuring optimal patient outcomes did not always require an overnight stay.
Nearly four in five eligible patients now return home on the same day, saving more than 300 hospital bed-days.
“The question is not how long patients stay. The question is whether they need to.”
– Dr Gavin Ng, Senior Consultant, Department of Cardiology, National University Heart Centre, Singapore (NUHCS) and Assistant Professor, NUS Yong Loo Lin School of Medicine (NUS Medicine)
“As a result, patients are more motivated to take ownership of their recovery. Being at home gives them greater confidence and independence.”
– Ms Yap El Fuon, Assistant Nurse Clinician, NUHCS
Post-Stroke Recovery
What are we not seeing?
A patient may appear to have physically recovered after stroke. But physical recovery tells only part of the story. Through Patient-Reported Outcome Measures (PROMs), clinicians are able to uncover challenges that traditional assessments often miss.
Among young stroke patients aged 18 to 60 evaluated using PROMs, nearly four in 10 reported anxiety symptoms, while more than one in four experienced fatigue and about one in six reported sleep disturbance.
“A patient may appear to have physically recovered after stroke, but recovery is not always visible. PROMs help us understand how patients are coping in their daily lives.”
– Dr Benjamin Tan, Consultant, Division of Neurology, Medicine, NUH and Adjunct Assistant Professor, NUS Medicine
Hospital at home
Where should recovery happen?
Through NUHS@Home, many cancer patients who once spent extended periods recovering in hospital can now recover at home under specialist supervision.
Remote monitoring, teleconsultations and daily clinical reviews brought specialist cancer care closer to home. Across the cancer pathway, NUHS@Home has saved 2,981 hospital days and reduced average admission duration by 14 per cent.
“The question was never whether patients could recover at home. It was whether they could achieve the same outcomes or better. Advances in remote monitoring and telemedicine have shown that we can.”
– Dr Hazel Teng, Consultant, Division of Advanced Internal Medicine, Department of Medicine, Alexandra Hospital (AH)
“Many patients recovering from stem cell transplantation who would once have spent two to three weeks in hospital can now recover at home under specialist supervision.”
– Dr Edwin Thong, Associate Consultant, Division of Haematology, Department of Haematology-Oncology, National University Cancer Institute, Singapore (NCIS)
Personalised Care and Support Planning
Who knows what matters most?
The patient and their loved ones.
The Personalised Care and Support Planning initiative has shifted the focus of consultations from disease-centred reviews to conversations anchored by patient-centegoals, increasing shared decision-making from 31 per cent to 56 per cent, helping patients feel more confident managing their health and reducing the emotional burden of living with diabetes.
“Clinical targets and personal goals are not competing priorities. The aim is to connect them, so that managing a condition helps patients achieve what matters most in life.”
– Dr Chin Chi Hui, Deputy Head, Jurong Polyclinic
What emerged was a simple lesson:
Better outcomes were not achieved by doing more. They came from understanding what mattered, questioning long-held assumptions and redesigning care around the answers.
From pioneer to national adoption
As Singapore's first healthcare cluster to pioneer VDO, NUHS demonstrated how measuring outcomes could drive better care. In 2017, those principles became part of Singapore's broader Appropriate and Value-Based Care journey.
As an Academic Health System, NUHS's role extends beyond delivering care.
It involves generating evidence, building capability, sharing knowledge and scaling what works. The goal was never simply to improve today's care. It was to shape how tomorrow's healthcare is delivered.
Value-based care was never intended to stop with today's healthcare professionals. It was about building a pipeline for the future.
The next decade
The first decade was about proving that outcomes matter. The shift was not from caring to caring more. It was from doing our best to knowing whether we were making a meaningful difference.
Good care was the starting point. Value became the goal.
Because the goal isn't lower cost.
The goal is appropriate, sustainable care and better outcomes for every patient.
In consultation with Adj Asst Prof Amritpal Singh, Head of Division & Senior Consultant, Division of Hip & Knee Surgery, Department of Orthopaedic Surgery, NTFGH and Senior Consultant, Division of Hip & Knee Surgery, Department of Orthopaedic Surgery, NUH; Dr Benjamin Tan, Consultant, Division of Neurology, Medicine, NUH and Adjunct Assistant Professor, NUS Medicine; Dr Chin Chi Hui, Deputy Head, Jurong Polyclinic; Dr Edwin Thong, Associate Consultant, Division of Haematology, Department of Haematology-Oncology, NCIS; Dr Gavin Ng, Senior Consultant, Department of Cardiology, NUHCS and Assistant Professor, NUS Medicine; and Dr Hazel Teng, Consultant, Division of Advanced Internal Medicine, Department of Medicine, AH; Ms Yap El Fuon, Assistant Nurse Clinician, NUHCS.
