Chapter Four: Pioneers of Tomorrow
Part Four
Towards the Alexandra Hospital of Today: The Contributions of Multiple Stewards
A Rising Storm
The year was 1980 and the Singapore General Hospital (SGH) has just been refreshed and re-opened following the rebuilding of its premises. Full of the biggest names in medical healthcare, the latest facilities and equipment, and new clinical services,
SGH began to draw staff and patients away from AH. However, AH still held on strongly as they continued to see an influx of hospital cases from the then developing Jurong Island. However, an impending storm of setbacks would soon sweep AH up in its wake. It was the beginning of an MOH exercise to restructure the public healthcare system in the mid-1980s and 1990s. This turned many hospitals in Singapore into private companies that were stil owned by the government.
In 1985, the National University Hospital (NUH), a powerhouse of a healthcare institution, opened its doors to the public at Kent Ridge. When NUH started receiving ambulance cases from Jurong Island and other parts of western Singapore in 1986, AH started seeing an even further decline in visitor and admission figures. On the medical service end, some of its sterling personnel were also poached by the new institution.
Mr. Liak Teng Lik, former CEO of Alexandra Hospital, standing at the washrooms that were refurbished as part of an initiative he led. This initiative modeled them after similar washrooms at the Singapore Zoo.
Five years later, KK Women’s and Children’s Hospital would be designated for restructuring. AH lost their obstetrics and gynaecology department, as well as the paediatric department, as they were transferred to the newly restructured KK Hospital.
Some of AH’s best doctors were being redesignated away to lead new hospitals and national centres. Two other major public hospitals, Tan Tock Seng Hospital and Changi General Hospital, were also rebuilt as part of MOH’s restructuring exercise in 1992 and 1997, respectively, further reducing AH’s market share.
AH’s facilities had become run-down over time. It did not help that the future of AH was undecided at the time; whether AH would be rebuilt onsite or shut down and relocated to another part of Singapore was unknown. This made it difficult to invest in new facilities and equipment, or even to refresh any existing facilities. Patient satisfaction dropped to an all-time low of 69 percent in 1999.
By 2000, the hospital’s market share plunged to less than a third of what it had been in 1980. Pharmacist Mr. Liak Teng Lit was brought in to give AH an overhaul as part of a restructuring exercise under the National Healthcare Group (NHG) on 1 October 2000. Under his guidance, AH’s modern-day foundations were established.
During his initial days at the helm, Mr. Liak faced several challenges. 40 percent of AH staff, including the entire nursing administration, opted-out of joining the newly restructured hospital. Many of them were older staff who had looked forward to a comfortable pension and healthcare benefits that came from working in a public hospital. With the new government directive to turn AH into a restructured hospital, these benefits were no longer available and the staff felt like they were at the losing end.
While most of the remaining staff soon accepted the reality of restructuring and Mr. Liak’s appointment professionally and politely, some senior management staff were openly resistant and hostile. A number of anonymous “poison pen letters” were sent to the prime minister, MOH, and the media during the initial months.
While Mr. Liak was at a conference in Sweden, about a third of the medical staff sent a letter titled “Report on Morale Situation in AH” directly to the chairman and chief executive officer of NHG, listing their various grievances. The then minister of health Lim Hng Kiang held a town hall meeting with existing senior staff to hear them out on their concerns while also making clear his unwavering support for the management team.
Gradually, staff members who stayed on began to trust the new management team. Ironically, Mr. Liak found it “very easy” to restructure since the hospital was in bad shape. He noted: “AH’s patient load had dropped drastically and, because of that, MOH recognised a great need for change and the minister himself was very supportive. So, together with my colleagues, we went in to make the changes required.”
In a League of its Own
As AH was sandwiched between the two superpowers of healthcare, NUH and SGH, standing out was a monumental task. Even its consultants were pessimistic about the situation, describing AH as trapped in a valley devoid of sunlight.
From the outset, Mr. Liak understood that AH was in a different league from the big boys. This was something to celebrate rather than bemoan, he said, in a much needed morale boost. “Being in the valley is more comfortable. Here, we are sheltered from the cold and wind. In the valley, we serve the community, i.e., tend to the heartlanders’ most basic needs. It is the best place to be,” he said.
Thus, instead of looking at what its competitors were doing, AH studied its own community and identified the ageing population as a cause for concern. “We looked at Queenstown, Redhill and Bukit Merah. A walk around showed us what these neighbourhoods needed.”
As the population was ageing, the number of patients requiring geriatric care was increasing. Diabetes was also becoming prevalent in Singapore. Furthermore, while the old and diabetic tended to require multidisciplinary care, large tertiary hospitals, with their many speciality and subspecialty department structures, were not organised to serve such patients in a holistic manner.
The large, sprawling campuses were hard for patients to navigate, oftentimes forcing them to go from pillars to posts on multiple visits to receive the care they needed. Thus, the concepts of “head-to-toe, life-long anticipatory care” and “customers for life” became subjects of intense discussion among the AH team.
The Geriatric Centre took up space where the former Sister Tutor Department was at.
Prof. Pang Weng Sun led the Department of Geriatric Medicine in the 2000s, prior to Alexandra Health moving to Khoo Teck Puat Hospital.
Focusing on building a geriatric service and a diabetic centre was quickly agreed upon.
The team reached out to well-respected clinicians who would be able to lead these developments successfully. Soon, Professor Pang Weng Sun and Associate Professor Sum Chee Fang agreed to head the Geriatric Medicine Department and Diabetic Centre, respectively.
The arrival of these highly regarded clinician leaders created an immediate ripple effect, attracting bright, young, and promising clinicians from elsewhere to the hospital. As one of them put it: “If Dr. Sum chose to close his very successful private practice to join AH, something must be going right.” Geriatric and diabetes care became the key pillars of the hospital for the next 10 years.
“We ran Saturday morning health education/promotion courses for older people 50 and above, conducted by geriatricians and Allied Health Professionals such as therapists and dietitians, together with nurses, covering nutrition, exercise, mental health,”
Dr. Pang recounted. “Each class was about 30-40 pax. This came to be known as Health for Older Persons (HOP). We also built a home concept called HIP (Home for Independent Persons), which was inspired by the concept of independent living centres in the UK. HIP was a home concept showing how homes can be modified and equipment used to support independent living, especially for seniors.
The space was divided into the living room, dining room, kitchen, and toilet, and each included displays on design and built-in equipment for safe and functional living.” While working to improve its existing strengths in diabetes and geriatrics, AH also focused on offering ambulatory services and outpatient care. It ran a health promotion programme for elderly members of the community as well as a palliative care service.
The hospital further specialised in catering to the various healthcare needs of an average person throughout his or her lifetime. It rolled out acute care, disease management, anticipatory healthcare, and dental services. It also expanded and beefed up its range of services with the addition of the department of otorhinolaryngology and a day surgery centre.
Mr. Liak and his team carved out three general principles for AH going forward:
Being patient-centric
Serving the society and community
Practising tight infection control to keep hospital-acquired infections at bay
To further refine AH’s niche offerings and services, Mr. Liak streamlined the patient experience. He said: “When you go to the hospital, the patient has to go all around to different departments to check their eyes, liver, etc. We focused on providing straightforward service.”
His strategy worked. Eventually, AH achieved the shortest average waiting time for patients, shortest average length of stay, and best patient satisfaction, while charging below-average bills. “We didn’t need spanking new buildings to provide good patient care. It was about doing what we could with what we had.”
“Like it or not, Singapore was becoming a first world country, and Singaporeans were getting exposed to better service standards and healthcare conditions. They were not going to sit around and accept anything less,” he added.
Taking Inspiration from an Airline Company, the Zoo, and a Car Manufacturer
What do an airline company, the Singapore Zoo, and Japanese car brand Toyota have in common? They each served as inspiration for AH’s restructuring exercise.
To start, Mr. Liak introduced hospitality practices into everyday staff culture soon after he arrived. Frontliners were sent for training at QS-First Pte Ltd with trainers from the Singapore Airlines (SIA), where they were taught how to look sharp and ready to tackle the challenges of the day. According to Mr. Liak, the service training QS-First provided at this point was not intended nor expected to improve service immediately.
“The emotionally charged atmosphere at the hospital, the angry and unhappy management staff, and the rules, systems, and processes in place at the time made any significant improvement almost impossible.
But the training provided a platform to share the need to improve service at the hospital. The sharing of success stories by experienced and credible trainers from SIA and other restructured hospitals helped staff to re-focus on service to others rather than on their fears and unhappiness while AH’s restructuring was in progress.
The view of Block 2, from the perspective of the former Officers’ Wards at Block 1.
The walkway connecting Blocks 1 and 2, both gazetted for conservation.
“It improved staff morale so that the incoming management team could push ahead and implement necessary changes.” Outside of QS-First’s training, AH also arranged for service training with SIA directly because of their remarkable service environment.
Mr. Liak also believed in learning from the best of other industries. To hammer home the importance of hospitality and customer service, Mr. Liak brought his team to the award-winning Raffles Hotel and the Ritz Carlton Hotel for inspiration. Hospital staff members were encouraged to ask questions such as “How may I be of service to you?” and make statements such as “It is my pleasure to serve.”
Dr. Pang Weng Sun noted that this approach was based on the principle introduced by senior management that the staff members were “ladies and gentlemen, serving ladies and gentlemen.”
Bringing the lush outdoors into the stark-white AH compound was another initiative Mr. Liak rolled out to improve the patient and visitor experience. AH’s toilets and wash facilities were upgraded to host jungle-style plantings and the like. Mr. Liak had been heeding the advice of Mr. Bernard Harrison, then CEO of the Singapore Zoo, which boasted an award-winning toilet design.
Unpleasant scents, which plagued the original design of AH’s toilets, were masked by the strategic addition of frangipani trees. The much-needed overhaul cost them $30,000. Parts of the walls were removed, and wooden poles and plants were used to provide users with privacy.
A small water feature was also added to create a pleasant sound of flowing water. Public behaviour at the toilet changed after the renovation. Coupled with better fittings and maintenance, the AH toilets soon received much positive feedback and won various awards of their own.
Mr. Liak also took a leaf from the book of then prime minister Lee Kuan Yew, who had initiated the island’s greening after taking over its reins in the 1960s. AH’s occupational therapist, Mrs. Rosalind Tan, who had a green thumb, was charged with AH’s version of the exercise. The idea, she said, was to change up the environment.
“At the time, most of the staff members there were ‘squatting’ and ready for retirement as AH was the last hospital to be restructured into a private healthcare institution. It was difficult to change their mindsets so we changed the environment as a start.”
Mrs. Tan added: “PM Lee, Singapore’s chief gardener, had done the same for our city. He had beautified Singapore with greenery and lined the path to Changi Airport with lovely bougainvilleas to create a positive first and last impression of Singapore. We wanted to change AH’s image to put us in good stead for the changes to come, so we embarked on something similar.”
Over time, Mrs. Tan created a new ecosystem at AH by planting nectar-rich and fruiting plants such as the lantana and soursop trees, which attracted both butterflies and birds, offering a slice of the forest to patients.
Members of the staff were charmed by the addition of flora, which greatly complemented AH’s colonial setting. “It provided a getaway from the usual concrete and was a breath of fresh air. It became difficult to discharge some of our patients,” said Mrs. Tan, laughing.
Mr. Liak, with his knack for turning problems into opportunities, was also responsible for the conversion of a soggy mosquito breeding ground into a koi pond. He had a hole dug and lined with rubber. Fishes, to nip the mosquito problem in the bud, were then added once water had accumulated.
Along the way, Mr. Liak appointed ground staff at AH to identify gaps, problems, and areas for improvement within the hospital in a bid to instil a sense of ownership towards the organisation they worked for. This was something Japanese car company Toyota practised.
Small adjustments had a great impact on the hospital and its patients. For instance, Mr. Liak ensured that patients had access to the parking lots at the front of the hospital for their convenience, going so far as to erect a sign board saying “Reserved for Patients.” Management staff and hospital personnel parked elsewhere. The arrangement encapsulated the hospital’s ethos that patients were the priority, he said.
Within 36 months, Mr. Liak and his team successfully turned the place around. The hospital was refurbished, adopting natural tone furniture, colour schemes, and an internal fittings design inspired by the Raffles Hotel. AH’s kitchen was also remodelled after SIA’s SATS aviation catering kitchen, and its bland menu was upgraded to cater to the hospital’s multicultural patient mix.
The compound was spick-and-span, and patient-centric. In 2004, AH came out on top as the hospital in Singapore with the greatest patient satisfaction. It also clinched other awards, which were reported in the press. Such coverage boosted staff morale and pride.
In 2021, over a decade after the Alexandra Health administration left, a small team comprised of staff from various departments, sought advice from famed ‘Butterfly Man’ Mr. Khew Sin Khoon.
With the advice of Mr. Khew, who served as President and Group CEO of CPG Corporation, they worked to bring back butterflies to Alexandra Hospital’s campus by testing out in a small plot, growing plants that would attract the insects.
The team spent a decade building up the hospital. Their labour paid off. They established a thriving and stable hospital environment, which went on to serve as the administrative training ground and run-in holding area for three new hospitals:
It was at AH that Khoo Teck Puat Hospital’s staff trained for two years before it opened in Yishun in 2010.
Similarly, AH nurtured JurongHealth Services’ staff, who would later open the Ng Teng Fong Hospital in Jurong in 2015.
It hosted employees of Sengkang Hospital before the new healthcare institution opened its doors in the northeast of Singapore in 2018.
AH’s foresight in raising a generation of well-trained and experienced geriatric and palliative care specialists also proved useful—its staff were deployed to set up operations in these fields at the trio of new hospitals.
More recently, the National University Health System took over the premises of Alexandra Hospital in 2016. The move was finalised in 2018.
The Sengkang Health and NUHS teams organised two events in the span of under a fortnight - the first on 23 May 2018 which involved the christening of new road names in campus, and the second on 1 June 2018, when the NUHS assumed full control of the hospital’s operations at the stroke of midnight.