60 Embedding ACP into daily workflows: a quality improvement journey in a new tertiary hospital

<h3>Aim or Purpose of the Presentation</h3> To share a ward-based quality improvement initiative aimed at increasing Advance Care Planning (ACP) completion in a newly established tertiary hospital, using the ACP-F framework to guide patient identification and promote integration of ACP into routine clinical care. <h3>Background</h3> Woodlands Health, Singapore’s newest tertiary hospital, began operations in May 2024. A baseline review showed that only 1% of inpatients had a completed Preferred Plan of Care (PPC), despite 30–50% of patients being appropriate for ACP. In Singapore, ACP includes General ACP (GACP) for future preferences and PPC for current care decisions. The ACP-F framework—Advanced Organ Failure, Advanced Cancer, Progressive Neurodegenerative Diseases, and Frailty—was used to screen patients suitable for PPC. This project was motivated by the need to embed ACP early into a new system’s clinical workflows and culture. <h3>Method</h3> A six-month quality improvement project began in September 2024 in a 40-bedded general medical ward. Interventions included the development of screening workflows using the ACP-F framework, mentoring junior doctors, engaging ward-based palliative resource nurses, and reinforcing ACP in daily multidisciplinary rounds. Staff received education and bedside coaching to enhance skills and confidence. By March 2025, the ACP/PPC completion rate in the ward rose from 1% to a peak of 4.4%. Although the original 10% target was not met, a culture shift was evident, with more consistent patient screening and initiation of discussions. Temporary dips occurred during festive periods and bed crunch due to system-level pressures. Institution-wide, 279 ACP discussions (226 PPCs, 53 GACPs) were completed. Nurses led 48% of all ACPs, with APNs driving PPC. General ACP was primarily facilitated by nurses (64%), followed by allied health (32%) and doctors (4%). <h3>Unique Contribution</h3> This submission provides insight into the early integration of ACP in a new tertiary hospital using a structured, condition-based screening approach (ACP-F). It demonstrates the impact of engaging nurses and embedding ACP into daily workflows. It also highlights real-world barriers such as staffing pressure and ward transitions, often overlooked in early implementation phases. <h3>Implications</h3> This experience suggests that ACP integration is feasible from the outset in new healthcare systems. Embedding ACP into routine care, supported by a multidisciplinary approach and nurse empowerment, enhances sustainability. Policymakers and clinical leaders should consider structured screening tools and nurse-led facilitation models to scale ACP uptake and normalize conversations across care settings.