Bringing Esther to Singapore.

Esther network is spreading around the world and on the September 20 three social workers from Singapore come to Jönköping County to learn more about the network in order to be able to implement it at their country.

Ms.Tan Jie Bin, Ms. Poh Soo Yee Karen and Mr. Muhammad Muzzammil Abu Hasan represent three different hospitals in Sinagpore. The management of these hospitals has previously visited our county in order to learn from good examples. Their main interest was model for integrated care and they found Esther network compelling. The management decided to send a representation from Singapore for a five weeks long training/apprenticeship with hope to be able to start a similar network in Singapore.

We’re very happy and thrilled to welcome our guests from Singapore. We appreciate your curiosity and are looking forward to see the outcome of our mutual learning. It is a great opportunity for us to see our system through your eyes and we hope that these five weeks will be unforgettable experience to all of us.

We’ve asked our guests from Singapore to write their reflections in this blog during their five weeks of stay:

  1. Tell us your reflections- what you think,not what you hear. What strikes you most.
  2. Ideas to bring home- what of the things you’ve heard/seen could be adapted in your system?
  3. Further questions. Is there anything  you’d like to beclarified?

You’re all welcome to ask questions and write comments and have a dialogue with our partners in co-learning.

Program at Qulturum Sept 22-23

Overall Trainee program for 5 weeks

Program for study visits Sept 28-29

Short presentation of our guests from Singapore

Programme October 12-14 at municipality in GIslaved and Gnosjö

More information about Esther(link to website in English)

Presentations:
Improvement methods 5P and flow chart. Pernilla Söderberg

Person-centered care, Annmargareth Kvarnefors

28 thoughts on “Bringing Esther to Singapore.

  1. Thank you very much for hosting our social workers from Singapore. They are flying off tonight! They feel very excited and are looking forward to the learning journey which they believe they will gain tremendously from it! Regards.

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  2. “There are two ways of spreading light: to be the candle or the mirror that reflects it” – Edith Wharton

    There are many ways to look at this quote. What it means to me today:

    The Esther network is like a candle spreading light. I am the mirror that is reflecting its light just by being in the presence of the candle.

    Two days into the programme, so far, we are being drilled to reflect, reflect, and more reflecting. To reflect with guiding questions and to articulate the reflections, both are equally hard. And the hardest so far is to formulate the ‘right’ guiding questions to guide my reflections.

    What does the quote say to you???

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  3. Gratis in Indonesian means Free and in Swedish means congratulations!

    In Singapore, schools are call “Sekolah” by the Malays. The Swedes call their schools “Skola”. Hmmm strikingly similar. Did the Malays borrowed the word from the Swedes or is the word has its origin elsewhere?

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  4. Healthy lunch from Highland Hospital Staff Canteen
    Aside from the patients, why can’t hospitals in Singapore also provide healthier food options for their staff and be congruent in their identity as a healthcare institution? As food plays an important factor in the cultural, social and health aspect of the Singapore identity, hospital can play an important role in shaping the food culture as well. If Ikea’s meatballs can be famous as their furniture, the hospitals’ food culture should aspired to be admired the same as how the system is admired for the efficiency and high quality of service.

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  5. Travelled to Vetlanda for an Esther Café session. What is an Esther Café? Why Café? Why not a learning Seminar, Forum, Dialogue session, focused group discussion, a conference? My first thought that the Esther Café was actually a café like the coffeehouses/shops like the one found in Singapore.

    Esther café session is facilitated by an Esther coach. Open invitation given to the Esthers to share their reflections and experience during their healthcare journey with the professionals in the healthcare and social services spectrum.

    On the development on Esther network – Swedes are humble and proud. When thing are wrong or troubling they want to make things right and organically do it on their own. Willing to make mistakes along the way and reflect upon them.

    If Esther Network was to come to Singapore what would it be named?
    What if the Esther Network already exists in Singapore but it’s not fully recognized for what its worth? We need to really look at the existing programmes in our hospital to find Ether’s long lost sister before we start to bring Esther to Singapore.

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  6. Ask any elderly in Singapore whether they want to go to the hospital when they are sick, the answer is usually no because they would prefer to be at the comforts of their own home with their love ones or their familiar environment.

    What is the value of sending our patients to the hospital?

    Whose interest are we serving when we sent patient to the hospital?

    Taking care of patients in the hospital is more expensive than taking care of them in the community.

    How can we place more responsibility in the primary care sector?

    How can the hospital be more supportive and responsive towards the needs of the primary care sector in order for them to be more effective towards supporting the patients in the community?

    Is the rate of taking up ownership by the primary care accelerating fast enough to cope with the ageing population in Singapore?

    In Jonkoping County, there is a trend towards reducing hospital beds as the emphasis is towards care for patient in the community and they have been able produce good outcomes in reducing the length of stay for patients.

    The challenge in meeting the increasing demands for hospital beds with the growing elderly population cannot be solve in the hospital. The hospital needs to embrace the community and vice versa. Funding should be poured in developing the primary and home care services to the point where hospitals are only playing supporting roles.

    Instead of pumping billions of dollars in building acute hospitals, we could propose that the money be used instead the build a strong ecosystem of primary and home care services partnership that can support patient effectively in the community.

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  7. 23/09/2015

    Visited the self-dialysis centre in Ryhov County Hospital. Person Centre Care at its best. Patient designed the area, they choose the type of dialysis machine, they choose their seat or beds, they choose their timing slots according their time and the nurses on duty, they needle themselves and take their own bloods. They operate the machine and take down the results themselves. It is just like going to the gym. The fitness trainer is there but is call upon only when needed. Moving forwards the centre is looking towards portable haemodialysis units weighing less the 40kg that can be transported anywhere with wheels. Patients can finally go for their holidays!

    It can exist because there is mutual trust and confidence between the healthcare system and the patient. Instead of the patient’s life revolving around the dialysis process, now the dialysis process is revolving around patient’s life. Patient is in control of his life.

    At present there is a sense that the supply for haemodialysis centres is not able to keep up with the growing number of patients needing dialysis because of the shortage of space and skilled manpower. If we can be creative with the use of space in Singapore and we can show more faith towards patients I believe we can mitigate some of the challenges the dialysis issues are facing.

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  8. Thank you for all the sharing and reflections so far. A critical and vital piece of change is changing our culture…culture of care, culture of trust, of empowerment etc etc. What’s the ‘know-how’ in shifting culture?

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  9. Reflecting about Tzer Wee’s question on the “know-how” in shifting culture:

    (A) Culture of Care

    In the story of how Esther inspired the creation of the network, the following points were noted:

    1) Identify the need(s). Esther met too many people. From home to A&E, to ward, she met 32 people asking her same questions.

    2) Tell it as the person’s story. Story-telling is powerful. And all this while, they only have 1 story, 1 vision, 1 value.

    3) Find a method. In their experience, they are using Health Care Process Re-engineering

    4) They had 1 Rule only : “What’s best for Esther?” “What does Esther need/want?”

    5) They also asked critical questions such as:
    – Who needs to cooperate to fulfil Esther’s needs?
    – How can they get the buy-ins from the Chiefs.
    – Communication is key: how to use technology to do it

    6) Esther herself is the owner of the process.

    7) Leave no partners behind, take everyone onboard.

    8) From Esther to Esther’s family
    – explaination: In Esther’s family, besides Esther who needs support, Esther’s other family members such as her daughter and grandchild may also need some support.

    Person-centred Care

    When we talk about person-centred care in our setting, we generally put Esther in the centre and the healthcare professionals surrounding the person. But in their context, they put Esther side-by-side as the group caring for her.

    Also, they always put Esther in the room. For instance, we met Esther(s) when we went to their Esther café, and at the coaches’ retreat today, one Esther was also present to give his inputs. And all the Esthers we met so far are all pro-active participants sharing their inputs, none passive.

    (B) Culture of Trust

    One of the take home message(s) from today’s session on this topic was “Understanding precedes Trust”. Trust is built on understanding one another, and when we seek understanding, there we will find the Culture of Trust.

    (C) Culture of empowerment

    From the visit to the self-dialysis unit and meeting the staff and patient(s), my reflection(s) on this topic:

    – Someone / Some people must first dare to let go and break some rules.
    – Understand that patient(s) are not out to harm themselves. And they know themselves best.
    – Start small and when the first one(s) is/are successful, confidence increased and others follow suit.
    – Seek first to understand and there is trust, and when there is trust, the culture of empowerment can be built.

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  10. What are some challenges your team have identified in bringing Esther home? If we can bring the whole of Esther home, what have to change?

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  11. The first week here has completely changed my impression of Esther Network. Esther Network is neither a project nor a service. I liken it to a movement and the essence of this movement is focusing on what the best for Esther is. Our programme has also given us exposure to the context in which Esther Network sits in, that is, the spirit of continuous quality improvement in our work and focusing our efforts on improving the experience of an individual as a patient requiring care (and not, for instance, to focus on reducing workload for healthcare providers).

    With that, we were showed many projects and initiatives with impressive results under Esther Network and in the Regional Jönköping County. I feel that there is a wealth of knowledge to be tapped on behind the conception and development of each of these initiatives. The concepts and models used in some of these initiatives could possibly be modified and adapted to our context. Some of the projects that we have seen includes:
    – Passion for Life
    – Senior Alert
    – Self-dialysis at Ryhov County Hospital
    – Medicine Direct
    – Welcome Back Home Package
    – Discharge Safety Receipt

    We also had the privilege of meeting many bright minds at Qulturum and Prof Paul Batalden, who shared with us concepts that could be expounded on for our work in care provision:
    – Person-centred care
    – Co-production of services
    – Micro-system approach to quality improvement
    – Healthcare process re-engineering

    A personal highlight in the past week was the dialogue session with Mats Bojestig, Healthcare Director at Region Jönköping County and father of Esther Network. Understanding the beginnings of Esther Network gave me greater insight on the factors that contributed to its success:
    – Having the right leader- I saw courage and foresight in Mats as a leader- Courage to break certain rules and redefine care, and foresight to realise the importance of developing a network of partners.
    – Having leaders involved right from the beginning- Mats was the chief of medicine in the hospital then when he decided to start Esther Network. He also engaged the chiefs of primary care and social care right from the beginning of Esther Network.
    – Starting it big in small ways- “Starting it big” by making sure all stakeholders are involved right at the start, and “in small ways” by encouraging every single one to take small steps in improving their work of care provision.

    After a week here, I think I have found my answer to the question- “Can we bring Esther Network to Singapore?” My answer is a definite yes. I believe the essence of Esther Network is close to the hearts of many healthcare workers- it will not be difficult to sell the idea that we need to focus on what the best for Esther is. Furthermore, with the established works of quality improvement efforts in our organisations, we are starting off on good grounds.

    The next question is “How?” Comparing the health and social care systems in Regional Jönköping County and that of Singapore, the following are some of my thoughts on the challenges of bringing Esther Network to Singapore:
    – The ongoing development of community care services in Singapore- While I acknowledge the ongoing efforts of the Ministry in building up the capacity of our community partners, my experience in working with community partners tells me of their current inadequacy and limitations in funding and manpower.
    In addition, it is Sweden’s practice that municipals workers have to fix the arrangement for patient’s care post-discharge within five days, upon doctor’s certification that the patient is fit for discharge. The municipal would have to be financially responsible for the hospitalisation bill should home care arrangement not be ready after five days. This increases the stake that the municipals have in the care for patients and hence, their involvement.
    – The management of primary care sector- Sweden has their primary care physicians governed by the municipality whereas in Singapore, general practitioners are private entities.
    – Issues of funding- The philosophy under-girding healthcare financing in Sweden and Singapore are starkly different. The complexity of Singapore’s healthcare financing will possibly be a hurdle that we would need to overcome in our implementation of Esther Network.
    – Complexity of our current situation- The successful implementation of Esther Network would require an overview of our current resources and capabilities as well as the knowledge to maneuver them to achieve maximum benefits. I write this with the appreciation of the many ongoing care integration initiatives with impressive results as well as the established culture of quality improvement and innovation in our organisations. Personally, I find myself being inadequately informed of resources within our own systems and see that as a hurdle to overcome.
    – Singapore’s penchant for evidence-based practices- Unfortunately, in care integration, there is no evidence-based approach. In fact, not every Esther Network replicated in other nations have achieved good results. It is, however, heartening to hear that ongoing evaluation and improvements are being made to these networks. Will we be able to do that in Singapore?

    My two cent’s worth 🙂 Please feel free to comment or correct me if I am wrong.

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  12. Dear all,

    Good to read your reflections and thoughts. It helps to think and develop our thoughts together. It is wonderful to have you here with your clever questions and new fresh eyes on what we are trying to do. The Best for Esther. It is always a challenge. How do we know what is best? Not only by asking and being curious but also to have a good sense of what is evidence based today. The combination is a challenge.
    Karen you wrote about the light. Could you help me with that? What light are you writing about? And what are the obvious signs you observe in our system that you see that light?
    Muzza I like your idéa of identifyiong your Esther in Singapore. You probably have wonderful initiatives, built on what you have, that seems a very good starting point.
    Jie Bin nice that you make a summary and pointed out keypoints. That can be helpful for those following the blogg.

    Well done your first week is ready. Next week more visits in the field.
    Wishing you a joyful and good learning time,

    Nicoline

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  13. Dear all, I am very impressed with your learning and reflections, and benefitting from your comments in strengthening my own understanding of the crux of it and its applicability in our context. Thank you for sharing those ‘blow-minding’ moments when you visited the various centres to understand the concepts behind. I look forward to more exchanges with you and do think our small team can make a big difference to truly deliver care that patients want. Kudos!

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  14. Reply to Nicoline’s post on 27/9/15 regarding a further elaboration about my post dated 22/9/15:

    A candle has to burn itself to emit light. When the candle burns, it is burning itself. It is like it is sacrificing itself. And why is it a sacrifice? Because the Esther coaches all have their primary work either as nurse/therapist/care staff/social workers etc, but they take on an additional hat as an Esther coach. Why do they want to do this? I think its because they believe in a greater mission than themselves – that is, to provide light for Esther.

    The candle is an interesting matter. It is made of wax. It is at first hard (solid). But when it burns, the wax melts. And whatever left during burning is moldable again into a candle.

    What this speaks to me is like the spirit of the Esther network. The solid part is in it’s belief in ‘What’s best for Esther?’ I liken the liquid wax to the innovative and reflective spirit of the network. And while the liquid wax reflects and reshape, it hardens again to become a candle. And that’s when the candle (which is now solidified) to ‘What’s best for Esther?’

    The light the candle emits is a hope. A hope for Esther. The light supports Esther during her dark moments, showing the light and guiding her the way in healthcare and social care. Besides light, the candle flame also emits warmth. That is the warmth I felt in the atmosphere at the Esther café.

    And of course, this candle (Esther network) is spreading light. It is spreading light to Esthers within Sweden and overseas. I liken myself to a mirror in my reflection blog entry because I dare not see myself like the candle that the Esther coaches are. We just started our learning journey here. There are more to see, ask, and reflect. Hence, as a mirror standing in the presence of the candle (of Esther network), I am reflecting about Esther network and about the current situation we have in Singapore.

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  15. It’s refreshing again to read all the responses. Jie Bin, you have identified a number of pieces that need to shift for Esther to come home – funding model, role of community, capability of primary care etc etc. I wonder if your team have any thoughts on how to shift the pieces in a systemic way based on what you learn from the experience of Esther Network. I also wonder what are the roles social workers play in shifting the pieces.
    Karen, your thoughts about the light, to me, is multi layers. I enjoyed seeing it from that perspectives!
    Continue the learning and sharing! Thank you!

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  16. My thoughts on Tzer Wee’s post dated 29/9/15:

    Role of community
    I observed that in Sweden, the community social worker(s) participates in the discharge care planning process and decides what services the elderly will get. This is possible because the community social workers and the social care services are under the charge of the community (aka Municipality in Sweden).

    In each RHS, we can identify our key partner(s) in each township (e.g Ang Mo Kio, Toa Payoh, Bishan, Whampoa etc). and build mini-networks. For township(s) where we have some relationship to start with, we can tap on platforms for networking, such as the events organised by the RHS office. On a smaller scale, we can walk the ground to build deeper relationships. The story of Singapore Esther can also be spread and shared on such platforms.

    We may also consider targeted attachment opportunities for our partners to the hospital (in social work department, outpatient clinics, or wards). Vice versa, MSWs can also have similar opportunities to attach with community partners to learn what they do. The length of attachment is open for negotiation, but generally, I’ll say let’s be keep it brief, say, ½ day or 1-2 days per annum. Such exchange programme(s) would promote mutual understanding of each other’s domain of work and challenges. It’d also promote mutual stimulation of improvement.

    Third, we can work strategically with key service provider(s) on providing a full suite of services which include both community based social care services and home medical, home nursing etc in each township. The idea is not to have multiple service providers for each pt and in each town, which can be confusing to everyone, pts and us. Ideally, there ought to be only 1 service provider.

    Fourth, we can proactively invite community partner(s) to participate in the care planning of pts. This is a deliberate move. To involve them is to invite their co-ownership in the care provision, rather than, being at the receiving end of referrals. Vice versa, there are also platforms where hospital social workers can go into the community to support care planning – I think there are ongoing dialogues regarding this.

    Quality improvement (QI) is identified as a critical key driving excellence and process improvements. In each RHS/hospital, we have established QI teams with the know-how, the tools, and the experience to do this work. They can be tapped on to support community partners who may lack the resources to do this piece. Hospital MSWs should also be exposed to this piece. Since coming here, I only realised how little I know.

    In summary, shifting the community piece is two-prong: building relationships, building capacity.

    Primary Care
    I think this one we need to consult the National Primary Care Workplan (2011) to see how we can contribute to this piece. A quick thought is that we currently have little connection with our NHGP MSWs counterparts. Perhaps we can look at working on this piece?

    What I observed and think it’s positive has been the clinical (medical) efforts of TTSH to connect with the primary care in our Region. e.g: Geriatric Integrated Network for Dementia (GeriND), PACH collaboration with THK Home Health team etc.

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  17. We spent most part of the second week understanding the home and social care services in Eksjö, which are under the charge of the municipality.

    Seeing how home and institutional care are being delivered in Eksjö really made me question the adequacy of the care currently provided in Singapore for our elderly. For instance, meals delivery service in Singapore meant hanging food packets on the doors of the elderly. In Eksjö, the nursing assistant whom I shadowed would deliver food to the place of the elderly and stay by the elderly’s side to encourage her to finish her meal. That definitely made a great difference for a malnourished elderly who usually has poor appetite and lives alone.

    Home care services in Eksjö allow the seniors to move at their own pace and for services rendered to be tailored to their needs. In comparison, home care services for elderly in Singapore are often designed to be delivered in the most efficient manner for service providers, and service users would have to conform to the service delivery model. There is definitely much more that can be done to improve home care services in Singapore.

    This brings me to one of Tzer Wee’s comments about the shifts required in the funding model in Singapore. Our current funding structure and subsidises and assistance schemes appeared to present disincentives for patients to seek care and treatment in the primary care and community settings. The allocation of financial resources needs to be done in a way that encourages persons to remain in and receive care from the community. Firstly, funding needs to be directed to boost the capacity and quality of community care services. Having quality community care services not only supports elderly persons to age in community but also provides the population with greater confidence and sense of security to remain in their community. Secondly, the financing model must make economic sense for both service users and providers. The out-of-pocket costs for service users would need to be adjusted to incentivise the consumption of services in the community. Incentives for service providers in the community would also be necessary for them to take on greater responsibility in managing the care of the population.

    With regard to the shifts required in primary care sector, there needs to be greater involvement of the GPs as primary physicians and care coordinators of individuals. I believe this is in the pipeline as I recall attending a town hall session with the health minister early this year with the same idea being surfaced. The current challenge, however, is that majority of our primary care doctors are private entities and the ministry may not have adequate control over their participation in the care of the community. I understand that there is a corporate planning team under the ministry specifically looking into the development envisioned for primary care. I do not have sufficient information on that but I wonder about the possibilities of adopting new operation models, such as the upcoming “Government Contracting Model” for the public bus industry and the “Build-Own-Lease Model” for nursing homes.

    After reading my previous reflection, one of my seniors, Nicole, also highlighted the difficulties in shifting mindsets. I wrote about the need to shift our focus to “what the best for Esther is” and that we need to move away from operational concerns such as workload and our bed crunch. Nicole was right in pointing out that expecting a shift in mindset may have been a tad too idealistic. Upon further reflections, however, I realised that inherent in our worries about bed crunch, workload, and discharging patients are our genuine concerns about the quality of care provided to our patients. Our worries about the bed crunch translate to concerns about promptness of having a place to rest for the next critically ill patient lying in the emergency room; Our worries about the high workload of healthcare workers translate to concerns about compromising the care rendered to those who genuinely require it; Our worries about discharging patients translate to our concerns about them catching nosocomial infection. Having to firefight daily may have caused us to forget about what we are fighting for and what is important to fight for. To create a shift in mindsets of our organisations and that of our partners, we cannot ignore the practical challenges that we are dealing with. What we can do, however, is to amplify the inherent concerns that we have for the care of our patients. In our interactions with both the municipality and the hospital workers in Esther Network, most have also provided the feedback that the story of Esther had been useful in re-directing their focus from organisation-centred to person-centred care. Having Esther Network as a neutral platform to work together in providing better care for Esthers and Esther Cafés to hear real-life stories of Esthers were also helpful in creating a shift to focus on the best for Esther.

    In my opinion, in shifting all these pieces, we need to look beyond ourselves as social workers and to see ourselves fundamentally as care providers. And implicit to that role is the need to constantly improve care provided for our patients. Nonetheless, I believe medical social workers are well-positioned to aid in making a shift in organisational mindsets and bridging the gap between health and social care services with our exposure to medical language and jargons as well as our training in systemic approaches to working with individuals.

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  18. Dear improvement friends!
    thanks for all valuable comments and reflections. Your visit creates great opportunities also for us to learn. Looking forward seeing you this week.
    Göran Henriks

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  19. Thank you for your thoughts. We may not have answers to all the pieces. Even if we have the answers, we are likely going to require a number of stakeholders to work together.
    1. Do social workers need to be under a ministry to facilitate Esther Network at home? Or is this too extreme?
    2. There’s talk about social workers being ideal in bringing integration, both vertical and horizontal. How can the current structure support (or prevent) us from facilitating integration?

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  20. Thank you for sharing your insights and reflections. Agree with Göran great opportunities for us to learn.

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  21. Dear all,

    Now the third week is already finished. We have had a lot of wonderful constructive conversations. What is already in place in Singapore and how can you built on that? You have a supportssytem as I understand called Shine and you have improvment chamipions. Could that be a start? Where will you find your supportssytem of bringning Esther forward in Singapore?

    To Nz Tee Wee. You write:
    – Do social workers need to be under a ministry to facilitate Esther Network at home? Very exiting thoughts
    That is a big step 🙂 In what way do you think that will benefit? Could you possible get the benefits anyhow in another way?

    We also have been talking about the name. What is in a name? How can you find a name that will be attractive for most of the people in Singapore.

    Some another experiences this last two weeks was the Esther coach internat and the strategiday. What do you think about this format of meetingplaces? Curious about how did it resonate in you?

    At least but not least: What was your highlight this week and why?

    We are very happy to have you here. You keep us alert with your questions and curiosity.
    Hope you also find some relaxing moments and enjoy the Swedish autum. See you next week.

    Nicoline

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  22. Greetings!

    I’ve been shown this blog by Nicoline and I must say it has been a very pleasant and informative reading. Thank you for sharing your thoughts and ideas so openly!

    I initially came here to say welcome to Muzza as Nicoline has helped us find a time and date to meet and discuss Sweden’s general view and actions regarding domestic violence. I would also like to hear about the equivalence in Singapore – maybe we can help spead some light to eachothers situations in this important issue?

    Looking forward to Thursday!

    Best regards,
    Eleonohra

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  23. Sounds like all three are fired up!!! Wonderful! While you are in the mountain top before you come home to the valley, if I can challenge you to develop a vision for our Singapore Esthers, what you wish to see happening at the professional, department, organizational, ministry, and community levels… don’t worry whether it is doable at this stage .. you must have big hairy audacious goals …. and we are excited and looked forward to learn from you.

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  24. An adorable 88-year old said yes today, to become my first Esther!

    So, what’s next?

    What do I need to do to prepare her for her role as an Esther ambassador?

    How can I tap on her help for the movement?

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  25. Fantastic Karen, Well done!

    Your question What is next is depending on several things. Most important: What does this Esther want to contribute with? Does she want to participate just one meeting or does she like to be a part of a longer improvement relationship? And probably she does not know this yet. In Esther Network, we normally start to invite Esthers just for one meeting, giving him/her a feeling what is it all about,and afterwards have a reflection with Esther about her experience of this improvemnet meeting and the reactions of the group. If Esther enjoyed to be a part of this way of working and found the meeting meaningful, we build on his/her own drive and invite her for other meetings or other possibilities.

    You can have an Esther as just a start for a meeting or as an improvement projectleader or in your steerings committe or whatever.There are a lot of opportunities to involve Esther in.

    The most important is not what you want her to do but what she thinks is important!
    To communicate with staff and what she sees are the biggest opportunities to improve.

    It is building on her experience and let this Esther decide herself how much time and what she would like to contribute with. You will find different people with different ambitions and possibilities.

    When you were in Sweden we talked a lot about feedback and relationship as very important when you are involving patientes in improvementwork. They want to know what happened with their story. So build in some kind of feedback after a few months. Did something happen? Did things change or was it just making people aware of the challenges Esther meet?

    Very good that you found Esther Singapore :-). Take good care of her and write your Learning for number two and more

    Thank you Karen for sharing this and welcome to others with more suggestions on this topic.

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