Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce

Figures & data

Figure 1. Cluster dendrograms for the speech-language pathologist (SLP) and manager groups.

Table I. Cluster themes, theme descriptions, and example statements for the speech-language pathologist (SLP) and manager groups.

Cluster ID	Theme (no. of statements)	Theme description	Example statements
Speech-language pathologist
1	Consumer awareness and support needs (n = 19)	Increasing public awareness and consumers’ access to dysphagia care resources	There should be increased public awareness about dysphagia and SLPs. There should be dysphagia educational resources (e.g. videos) in different languages.
2	Accessible resources for SLPs (n = 11)	SLPs having access to resources in providing optimal dysphagia services (e.g. feeding utensils, interpreter, etc.)	There should be interpreter services available. SLPs should have regular access to instrumental assessments.
3	Information management systems (n = 9)	Using integrated systems to manage information and services	SLPs should have access to patients’ previous medical and dysphagia notes.
4	Cross-institution communication and collaboration (n = 12)	Improving cross-institution communication and collaboration	TigerConnect^a should be available to the professionals outside of the acute settings. The interinstitution dysphagia referral process (including instrumental assessments) should be simplified.
5	Speech-language pathology workforce and development (n = 7)	Expanding the SLP workforce and increasing SLP professional training	There should be more SLPs to provide dysphagia services. SLP dysphagia training should be standardised across service providers (including community and private sectors).
6	Interprofessional education and collaborative care (n = 15)	Enhancing dysphagia education and collaboration for all relevant professionals	Relevant professionals (e.g. healthcare assistant, nurse, doctor) should be equipped with dysphagia knowledge and skills. Patients should be managed holistically by a multidisciplinary team.
Manager
1	Instrumental assessments and technology-enhanced care (n = 8)	Having resources to provide instrumental assessments and technology-enhanced care	Patients should have timely access to dysphagia services (including instrumental assessments). Dysphagia telehealth services should be provided.
2	Clinical workflow and information management systems (n = 8)	Enhancing clinical workflow and using integrated systems to manage information and services	There should be a triaging system to determine the urgency of dysphagia reviews. SLPs should have access to patients’ previous medical and dysphagia notes.
3	Collaborative care (n = 6)	Engaging other healthcare professionals to provide collaborative care	There should be a cohesive team (e.g. doctors, nurses, assistants) that readily provides support to SLPs in dysphagia care.
4	Capacity and capability of the workforce (n = 13)	Expanding the workforce, and increasing professional training and collaboration for all relevant professionals	There should be more SLPs to provide dysphagia services. There should be more interprofessional education and collaboration opportunities.
5	Consumer support needs (n = 7)	Increasing consumers’ access to dysphagia care resources	There should be a national dysphagia resource library or website that is accessible by the general public (e.g. health-hub on dietary preparation).
6	Subsidies and cross-institution referral workflow (n = 9)	Improving cross-institution referral process and enhancing dysphagia subsidies	SLPs should have a guide, which lists the criteria for a patient to qualify for subsidised cross-institution referrals.

^aTigerConnect is a secured messaging platform for healthcare professionals in Singapore.

Figure 2. Pattern matching maps comparing importance and changeability of each cluster for the speech-language pathologist (SLP) and manager groups.

Figure 3. Go-zone plots comparing importance and changeability of each statement for the speech-language pathologist and manager groups.

Note. The numbers represent statement IDs (e.g. number 53 means Statement ID 53).

Table II. Twenty-seven go-zone statements rated as both highly important and highly changeable by the speech-language pathologist (SLP) group.

Statement ID	Cluster ID	Statement	Mean importance rating	Mean changeability rating
3	1	Thickened fluids should be easily accessible to patients.	3.6	2.1
20	1	There should be dysphagia educational resources (e.g. videos) in different languages.	3.3	3.4
29	1	Dysphagia educational resources (e.g. videos) should be available online so that SLPs, patients, and caregivers can access them anywhere.*	3.0	2.4
37	1	SLPs should involve caregivers as early as possible in dysphagia care.	3.0	3.0
58	1	There should be increased public awareness about dysphagia and SLPs.	3.4	2.2
65	1	Dysphagia telehealth services should be readily available and accessible.*	2.7	2.2
66	1	Dysphagia education should be ongoing in the community hospital to engage patients continuously.	2.7	2.7
64	2	SLPs should have regular access to instrumental assessments.	3.7	2.1
6	3	There should be a way to collect dysphagia clinical outcomes easily.	2.6	2.3
34	3	SLPs should have access to patients’ previous medical and dysphagia notes.*	3.8	2.3
43	3	There should be an integrated system where SLPs can write notes and order diets on a same platform.	3.0	1.9
45	3	SLPs should have access to the estimated cost of dysphagia services rendered by different service providers (e.g. day rehab charges vs. home SLP charges etc.).	2.7	2.9
60	3	All institutions should have standard types of resources (i.e. IOPI, sEMG).	2.6	1.9
61	3	SLPs should have a directory of speech-language pathology services that are available in Singapore.*	3.1	2.8
71	3	Dysphagia clinical outcomes should be tracked across all institutions.	2.7	2.5
1	4	TigerConnect^a should be available to the professionals outside of the acute settings.	3.0	3.1
10	4	The protocol of raising blanket dysphagia referrals for patients who have seen a SLP on the same day at the previous institution should be reviewed.	2.7	2.8
18	4	There should be communication channels between acute and community hospitals where SLPs can feed back about dysphagia assessment differences.	2.7	1.8
41	4	There should be better methods of memo transfers between SLPs.	3.5	2.5
53	4	Everyone should use the same modified consistencies terminologies.*	3.8	3.3
63	4	The interinstitution dysphagia referral process (including instrumental assessments) should be simplified.*	3.6	2.2
8	5	There should be more trained therapy assistants to support dysphagia clinical tasks.*	3.2	2.0
12	5	There should be more SLPs to provide dysphagia services.*	3.3	1.8
31	5	All SLPs should be trained in all dysphagia therapy techniques.	3.3	1.8
67	5	SLPs should learn techniques or therapies in effective counselling and persuasion skills to promote compliance to dysphagia recommendations.	2.6	2.6
39	6	Patients should be managed holistically by a multidisciplinary team.*	3.6	2.2
48	6	Relevant professionals (e.g. healthcare assistant, nurse, doctor) should be equipped with dysphagia knowledge and skills.*	3.2	1.8

Note. IOPI = Iowa Oral Performance Instrument; sEMG = surface electromyography.

*Similar statements as the manager group.

^aTigerConnect is a secured messaging platform for healthcare professionals in Singapore.

Table III. Twenty-two go-zone statements rated as both highly important and highly changeable by the manager group.

Statement ID	Cluster ID	Statement	Mean importance rating	Mean changeability rating
9	1	There should be standardised protocols regarding usage of therapy instruments (e.g. how we should use it, have research evidence to back it up).	2.7	3.1
22	1	Dysphagia telehealth services should be provided.*	2.6	3.3
1	2	SLPs should have access to patients’ previous medical and dysphagia notes.*	3.2	3.1
51	2	Medical discharge summaries should contain a summary of SLP’s assessment and rehabilitation.	2.8	2.6
7	3	There should be a cohesive team (e.g. doctors, nurses, assistants) that readily provides support to SLPs in dysphagia care.*	3.1	2.5
43	3	Medical team should advocate for SLPs’ roles when speaking to patients and families.	3.1	2.3
44	3	There should be a platform for ward staff to share their issues with SLPs on dysphagia management.	3.2	3.1
15	4	Relevant healthcare staff should be equipped with dysphagia knowledge and skills.*	3.1	2.9
21	4	There should be cross-institution training opportunities to facilitate professional and clinical skills development (e.g. FEES, VFSS, sEMG, complex patient).	3.1	2.7
29	4	There should be more interprofessional education and collaboration opportunities.	3.3	3.5
30	4	There should be more trained therapy assistants to support clinical tasks.*	2.7	2.7
35	4	All food services should be trained in IDDSI.*	3.1	2.7
42	4	Dysphagia training for nurses should be conducted regularly in an effective and efficient way.	3.2	3.2
46	4	There should be training for SLPs to become competent in providing dysphagia telehealth services.	2.7	3.3
47	4	There should be more SLPs to provide dysphagia services.*	2.9	2.4
6	5	Community-based dysphagia services should be more accessible.	3.5	2.3
27	5	There should be a national dysphagia resource library or website that is accessible by the general public (e.g. health-hub on dietary preparation).*	3	2.9
33	5	There should be a system where patients can keep track of their dysphagia exercises and progress.	3	2.5
40	5	Patients should have avenues to get in touch with SLPs easily.	2.8	2.3
23	6	There should be a standardised workflow for interinstitution referral that is easy to execute.*	2.9	3.1
32	6	There should be a way to measure productivity, outcomes, and cost-effectiveness of dysphagia services.	3	2.5
36	6	SLPs should have a directory of speech-language pathology services that are available in Singapore.*	2.9	3.6

Note. SLP = speech-language pathologist; FEES = fiberoptic endoscopic evaluation of swallowing; VFSS = videofluoroscopic swallowing study; sEMG = surface electromyography; IDDSI = International Dysphagia Diet Standardisation Initiative.

^*Similar statements as the SLP group.