«SEPTEMBER 2015 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development ...»
Indonesia Hospital Accreditation
Process Impact Evaluation:
This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for
International Development (USAID) and authored by Edward Broughton of URC and Anhari Achadi, Kamaluddin
Latief, Fitri Nandiaty, Nurhaidah, Siti Nurul Qomariyah, Tika Rianty, Sri Wahyuni, and Arum Eskaning of the Center for Family Welfare/Universitas Indonesia under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. The work of the USAID ASSIST Project is made possible by the generous support of the American people through USAID.
DISCLAIMERThe contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Acknowledgements This report was prepared by University Research Co., LLC (URC) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER LLC.
For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write firstname.lastname@example.org.
Recommended citation Broughton E, Achadi A, Latief K, Nandiaty F, Nurhaidah, Qomariyah SN, Rianty T, Wahyuni S, Eskaning AP. 2015. Indonesia hospital accreditation process impact evaluation: Midline report.
Technical Report. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
TABLE OF CONTENTSGlossary
Index of Tables
Index of Figures
A. Recent History of Accreditation in Indonesia
B. HAPIE Study Phases
C. Changes in Indonesia’s Health System
A. Study Design
C. Data Sources
D. Revision of Indicators Evaluated in the Midline
E. Data Collection
F. Data Analysis
G. Ethical Considerations
H. Issues on Categorization of Studied Hospitals
A. Clinical Charts and Patients Discharged
B. Hospital Review
C. Organizational Audit
D. Clinical Chart Review
E. Patient Interview
IV. QUALITATIVE RESULTS AND DISCUSSION
A. Key Informant Interviews
Acronyms AMI Acute Myocardial Infarction ASSIST USAID Applying Science to Strengthen and Improve Systems Project BPHS Basic Package of Health Services BPJS Badan Penyelenggara Jaminan Sosial (Social Insurance Board, Administrator of the National Health Insurance Program) CBG Cost-based Group GoI Government of Indonesia HAPIE Hospital Accreditation Process Impact Evaluation HCI USAID Health Care Improvement Project ICCU Intensive Cardiac Care Unit ICD International Classification of Diseases HAPIE Midline Assessment v ISO International Organization for Standardization JCI Joint Commission International JKN Jaminan Kesehatan Nasional (National Health Insurance Program) IRMIK Medical Record Unit KARS Komisi Akreditasi Rumah Sakit (Commission for the Accreditation of Hospitals) MoH Ministry of Health NHA No Hospital Accreditation NHI National Health Insurance OA Organizational Audit OHSAS Occupational Health and Safety Advisory Services ORIF Open Reduction and Internal Fixation PPK Panduan Praktek Klinik (Clinical Practice Guideline) SJSN National Social Security System SPM Standar Pelayanan Medik (Medical Services Standard) USAID United States Agency for International Development WHO World Health Organization vi HAPIE Midline Assessment Index of Tables Table 1. Instruments and Sample Sizes
Table 2. Additions and Deletions in Hospital Review Instrument
Table 3. Additions and Deletions of Organizational Audit Instrument
Table 4. Additional of Clinical Review Instrument
Table 5. Additional of Patient Experience Instrument
Table 6. Data Collection Instruments and Their Use
Table 7. Informants’ Characteristics
Table 8. Clinical Conditions for Patient Record, Patient Experience
Table 9. Data Collection from Chart Reviews
Table 10. Samples Acquired from Hospitals
Table 11. Hospital Description
Table 12. Hospital Performance Indicators
Table 13. Methods of Payment for Normal Delivery Patients by Hospital Category
Table 14. Length of Stay for Normal Delivery Patients By Hospital Category
Table 15. Condition at Discharge of Delivery Patient by Hospital Category
Table 16. Percentage of Medical Examination Recorded in Normal Delivery
Table 17. Percentage of Patient Characteristic at Pneumonia by Hospital Category
Table 18. Method of Payment of Pneumonia Patients by Hospital Category
Table 19. Condition at Discharge of Pneumonia Patients by Hospital Category
Table 20. Percentage of Medical History Recorded at Pneumonia Patients by Hospitals and Hospital Category
Table 21. Percentage of Physical Examinations Recorded of Pneumonia Patients by Hospitals.
...... 40 Table 22. Age and Length of Stay of AMI Patients by Hospital Category
Table 23. Characteristic of AMI Patients (Method of Payment) by Hospital Category
Table 24. AMI Patients’ Condition of Discharge by Hospital Category
Table 25. Percentage of Clinical Examination Recorded in AMI Patients by Hospitals and Hospital Category
Table 26. Percentage of Medication at Discharge Recorded in AMI Patients by Hospitals and Hospital Category
Table 27. Percentage Medical History Recorded in AMI Patients by Hospitals and Hospital Category
Table 28. Age and Length of Stay of Hip Fracture Patients by Hospital Category
Table 29. Method of Payment of Hip Fracture Patients by Hospital Category
Table 30. Percentage of Standard Interventionfor Hip Fracture Patients
Table 31. Percentage of Mobilization and Treatment Received of Hip Fracture Patients by Hospitals and Hospital Category
Table 32. Characteristics of Respondents by Hospital Category
Table 33. Percentage Method of Payment by Phase by Hospital
Table 34. Length of Stay (Days) of Patients Experience by Hospital Category
Table 35. Percentage of Patient Experiences on Medical Services by Hospitals
Table 36. Percentage of Patient Experience on Nursing Services by Hospitals
Table 37. Percentage Change from Baseline to Midline in Patient Perceptions on Medical Decision and Discharge Explanation
Table 38. Percentage Difference between Baseline and Midline in Favorable Perception of Patients toward Hospital Facilities
HAPIE Midline Assessment vii Index of Figures Figure 1. Data Collection Timeline for HAPIE Study
Figure 2. Summary for Hospital Governance in Nine Hospitals by Phase by Group
Figure 3. Summary for Patient Orientation in Nine Hospitals by Phase and Group
Figure 4. Summary for Human Resources in Nine Hospitals by Phase by Group
Figure 5. Summary for Clinical Practice and Patient Care in Nine Hospitals by Phase by Group.
...... 25 Figure 6. Summary for Health Care Associated Infections in Nine Hospitals by Phase by Group...... 26 Figure 7. Summary for Transfusion in Nine Hospitals by Phase by Group
Figure 8. Sumary for Facilities Management in Nine Hospitals by Phase by Group
Figure 9. Summary for Medication Safety in Nine Hospitals by Phase by Group
Figure 10. Summary for Surgery, Procedures and Anesthesia in Nine Hospitals by Phase by Group 28 Figure 11.
Summary for Documentation and Records in Nine Hospitals by Phase by Group............. 28 Figure 12. Comparison of Total Scores of 10 Keys OA Criteria between Baseline and Midline by Hospitals
Figure 13. Comparison of Total Scores of 10 Keys OA Criteria between Baseline and Midline in All Hospitals
Figure 14. Total Scores of 10 Keys OA Criteria between Baseline and Midline by Departments.
....... 30 Figure 15. Percentage Laceration and Episiotomy Recorded on Delivery Patient by Hospital and Hospital Category
Figure 16. Percentage of Medical Examination Recorded on Delivery Patient by Hospital and Hospital Category
Figure 17. Percentage Difference of Medical Examination Recorded for Delivery by Hospital Category
Figure 18. Percentage Difference of Medical History Recorded for Pneumonia Patients by Hospital Category
Figure 19. Percentage Difference Physical Examinations Recorded for Pneumonia by Hospital Category
Figure 20. Percentage Difference of Clinical Examination Recorded in AMI Patients by Hospital Category
Figure 21. Percentage Difference of Medication at Discharge Recorded by Hospital Category.
......... 44 Figure 22. Percentage Difference of Medical History Recorded for AMI by Hospital Category........... 45 Figure 23. Difference of Clinical Examination (Prop Yes) for HIP Fracture by Hospital Category...... 49 Figure 24. Method of Payment by Phase by Hospital
Figure 25. Percentage Difference between Baseline and Midline Study of Favorable Patient Experiences toward Medical Services by Hospital Category
Figure 26. Percentage Difference between Baseline and Midline Study of Favorable Patient Experiences toward the Nursing Care by Hospital Category
Figure 27. Percentage Favorable Perception of Medical Decision-making and Clarityof Discharge Instruction by Hospital Category
Figure 28. Percentage of Favorable Perception toward Hospital Facilities, by Hospital Category.
..... 60 viii HAPIE Midline Assessment
EXECUTIVE SUMMARYIntroduction In 2011, USAID Indonesia commissioned the USAID Health Care Improvement Project (HCI) to conduct a study of hospital accreditation. After the baseline assessment, support for the activity was provided through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project.
The overall objective of the Hospital Accreditation Process Impact Evaluation (HAPIE) longitudinal study is to examine changes in quality and safety performance of nine hospitals undergoing accreditation with: 1) Joint Commission International (JCI); 2) Komisi Akreditasi Rumah Sakit (KARS – the Indonesian accreditation system) before 2016; and 3) KARS after 2016 but no hospital accreditation (NHA) during the study.
The study is being conducted in three phases: baseline (completed August 2013), mid-line (current report) and end line (data collection planned for January 2016). This report examines the midline data
in relation to the baseline. The questions addressed in this study are:
Are there changes in the quality of services and patient outcomes and experiences in the hospitals associated with the accreditation process they are undergoing?
Are there differences in the changes in service quality and related patient outcomes and experiences among the nine hospitals associated with the type of accreditation they are undergoing?
What is the general experience with the accreditation process in the period since the baseline assessment?
Primary qualitative and quantitative as well as some secondary data collected by the hospitals was used to determine changes in quality performance in the hospitals.
Changes to Indonesia’s Health System One major confounder in the HAPIE study is the implementation of the new JKN (Jaminan Kesehatan Nasional) national health insurance program which began January 2014. JKN is a guarantee of health health insurance coverage for all people living in Indonesia as mandated by the Constitution (UUD) 1945 Section 28 H on the right of every person to obtain health care. When fully implemented as planned for 2019, it will be the largest single-payer health insurance system in the world, covering approximately 250 million people.
Implementation has impacted the nine hospitals profoundly but differently. While it was not part of this study to specifically evaluate the consequences JKN on the quality performance of hospitals, is has become an important part of the study. It is difficult to distinguish between the effects of the JKN system and those associated with the different accreditation process and it is possible that the two are related.
Study Design Quantitative methods were applied to determine hospital service quality and performance and included clinical charts review for one of four conditions (normal vaginal delivery, pediatric pneumonia, acute myocardial infarction and hip fracture) and interviews from inpatients in four wards (obstetric, pediatric, internal medicine and surgery). We also collected data from observations and reviews of hospital documents, regulations, and policies along with interviews with key informants from all hospitals.