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«SEPTEMBER 2015 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development ...»

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Hospitals C and D has similar experience. At the beginning of the JKN transition, liquidity was very disturbed. The numbers of claims that JKN agreed to pay were too small and problems with other claims need to be fixed. Some problems were caused by incomplete medical record, a lack of understanding of JKN concepts, software that had changed several times, and the productivity of verifier from BPJS. An informant from the Finance Department commented, “On schedule of payment, usually below our expectation because of delay due to bureaucracy processes. We have submitted the report, but they did not pay us timely. We sometimes have to wait until 2-3 month later."

One study hospital submitted medical records to BPJS at end of January 2014, but 70% were rejected by BPJS, and after two correction processes BPJS agreed to pay 50% of the amount claimed. To revise the returned files requires great effort by the hospital, involving finance managers, medical record staff and sometimes medical specialist who provided services.

To overcome these problems, hospital management has several initiatives include socialization to the entire staff, especially medical doctors who provide care to patient. They must follow clinical guideline and pathways to be efficient in their services. In Hospital B, management has emphasized completeness of discharge summaries. Other hospitals have appointed medical doctor in every unit as the person in charge. This person has to ensure completeness of charts and claims. However, implementation has not been smooth partly due to lack of compliance by some doctors, mainly the senior ones.

Management of Hospital E seeks to overcome obstacles by evaluating and supervising the service regularly, every month. For example, when reimbursements for the surgery department are high compared to the standard rates, the hospital tried to investigate the cause of the problem.

Initiative to overcome the problem can also come at the department level. There are departments in one of the study hospital that conduct training on the INA-CBG system for specialists to develop a better understanding of the new system, specifically on coding and cost control for medical procedures.

Another aspect of JKN implementation is related to hospital tariffs [29]. Under JKN, tariffs are regulated by the Ministry of Health which states that tariffs are based on hospital class (A,B,C,D) and region where the hospital belongs, and this makes some hospitals express their disagreement.

Another problem experienced by our study hospitals is the fact that these are teaching hospitals.

Compared to non-teaching hospitals, here there are more personnel involved in treating patients, including residents and consultants, which further complicates the provider payment system.

HAPIE Midline Assessment 67 V. CONCLUSION This study was carried out in nine top (A Class) government owned hospitals located in eight provinces in Indonesia. The overall objective of this longitudinal comparison study is to examine changes in quality and safety performance of these hospitals, among those undergoing the JCI accreditation process, those undergoing the new KARS accreditation process, and the ones which

are not due to have any accreditation until 2015. This study is being conducted in three phases:

baseline (October – December 2012), mid-line (March- July 2014), and end line (planned in January 2016). 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.

The hospital review captured data in ten domains. An organizational audit was conducted to describe the quality of care at the unit/department level within a hospital related to the four diagnoses listed above. A questionnaire captured patients' experiences with their care during their inpatient stay. A total of fifty five key informants were interviewed.

The following are conclusions based on baseline and midline data.

1. Among the nine hospitals some have been accredited based on the old KARS (2007) standards, three hospitals have been accrediated based on the new (2012) KARS standards, and two hospitals have been accredited by JCI. Government of Indonesia sets requirement that every hospital taking JCI accreditation needs to be accrediated with 2012 KARS as a prerequisite

2. In general we see improvement of hospital status from baseline to midline, with the different trend among the three groups of hospital. In three JCI hospitals, five out of ten variables improved, and these are a) patient orientation; b) clinical practice and patient care; c) health care associated infection; d) facilities management; and e) medication safety. Only one variable (medication safety) which improved in all four hospitals KARS hospitals accreditation, and in NHA hospitals accreditation only “health care associated infection” variable which improved. Overall, JCI hospital showed the most variables improved, followed by KARS hospitals, and the NHA hospitals has the least variables improved.

3. In the clinical review, the midline average score of all hospital was higher than baseline, except that related to medical history in pneumonia case. However, there was no obvious change pattern among the three group of hospitals., that related to clinical examination for acute myocardial infarction case, the midline score is higher then baseline in seven out of nine hospital, while related to standard intervention in hip fracture case the midline score is higher then baseline in six out of nine hospitals. In one hospital belongs to NHA hospitals group, midline score of all varibles related clinical review is higher then baseline, except one variable (i.e., medical history in pneumonia case).

4. From the patient interview we see that midline average score of the nine hospitals of every variable is lower then that of baseline, except on “overall patient satisfaction”.

Midline score of patient perception on facilities is higher than in baseline in hospitals belong to JCI hospitals accreditation group, and that is not the case with other hospital groups. Similarly with overall patient satisfaction.

5. The GoI has developed safety standard on hospital facilities, and all these nine hospitals are trying to meet those standards. Some hospitals have developed operational cooperation with the private company in order to equip the hosptal with high cost medical equipment. Clinical practice guidelines has been developed in all the hospitals following the guidance provided by Ministry of Health, however, this guideline is neither complete nor deligently followed by the clinicians working in the hospital.

68 HAPIE Midline Assessment

6. Increased concern on patient’s right has been acknowledged by most hospital personnel, but this concern has not been followed with the significant action. Providing comprehensive information to patient has not been the standard practice in all the hospitals, and there is hospital that still neglect the privacy of patients in the third class ward.

7. Most hospitals, with different degree of enthusiasm from top level management, are in the process of pursuing an accreditation status, either to KARS or JCI. Some hospitals acknowledged that this accreditation process has changed the personnel’s mindset towards the more professional attitude and comply with procedures and guidelines in delivering services. On the other hand, critical opinion has been extended to KARS surveyors regarding their inconsistencies in implementing the accreditaion process.

8. Implementaion of National Health Insurance has had a significant impact on hospital, in particular financially. Nevertheless some hospitals have seen this national policy as a challenge to improve their clinical paractice, provider’s payment, and financial management.

REFERENCES 1 Soepojo, P., Koentjoro, T., and Utarini, A. Benchmarking of Hospital Accreditation System in Indonesia and Australia. Jurnal Manajemen Pelayanan Kesehatan (2002), 5(2): p. 93-101.

2 Irfianti, I. Evaluation of Hospital Accreditation in Indonesia by the Hospital Accreditation Commission (KARS): Perceptions of Hospitals and ISQua Standards. Yogyakarta, 2011.

3 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA. Pedoman Klasifikasi dan Standar Rumah Sakit Pendidikan (Teaching Hospital Classification and Standard Guidlines). MoH RI, Jakarta, 2009.

4 MINISTRY OF HELATH OF REPUBLIC OF INDONESIA (MOH RI). List of Accredited Hospital Version-2012. In http/kars.or.id/rekap_akreditasi/. MoH RI, Jakarta, 2014.

5 REPUBLIC OF INDONESIA. Law of the Republic of Indonesia Number 24 of 2011 Regarding BPJS. Republic of Indonesia, Jakarta, 2011.

6 REPUBLIC OF INDONESIA. Law of the Republic of Indonesia Number 40 of 2004 Regarding National Social Security System. Republic of Indonesia, Jakarta, 2004.

7 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Regulation of MoH RI Number 755 of 2011 Regarding Medical Committee. MoH RI, Jakarta, 2011.

8 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Clinical Practice of Normal Delivery (JNPK-RI). MoH RI, Jakarta, 2008.

9 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Asuhan Persalinan Normal (Normal Delivery Care). MoH RI, Jakarta, 2004.

10 Van de Werf, Frans, et al. Management of Acute Myocardial Infarction in Patients Presenting with Persistent ST-Segment Elevation. European Heart Journal (2008), 29; 2909 – 2945.

11 O'Gara, Patrick T, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. American Heart Association (2012).

12 Skudal, K.E., et al. The Nordic Patient Experiences Questionnaire (NORPEQ): Cross-National Comparison of Data Quality, Internal Consistency and Validity in Four Nordic Countries. BMJ Open (2012).

13 Shaw, C., et al. Self-Assessment for Patient Safety in Hospitals. 2012.

14 REPUBLIC OF INDONESIA. Government Regulation Number 74 of 2001 on the Management of Hazardous and Toxic Waste. Republic of Indonesia, Jakarta, 2001.

HAPIE Midline Assessment 69 15 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Decree of MoH RI Number 856 of 2009 Regarding the Standards of Emergency Services. MoH RI, Jakarta, 2009.

16 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Decree of MoH RI Number 1438 of 2010 Regarding the Standards of Medical Care. MoH RI, Jakarta, 2010.

17 REPUBLIC OF INDONESIA. Law of the Republic of Indonesia Number 36 of 2009 Regarding Health. Republic of Indonesia, Jakarta, 2009.

18 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Standar Pelayanan Minimal Rumah Sakit (Hospital Minimum Services Standard). MoH RI, Jakarta, 2008.

19 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Standar Pelayanan Minimal Rumah Sakit (Hospital Minimum Services Standard). MoH RI, Jakarta, 2012.

20 Qomariyah, Siti Nurul et al. Identification Process of Maternal Death in Facility. In Research Report of Indonesian IMMPACT. CFW UI, Depok-West Java, 2007.

21 INDONESIAN MEDICAL COUNCIL. Competence Standard in Medical Council of Indonesia.

Jakarta, 2012.

22 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Decree of MoH RI of 2004 Regarding Guidelines for the Preparation of Health Human Resources Planning in the Province.

Moh RI, Jakarta, 2004.

23 Adisasmito, Wiku, et al. Rapid Situational Analysis Report. In Indonesia: Health System and Pandemic Preparedness. Jakarta, 2009.

24 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Decree of MoH RI Number 340 of 2010 Regarding the Classification of the Hospital. MoH RI, Jakarta, 2010.

25 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Competency Test of Nurses and Midwifes. In http://bppsdmk.depkes.go.id/pustanserdik/index.php/pustanserdik/kontenberita/94. MoH RI, Jakarta, 2013.

26 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Accreditation Standard 1st Edition. MoH RI, Jakarta, 2011.

27 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Regulation of MoH RI Number 71 of 2013 Regarding Health Services on JKN Program. MoH RI, Jakarta, 2013.

28 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Regulation of MoH RI Number 001 of 2012 Regarding the Health Care Referral System. MoH RI, Jakarta, 2012.

29 MINISTRY OF HEALTH OF REPUBLIC OF INDONESIA (MOH RI). Regulation of MoH RI Number 69 of 2013 Regarding Health Care Tariff of JKN Program. MoH RI, Jakarta, 2013.

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