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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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The hospital review captured data in ten domains: Hospital Governance; Patient Orientation; Human Resources; Clinical Practice & Patient Care; Health Care-Associated Infections; Transfusion; Hospital Facilities Management; Medication Safety; Documentation and Records; and Surgery, Interventional Procedures and Anesthesia.

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 55 key informants, most from hospital HAPIE Midline Assessment ix accreditation teams, were interviewed. There were two from each hospital except for the four from one hospital.

The midline phase of the study was approved by the Institutional Review Boards of Universitas Indonesia and conducted with support from the Indonesian Ministry of Health (MoH). Hospital administrators gave permission for data collection to occur in their hospitals. All patients and informants interviewed were asked for their informed consent and precautions were taken to ensure their anonymity.

Data Collection and Analysis Organizational audit: This describes the quality of care at the unit/department level for the four diagnoses of interest, i.e., in-patient ward, delivery ward, perinatal ward and Intensive Cardiac Care Unit (ICCU).

Clinical review: Patient medical records were reviewed from a sample taken at random for the diagnoses normal vaginal delivery, childhood pneumonia, hip and femur factures and acute myocardial infarction. The charts were reviewed for elements such as patient characteristics, completeness of clinical information and patient outcomes.

Patient questionnaire: This tool captured patients’ experiences with care they received during their inpatient stay.

Hospital-based data: Secondary data were collected from each hospital where possible on service quality, hospital company profile, hospital performance indicators, policies on regulations in all aspects, adverse events, and the formulation of committees to address deficiencies in patient care or hospital operations and, when available, the costs related to accreditation preparation.

Stakeholder interviews: Interviews with Chiefs of Medical Services, Hospital Accreditation Team members, Finance Manager, Unit of hospital information system, and the Health Insurance Unit aimed to understand their opinions on the purpose of hospital accreditation, how the accreditation program was progressing from the perspectives of senior officials at participating hospitals, KARS, and the MoH, and how the accreditation process influences the quality of care available delivered at the hospital in the future as well as changes in hospital policy regarding JKN.

For the hospital review and organizational audit, the research team discussed the results obtained to ensure standardization of scoring. Hospital review data were scored against standardized criteria using a 0-4 rating (0 is non-compliant, 4 is fully compliant). Organizational audit data were scored 0, 2 and 4. Data from clinical chart reviews and from patient experience questionnaires were analyzed by individual hospitals. Stakeholder interviews were recorded, transcribed and analyzed. Descriptive analysis was done to all variables. Chi-square statistical tests were used to examine associations between variables.

Categorizing studied hospitals: From baseline to midline, the accreditation status and plans of some hospitals changed. One hospital designated for JCI opted out while another decided to progress toward JCI accreditation without a mandate from the MoH. One JCI hospital delayed their seeking JCI for a year. The midline categorization of hospitals reflects these changes.

Results Hospital Review  Hospital governance: Performance on this domain was generally mixed.

 Patient orientation: JCI hospitals showed an increases as did Hospitals C and G (KARS).

Only Hospital H among NHA hospitals showed an increase. Average scores for all hospitals increased from 2.8 to 3.0.

 Human resources: Hospital B (JCI) showed a decrease while KARS hospitals showed an increase or were unchanged. Among NHA hospitals, only hospital I showed an increased.

Average score for all was 2.9 at baseline and increased to 3.1.

 Clinical practice and patient care: All JCI hospitals and all KARS hospitals except Hospital C also increased. All hospitals NHA decreased, mostly due to a lack of resuscitation x HAPIE Midline Assessment equipment and diagrammatic instructions and guidelines on antibiotics use.

 Health care associated infections: The average scores for all nine hospitals increased by

0.2 with only Hospitals F and G (KARS) showing a decrease. NHA hospitals were generally lower.

 Transfusion: Two of three JCI hospitals decreased while two KARS hospitals improved and two remained unchanged. There was no change in the NHA hospitals.

 Facilities Management: There was minimal change in the overall average in this domain. All JCI hospitals showed a slight increase.

 Medication Safety: Scores for medication safety ranged from a mean of 2.5 at baseline to a mean of 3.2 in the midline. Only Hospital H (NHA) did not shown an increase over the period and they started from a lower baseline.

 Surgery, Procedures and Anesthesia: The mean difference from baseline to midline was an increase of 0.2 to 3.0 overall. Only Hospitals A (JCI) and H and I (NHA) did not shown an improvement. NHA hospitals started from a generally lower baseline.

 Documentation and Records: Two of three JCI hospitals increased, while three KARS hospitals decreased, and all NHA hospitals decreased.

Organizational Audit The Organizational Audit (OA) was based on 10 criteria determined from the four hospital departments, obstetric, pediatric, internal medicine and surgery. Composite results showed that the majority of hospitals improved from baseline to midline. There were major improvement in Hospitals A, E and G, while Hospital F experienced a slight decrease. Maternity departments had high compliance with quality standards than units treating hip and femur fractures.

Clinical Chart Review There were significant changes in payment methods noted in clinical charts and there was generally an improvement in the degree of completeness of the records but major deficiencies remain. There was no major differences between the hospital groups. The length of stay in most hospital categories at each department decreased in the midline, especially in JCI hospitals. In KARS hospitals in pediatric departments, there was a slightly increase from baseline to midline (from 5 to 6 days).

Patient Questionnaires In Hospitals C and D there was an improved inpatient perception of medical services but in all seven others there was a decreased. There was a decrease from baseline to midline in all categories with KARS hospitals experiencing the greatest decline. The perception of nurses also decreased with the again KARS hospitals experiencing the greatest gains. For perceptions of medical decision-making and discharge instruction category, JCI hospitals showed an improvement while KARS hospitals had a slight decrease and NHA hospitals had a greater decrease.

In all hospitals, the perception of patient of hospital facilities decreased around 2% between baseline and midline. By hospital category, JCI hospitals were essentially unchanged while the other two hospital categories decreased by about the same proportion.

Key Informant Interviews The informants included hospital management at all levels, accreditation team members and various committee members in the nine study hospitals. We grouped the information into three categories: 1) hospital review; 2) accreditation process; and 3) national health insurance implementation.

Hospital Review Five of nine hospitals performed poorly for reasons such as medical record sheet absences, incomplete clinical information in the medical records, incorrect or missing coding, missing or incomplete discharge summaries and deficiencies in case note storage. Informants from four hospitals admitted they still had deficiencies in medical records standards. This has caused major disruptions in hospital management, especially with implementation of JKN, given its requirements for accurate medical records for payment of claims.

HAPIE Midline Assessment xi In general the JCI hospitals group performed better than the other two groups. Five of ten domains improved, including patient orientation, clinical practice and patient care, health care-associated infection, facilities management; and medication safety. Factors that appeared associated with this included strong management and leadership, a visibly better work culture, effective communication between management and clinicians, funding and logistics support, and human resources. These criteria are closely associated with patient-centered standards and organization management in the JCI survey instrument. It is not possible from this study to determine whether the improvement is due to the fact that they were seeking JCI accreditation or because they are hospitals with the strongest quality systems even before seeking accreditation. These hospitals generally start from a higher base for most indicators of quality performance used in this study. The hospitals appeared to take JCI accreditation seriously, assigning significant human and material resources to the process.

Facilities In the midline period, we observed that some hospital facilities did not meet standards for patient safety, especially Hospitals H and I. For example fire extinguishers were absent or outdated, some evacuation routes were inadequate or locked and facilities for the disable were deficient. Almost all study hospitals did not meet safety standards because they were built long ago and had not been renovated as standards evolved. However, some hospitals had made specific changes since the baseline. For example, Hospital E provided standard ward beds, installed central gas facilities and made supply and evacuation route signs. Other hospitals renovated emergency rooms and constructed a new building for Class 3 patients. Three hospitals were renovating their facilities following the Standard of Facility Management System from JCI primarily related to patient safety.

Facility renovation and management depend on commitment of hospital management to achieve better quality of care and services.

Clinical Practice The midline survey showed that all participating hospitals had clinical practice guideline (Panduan Praktek Klinik or PPK), but some were incomplete and some Informants stated that they were not yet known and referenced by all hospital clinicians – some did reference them for treatment but others consider them as documents used as a prerequisite for achieving accreditation rather than guidelines for clinical use. There appeared to be no change in the way PPK was implemented in the midline compared to the baseline. Observations and responses in the midline showed that all study hospitals increased their attention to medication safety standard, and all but one hospital, H, showed improvements. In seven of nine hospitals, annual evaluation has been done to examine the appropriateness of the prescription using formulary as the standard.

Patients’ Rights Midline observations showed that all study hospitals had increased attention to patient’s rights compared to the baseline, but deficiencies were still noted. Seven of nine hospitals had patient rights information in locations readily seen by patients and families but facilities generally did not appear well designed to maintain privacy for patients and families. In five of nine hospitals patient beds in the third class ward were not provided with curtains between beds. Informants from three hospitals expressed increased concern on patient’s right after a highly publicized court trial of a hospital medical doctor. They expressed concern that patients will be more critical of hospital services if they understood their rights. Results from the patient survey showed that not all nine study hospitals explained to patients about their rights and obligations.

Hospital Information System Examination of hospital documents generally revealed poor data quality and variability between hospitals, making it very difficult to compare their data with the national indicators (Medical Services Standard or Standar Pelayanan Medik/, SPM). The MoH conducted several trainings on hospital indicators, performed annual evaluations, and provided special rewards (certificate) to hospitals showing high-functioning information system. No hospitals had in place a system to validate their own data. The number of deaths, net death rate and rates of hospital-acquired infection all were not recorded completed in all of the hospitals. Such a fundamental deficiency in tracking important xii HAPIE Midline Assessment performance data across all three hospital groups represents a departure from international standards. Considering the importance of hospital performance data to determine the quality of services, there is a need for improvement in data management systems and this may require substantial investment.

All study hospitals enter and process medical records information manually, except billing systems.

Five hospitals collect census data from the wards every day, submitted those data to the Medical Record unit (IRMIK) who will process data into standardized reports.

Patient Experience All hospitals except C and D decreased from baseline to midline period on patient perceptions of their doctors’ performance. This could have been because the increasing patient-to-physician ratio and the medical education curriculum or implementation of JKN which has increased demand for hospital services without increasing capacity for medical services of the same quality. Further investigation is needed to determine this relationship. Almost all hospitals decreased in perceptions of nursing services also. The decline may be due to the shortage of nurses, which the MoH has tried to improve using accreditation of medical education institutions and implementing competency tests.

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