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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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Satisfaction in JCI hospitals increased while in the two other hospital groups it decreased. One reason for the decrease could be implementation of JKN. The first groups to be covered by JKN were active and retired civil servants and military, and Jamkesmas and Jamkesda recipients (both for the poor and near-poor). As stated by some informants, this means that military and civil servants are now essentially receiving the same services as the poor and near-poor, a situation that those of the former group, at a higher social-economic level, may see as objectionable.

Accreditation Observation showed that success of hospitals achieving accreditation depends on workers’ culture and attitudes towards work, leadership, and the readiness of designated teams in the hospitals to implement changes necessary to achieve accreditation. Among the nine study hospitals in this midline survey, five (A, B, D, F and H) hospitals essentially did not experience change since the baseline survey, while three hospitals (B, D, and E) showed a significant improvement in many aspects of their operations. The improved hospitals all had active accreditation teams eagerly pursuing implementation of actions towards accreditation while top management was giving the needed support and authority. In the other six hospitals this was either not as strong or lacking completely.

Informants in hospitals successfully accredited by JCI and KARS emphasized the role of top management in this process. Commitment from top management and financial commitment are needed to drive the process of change. Successful hospitals used their budget on in-house and visits to other successfully accredited hospitals in Indonesia.

KARS (2012) Version The GoI revised the hospital accreditation instrument based almost entirely on the JCI instrument and have called it the KARS (2012) version. In this midline study, hospitals A, B, and D experienced both JCI and KARS accreditation and informants from these hospitals noted differences between KARS and JCI surveyors, both methods and results. The inconsistency of KARS surveyors was a major concern mentioned by informants from all hospitals.

Informants in five hospitals (A, B, D, E and G) noted that the accreditation process changed the attitudes of hospital personnel, especially those whose job were directly related to patient services.

National Health Insurance (JKN) Implementation JKN was implemented by the Badan Penyelenggara Jaminan Sosial (BPJS, Social Insurance Board and administrator of the National Health Insurance Program) on January 1, 2014 seven months before this midline data collection. According to Indonesian legislation, JKN is compulsory for all Indonesians. The poor and near-poor have their premiums paid by government so they are eligible for health services provided at all government and participating private hospitals. Interviews with hospital HAPIE Midline Assessment xiii managers reveal that most believe JKN is an excellent program, and they strongly supported its policies.

Implementation of JKN appears to have had different effects on the nine hospitals. One is the change in caseloads and case-mixes in certain parts of the hospital. Several examples lost 20 to 50% of normal delivery cases because they were seen at lower level facilities.

The number of patients with government insurance increased sharply with JKN implementation. At baseline, the proportion of Jamkesmas (pre-JKN government supported insurance for the poor and near-poor) patients was around 30%, but at midline, the proportion of JKN patients was over 50%. In some hospitals the proportion up to 80-90% of the total patients. At baseline, the highest proportion of patients paid out of pocket, and the proportion with government insurance was below 50%.

Another impact of JKN is the average length of stay in the hospital as seen in the clinical chart review for AMI patient that decreased by an average of 2 days overall. It is influenced by the degree of cases handled and service system in the hospital. The use of clinical pathways in patients will be very helpful in providing care and treatment to patients, and this is more apparent in the era of JKN. Here service charge is based on INA-CBG's package and length of stay will influence the cost of hospital services.

JKN has had a major impact on hospital finances, especially on liquidity, so far. Out-of-pocket payments are received directly and immediately by hospitals, while government insurance payments go through claim processes that can take a long time and involve several administrative steps.

Hospitals are paid based on diagnostic groups. Some hospitals had experience of short-term liquidity problems but were generally more stable in the long-term.

At midline, four hospitals (B, C, F and I) experienced problems with claims to BPJS which disturbed their cash flow while other hospitals had no adverse impact. Funding for operational costs in the former hospitals was still safe because they had healthy beginning balance. Hospital I for example, had not received any payment claim from BPJS for 3 months. As a result, incentive payments for medical staff were delayed. Of greater impact was when some suppliers stopped providing medicine or goods because the hospital failed to pay balances for several months. 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.

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.

Conclusion JCI hospitals started at a higher base of performance on most of the indicators of quality of processes and outcomes of care and generally increased slightly more than the other hospitals though this did not follow for all of the variables measured. Qualitatively, hospitals undergoing JCI accreditation took the process more seriously and invested more time and other resources changing hospital systems than those undergoing just KARS or no accreditation.

Even with the adoption of new standards by KARS in 2012 and other changes in the organization, it still appears that hospitals note problems with the KARS accreditation system that should be addressed. It also appears that the need for KARS (2012) accreditation has not been a stimulus for hospitals to allocate resources and develop systems to address issues in their facilities that may present problems during the accreditation process. We see little evidence that KARS is fostering an improvement in the quality of services in the participating studies.

Implementation of JKN has changed hospital operations, case mix and the attitudes and behavior of patients. Therefore it has been a significant confounder in the HAPIE study, and one taken into consideration.

xiv HAPIE Midline Assessment I. INTRODUCTION A. Recent History of Accreditation in Indonesia To improve the quality of hospital services, the Government of the Republic of Indonesia (GOI) requires hospitals to undergo periodic accreditation. To that end, in 1996, a hospital accreditation body known as KARS (Komisi Akreditasi Rumah Sakit or Commission for the Accreditation of Hospitals) was established by the Indonesian Ministry of Health [1]. Although all hospitals are required to obtain accreditation through the KARS system, as of 2011 only 720 of the approximately 2300 hospitals (42%) in the country had achieved such accreditation [2].

The KARS system offers three levels accreditation: 5-services, 12 services or 16-services, which hospitals could apply for depending on the number of health services they provide and how they rate their performance on them. In 2012, KARS updated its accreditation standards to be in line with the standards used by the international hospital accreditation agency, Joint Commission International (JCI). By the end of 2014, there were 64 hospitals accredited based on 2012-KARS version.

However, 11 hospitals received provisional accreditation, meaning they had deficiencies that need to be rectified before full accreditation can be conferred. Four are government hospitals and seven private. Of those fully accredited, 11 are Class A, 35 are Class B, 12 are Class C and 2 are Class D [3]. Twelve are government hospitals, and 52 are private, and collectively they are less than 2% of the 2,322 hospitals throughout Indonesia [4]. Three government hospitals that were KARS-accredited are hospitals this study, while one hospital is in the process of accreditation inspection at writing.

There were 1,277 hospitals accredited based on 2007 version of the KARS standards with 73% accredited for 5-services; 11% for 12-services; and 16% for 16-hospital-services. However, all accreditation certificates for the 2007-KARS Standards version will expire in June 2015 or before.

The accreditation system was reported to have failed in its objective of improving hospital care for several reasons: 1) there was a lack of independence of KARS from the MoH, the owners of the public hospitals, which created a conflict of interest, 2) the standards focused on input indicators rather than on patient safety, process or quality performance indicators and 3) accreditation was not linked to licensure of the hospitals so there was no significant consequences to not seeking or passing accreditation.

In 2011, the United States Agency for International Development (USAID) agreed to support the GoI to improve health care quality in Indonesian Hospitals. It supported seven hospitals seeking international accreditation through JCI and funded technical assistance for restructuring and upgrading the KARS system to have the process approved by the ISQua “International Accreditation Program” (accrediting the accreditors).

The seven state-owned A-class hospitals that received support from USAID for JCI accreditation


 Cipto Mangunkusumo Hospital (Jakarta)  Sanglah Hospital (Denpasar, Bali)  Dr. Sardjito Hospital (Yogyakarta)  Fatmawati Hospital (Jakarta)  H. Adam Malik Hospital (Medan, North Sumatra)  Dr. Wahidin Sudirohusodo Hospital (Makassar, South Sulawesi)  Central Army Gatot Subroto Hospital (Jakarta)  Hasan Sadikin Hospital (Bandung) Cipto Mangunkusumo Hospital in Jakarta underwent JCI accreditation survey in December 2012.

They initially received a provision pass before a second survey resulted in full accreditation. Sanglah Hospital in Denpasar also underwent JCI survey fully in December 2012 with similar results.

Fatmawati Hospital in Jakarta underwent the JCI survey in December 2013 with full accreditation granted on the first attempt. Hasan Sadikin Hospital in Bandung underwent a mock survey with JCI in January 2013, and is planning to undergo final survey in 2015. A large number of deficiencies were HAPIE Midline Assessment 1 discovered by the surveyors and feedback was given to the hospital to help them prepare for the final survey. They developed quality improvement teams to address deficiencies identified in the mock survey. Sardjito Hospital in Yogyakarta underwent the full JCI surveying October 2014 and received a provisional pass. Dr. Kariadi Hospital in Semarang underwent their mock survey in May 2014 and is planning for the full survey in 2015. M. Hoesin Hospital in Palembang was planning their mock survey in the second quarter on 2015.

B. HAPIE Study Phases In 2011, USAID Indonesia commissioned the USAID Health Care Improvement (HCI) Project to conduct a study of hospital accreditation. 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: three undergoing the JCI accreditation process here after JCIs), two undergoing the new KARS accreditation process (hereafter KARSs) and four who will have no hospital accreditation until 2015 (here after NHAs). The HAPIE study is being conducted in three phases: baseline (completed August 2013), mid-line (current report) and end line (data collection planned for January 2016). Support for the study’s midline and endline is being provided through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project.

The specific objectives of the study are to analyze the differences and trends in the quality and safety of services among the three hospital groups over three years, estimate fees paid to consultants, facilitators and assessment organizations, and determine how the implementation of the accreditation programs is progressing from the perspectives of senior officials at the Ministry of Health, KARS, and

the participating hospitals. The hypotheses are:

 There is a change in the quality of services and related patient outcomes and experiences in the hospitals associated with their undergoing the accreditation process.

 There is a difference in the change in the quality of services and related patient outcomes and experiences among the nine hospitals undergoing JCI accreditation, KARS accreditation or no accreditation.

The purpose of the midline phase of the study is to determine if there was any difference in the change in selected indicators of hospital performance from baseline to midline among the nine hospitals and if those differences were related to the type of accreditation they had undergone in that period. Quantitative data were collected using methods congruent to the the baseline evaluation.

Qualitative data were also collected using methods consistent with the baseline with additional questions about the changes seen and the opinions there of from the baseline to midline periods.

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