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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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C. Changes in 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.

In order to provide universal health insurance, the implementation of JKN is being undertaken by the Social Insurance Board (BPJS) health as mandated by National Social Security Law 24 [5,6].

Government insurance mechanisms in place before January 2014 were merged into a single system and managed by the new BPJS health board in the first quarter of 2014. Insurance machanisms were Askes PNS (health insurance for civil servants and retired military personnel), Asabri (social insurance for active military and national police), Jamsostek (social insurance for formal workers in the private sector) and Jamkesmas (tax-funded health insurance for the poor and near-poor). As of the beginning of data collection for this midline of the HAPIE study, these separate pre-existing insurance schemes had been merged into one system covering approximately 30% of the Indonesian population.

Payments for drugs, devices and medical services provided to those presently covered by JKN are calculated individually based on what drugs, devices or services were dispensed, the type of hospital

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HAPIE Midline Assessment 3 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 55 key informants, most from hospital 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 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.

B. Sampling The same nine hospitals that participated in the baseline study also consented to inclusion in this phase. The numbers for the samples of specific components of the study also remained the same (Table 1).

C. Data Sources Hospital Review

This tool captured data on documentation of policies and practices in ten criteria:

1) Hospital Governance. Elements in this criterion include:

 Management has established an annual safety action plan and receives annual reports  There is a leader for quality improvement and safety  The hospital has a multidisciplinary group to coordinate quality improvement and safety  Policy covering emergency preparedness for both internal and external critical situation has been set and available for all staff  Medical laboratory and the diagnostic radiology is certified by International Organization for Standardization (ISO)  Medical laboratory and radiology departments participate in formal external quality assurance

2) Patient Orientation. Elements in this criterion include:

 The hospital has approved and implemented a policy for obtaining informed consent and retained these records in the Medical Records Department  The hospital has a policy for accommodating children in separate areas  There are changing rooms for patients who are required to undress  All patient complaints are investigated and responded to and complaints handling is published annually

3) Human Resources. The elements required are:

 Hospitals have a mechanism to verify professional qualifications in line with national law [7]  Clinical staff are given Cardiopulmonary Resuscitation training with annual updates  Records of all staff engaged in regular continuous professional development activities are maintained and audited to ensure compliance with adequate levels of continuing education  Blood borne exposure control policy for staff has been defined

4) Clinical Practice and Patient Care. The elements include:

 The hospital has a formal procedure by which clinical guidelines are agreed upon and implemented [7] 4 HAPIE Midline Assessment  There are clinical groups established to coordinate the use of pharmaceuticals and therapeutics  There are written guidelines on use of antibiotics and they have been adopted  There is a specialist physician responsible for coordination of resuscitation services and training  Resuscitation equipment and its diagrammatic are accessible, complete, clearly organized and fully functional  There is documented protocol for process and information about patient transfers within and between hospitals

5) Health Care-Associated Infections. This criterion includes the following elements:

 A multi-disciplinary group (Infection Control Committee) has been established and assigned to coordinate and take responsibility for infection control  An infection control manual or policies are accessible to staff in each department  Staff are appropriately trained in all aspects of infection control relevant to their work  Gloves are worn in all activities that have been assessed as carrying an infection risk  Safety/sharps boxes are available in sufficient quantities, are not overfilled and are disposed of adequately  Laboratories perform susceptibility testing for antibiotic-treated organisms  Food-handler staff are medically screened to exclude pathogen carriers before employment  There are clear signs that unauthorized entry into food preparation and service areas is not permitted  Hand washing facilities with disposable nail brush, soap dispenser, paper towels and pedal operated bins are available in all food preparation areas  Non-food items such as drugs, specimens or blood are not stored in the food fridges  All food-handling staff conform to a written dress code including headgear  Alcohol hand-rub available and accessible in every point of patient care  Surveillance data of hospital-acquired infections is performed annually

6) Transfusion. The three elements for this criterion are:

 Blood for transfusion is stored in a designated lockable refrigerator  There is continuous record of blood bank temperatures, to ensure it is maintained consistently at an appropriate temperature  There is written guidelines concerning the prescription and administering of blood and blood products

7) Hospital Facilities Management. This criterion has the following elements:

 Hospital has disabled access to all areas routinely visited by patients  All signs within the hospital are clear and coherent  Staff are protected by fume cabinets, extractors and ventilation systems in areas using hazardous substances  Compressed gas cylinders are secured to prevent falling when in use or stored in racks  Main gas stocks are securely stored separately from other materials  In the radiology area, there are signs warning women of the dangers of radiation for pregnancy  The hospital has a mechanism to monitor staff exposure of ionizing radiation and to identify high levels of exposure  All defibrillators are subject to maintenance programs by an electrical engineer or technician  Emergency generator(s) is tested on full load routinely  All firefighting equipment are inspected once a year with the date of inspection recorded, Pictograms indicating fire exits are illuminated, clearly visible, unobstructed and are conspicuously displayed at appropriate locations  Smoking is not allowed inside the hospital  The color of bags and the types of container are appropriate to each type of waste HAPIE Midline Assessment 5  All staff who work in areas where clinical waste is handled are suitably trained and wear protective clothing

8) Medication Safety. This criterion includes the following elements:

 The hospital should have a systematic procedure for reviewing the hospital formulary  The hospital’s policy requires the use of international non-proprietary names  High risk medicines are included among nonemergency floor stock medicines in patient care areas  Pharmacists regularly check that medicines are stored properly  Infusions of complex and high risk medicines are prepared centrally by the pharmacy  Patients are provided with written medication information  Patient’s identity is verified/double-checked  Medication doses are not removed from packaging or labeling until immediately before administration,  The hospital has adopted reporting guidelines about reporting near misses for medication errors

9) Surgery, Interventional Procedures and Anesthesia. The following elements are required:

 The hospital has defined procedures for the pre-assessment of patients undergoing elective interventions under general anesthetic  There is a documented protocol for administering prophylactic antibiotics less than 60 minutes prior to an incision procedure  There is a monitored protocol where the operating practitioner unambiguously marks the operative site  The hospital has implemented and monitors use of the World Health Organization (WHO) Patient Safety Checklist  During anesthesia, tissue oxygenation is monitored using a pulse oximeter  The hospital has defined and implemented a policy for maintaining accurate, complete and signed surgical record within the patient medical record, and there is a documented protocol for discontinuing the administration of prophylactic antibiotics within 24 hours following an incision procedure

10) Documentation and Records. The following elements of this criterion are needed:

 A policy for the physical identification of all patients  Patient records must contain sufficient information to identify the patient, provide a clinical history, details of investigations, treatment, medication and discharge details  There is only one set of case notes for each patient and it contains up-to-date patient identification with legible date and signed  Admission notes are completed prior to any surgical procedure except in emergencies  All diagnoses/procedures are coded in a standard system immediately upon patient discharges  Discharge summary is available to all patients, case note retention policy accordance to current national guidelines.

The hospital level assessment used an instrument examining elements of the criteria listed above, with a range of scoring 0 to 4 according to the definition given previously. This tool was designed by the SANITAS Project. The criteria were developed based on the European Union and international (including United Nations and WHO) guidance, research and legislation.

Organizational Audit The organizational audit describes the quality of care at the unit/department level within a hospital for the four diagnoses of interest, i.e. in-patient ward, delivery ward, perinatal ward and Intensive Cardiac Care Unit (ICCU). The assessment used a tool validated from a previous study of the quality of hospital care, the DUQue Project.

6 HAPIE Midline Assessment Clinical Review Chart reviews were conducted on four separate samples of the four clinical conditions. The reviews used tools developed and validated in the DUQuE project which were taken from the evidence-based

clinical guidelines:

 National Institute of Clinical Excellence (NICE) in the UK Guideline 55 (for intra-partum care) and MoH, 2004 in Guideline of Normal Delivery Care [8,9].

 World Health Organization’s case management on the pediatric ward for cough or difficult breathing and the British Thoracic Society annual national pediatric pneumonia audit UK.

 Hip and femur fracture  American Heart Association Guideline for Acute Myocardiac Infarction (AMI) [10,11].

The tool was designed to capture whether or not specific evaluation, history-taking, and procedures were reported in the medical record in patients with one of the four diagnoses.

Patient Questionnaire This tool captured patients’ experiences with care they received during their inpatient stay. The questionnaire was adapted from the Nordic Patient Experiences Questionnaire (NORPEQ). The tool has been validated in Finland, Norway, Sweden and the Faroe Islands [12].

D. Revision of Indicators Evaluated in the Midline Based on results in the baseline, there were minor changes to some indicators as outlined in Tables 2-5. For the indicators added, we were able to determine the responses from the baseline by inference of the data collected. For the indicators that were eliminated, it was because some questions were found to be irrelevant to the current hospital conditions. For example, fume cabinets were no longer used in the hospitals and non-food items were never stored in food fridges. Finance question in the hospital review have been removed to qualitative part because data were unavailable.

Many question in the organizational audit were removed to the hospital review because they addressed management of the hospital overall, not the individual department.

Hospital Review Additions and deletions in the hospital review instrument are summarized in Table 2.

Table 2. Additions and Deletions in Hospital Review Instrument Hospital Review Additions Number Data Captured

1.3M Mechanism for determining the validity from the outcomes of clinical performance measures (feedback).

1.6 Hospital has a policy covering emergency preparedness/contingency planning (Crisis Preparedness Plan) for both internal and external critical situations, reviewed annually and available to all staff and implemented

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