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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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Patient Perceptions of Medical Decisions and Discharge Instructions In Hospitals C, D, E, F, G and H, the proportion of patients with favorable perceptions of medical decision-making and discharge instructions decreased from baseline to midline (Table 37). By category, JCI hospitals showed an improvement while KARS hospitals had a slight decrease and NHA hospitals had a greater decrease (Figure 27).

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10 8 6 4 4

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In all hospitals, the perception of patient of the hospital facilities decreased around 2% between baseline and midline (Table38). By hospital category, JCI hospitals were essentially unchanged while the other two hospital categories decreased by about the same proportion (Figure 28).

Table 38. Percentage Difference between Baseline and Midline in Favorable Perception of Patients toward Hospital Facilities

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60 HAPIE Midline Assessment


A. Key Informant Interviews The informants include hospital management at all levels, accreditation team 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 Hospital Review General Findings Based on our Hospital Review scoring system, all variables scores in the midline were higher compared to baseline. All the criteria in Hospital Review increased from baseline to midline, except documentation and record. Documentation is one of important issue that often becomes a priority.

The MoH has made guidelines to regulate clinical governance to achieve better quality medical care and patient safety in hospitals. However, implementation of the policy has been poor. 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 that they still had major deficiencies in medical record standards. It is the most common problem faced in many hospitals. This has caused major disruptions in hospital management, especially with the implementation of JKN, given its requirements for accurate medical records for payment of claims.

The number of improved domains in Hospital H is the lowest of all participating sites. Decreased scores showed for patient orientation, clinical practice, medication safety, surgery/anesthesia procedures and documentation and records. The hospital was damaged in an earthquake in 2009 and while much of the facilities had been repaired, they continued to report difficulties with their management systems. Hospitals D and E had the highest number of domains that had increased between baseline and midline. Hospital D was observed to have good management and effective communication with their clinicians. The improvement of Hospital Review in Hospital E appeared to be due to strong leadership and management. In term of the hospital governance domain, improvement occurred in all hospitals except C.

In general the JCI Hospitals group performed better than the other two groups. Five out of ten domains improved, including patient orientation, clinical practice and patient care, health careassociated infection, facilities management; and medication safety. Factors that appeared associated with that 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 JCI instrument. It is not possible from this study to determine whether the improvement is due to the fact that they were seeking the international accreditation or because they are the 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. These hospitals appeared to take JCI accreditation seriously, assigning significant human and material resources to the process.

Facility Improvements In the midline period, we observed that some hospital facilities did not meet standards for patient safety, especially in hospitals H and I. For example fire extinguishers were lacking or beyond their expiration date, some evacuation routes were inadequate of 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. New safety standards have been developed by MoH referring to the JCI standards, ISO, and OHSAS.

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 HAPIE Midline Assessment 61 patients. Hospital E was planning to build a new kitchen facility because of safety deficiencies in the existing one. 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 the commitment of hospital management to achieve better quality of care and services. While each hospital has its own financial capabilities and priority, we observed that each hospital has different way of accomplishing it. Some hospitals try to incorporate improvements of their facility in the national budget (APBN), while others tried to work out from their own budget. Other way to equip the hospital is by developing collaboration with the private company.

Eight hospitals had developed cooperation agreements with private companies to provide high-cost medical equipment such as CT scanners and MRI units because it is not feasible for hospitals to provide these with their own budgets. In Bahasa Indonesia, this is called KSO or Kerjasama Operational. Both parties agree to share the costs and revenues from operating such equipment for a specified time period. Five hospitals used KSO to provide services in this midline survey. All hospitals have KSOs on hazardous and toxic waste management (In Bahasa Indonesia this is abbreviated as B3 for Limbah Bahan Beracun dan Berbahaya), and six hospitals manage their own medical waste.

This type of subcontracting can be done by all study hospitals because all have been granted autonomy to manage these arrangements [14].

Emergency Services In accordance with the regulation from the Ministry of Health [15] on the Standards of Emergency Services, all hospitals participating in this study are class A hospitals, meaning that emergency departments must have medical specialists on-site for internal medicine, pediatric, obstetrics, and surgery as well as anesthesia. They must also have a resident doctor and a general practitioner trained in emergency medicine and specific nursing and non-medical staff on-site 24 hours a day.

Observation showed that not all hospitals complied with these requirements. In hospitals H and I, specialists do not work on site and if emergency cases require surgery they are usually performed by resident physicians alone. It is stated in the guideline that resident physician must be supervised by a consultant physician who is in charge.

Observation also showed that there are differences in how emergency patients are handled. For example in hospital A, patients are classified based on initial examination in the triage system and categorized as emergency, urgent, not urgent and false emergency. With this categorization system, the handling of patient is no longer based on type of cases. In hospitals E and H, categorization of patients was as emergency (resuscitation) cases or not-emergency (not-resuscitation) cases. Nonemergent cases are then differentiated into surgical, obstetric, pediatric, or internal medicine cases. It seems that the system implemented by hospital A provide much clearer information with regard to the level of emergency. Patients with “false emergencies” can be transferred to outpatient clinics or provided with outpatient service in the emergency room.

Clinical Practice

The MOH has issued National Guidelines for Medical Services (in Bahasa Indonesia abbreviation:

PNPK) [16], for every hospital to initiate development of clinical guidelines to be followed by clinicians working in the hospital. The midline survey showed that all participating hospitals had such clinical practice guideline (Panduan Praktek Klinik or PPK), but some were incomplete. Informants also stated that the PPKs 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 Hospital D, every prescription was reviewed by pharmacy to ascertain whether the prescription was appropriate for the case. We observed that some hospitals used posters to describe appropriate administration of drugs 62 HAPIE Midline Assessment and warning of “Looks alike – sounds alike (LASA)” (in Bahasa Indonesia abbreviation is NORUM for Nama Obat Rupa dan Ucapan Mirip) medications as reminder for medical staff. In seven of nine hospitals, annual evaluation has been done to examine the appropriateness of the prescription using formulary as the standard.

Patient’s Rights Midline observations showed that all study hospitals had increased attention to patient’s rights compared to the baseline, but deficiencies were still noted. Indonesian Hospital Law clearly describe patients' rights including the right to choose the doctor, the right to be treated and to refuse treatment after receiving information, the right to privacy, the right to die with dignity, and the right for moral or spiritual support. Article 32 of the Indonesian Health Law explains that each patient has the rights to obtain information on patient rights and obligations, and to obtain effective and efficient health services, avoid physical and material losses, maintain privacy of their medical data, and approve or refuse any medical action which will be conducted by any medical staff against illness suffered by him/her [17].

Midline observation showed that seven of nine hospitals had patient rights information in locations readily seen by patients and families. Service facilities generally did not appear well designed to maintain privacy for patients and families. Interviews with hospital personnel showed that there was a different perception of patient privacy among different hospitals and sometimes the practice is different among departments within a hospital. One hospital ward placed male and female patients in one single ward without any curtain. The reason given by an informant was that patients in this ward were over 50 years of age. Also, in five of nine hospitals patient beds in the third class ward were not provided with curtains between beds.

Hospital I did not explain the rights and responsibilities of patients during their stay and three hospitals conveyed only limited information especially on payment mechanisms and treatment to be received by the patient. 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.

Result from the patient survey showed that not all nine study hospitals explained to patients about their rights and obligations. Hospital I did not explain rights to patients at all, while hospital E generally gave explanation of patient rights and obligations better than the others. Both our qualitative and quantitative findings showed that in eight of the nine hospitals, explanation on the patient’s rights were still far below what was required.

Hospital Information System Examination of hospital documents generally revealed poor data quality and variability between hospitals, especially regarding performance indicators. It is very difficult to compare their data with the national indicators (Medical Services Standard or Standar Pelayanan Medik/ SPM) [18,19] because of the lack of standardization of indicators, incomplete data collection and low capacity of data collection methods used by some hospitals. One study hospital has no hospital performance statistics at all for certain years. During the baseline, most hospital had collected various data as requested by the Director of Medical Services in the MoH. The MoH conducted several trainings on hospital indicators, performed annual evaluations, and provided special rewards (certificate) to hospitals that have shown high-functioning information system. No hospitals had in place a system to validate their own data.

The only hospital-wide indicator that seemed valid because it was directly linked to reimbursement, was bed occupancy rates (BORs). Overall, this was slightly decreased in KARS hospitals, mixed in JCI hospitals and not recorded in one of the two NHA hospitals. 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 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.

HAPIE Midline Assessment 63 All study hospitals enter and process medical records information manually, except billing systems.

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