«SEPTEMBER 2015 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development ...»
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. Observation revealed obstacles for Hospital Information System (in Bahasa Indonesia called SIRS or Sistem Informasi Rumah Sakit) including lack of a systematic approach, limited resources and lack of training in the four hospitals.
There are still many units within these hospitals that do not understand how to use online information systems. Observations in the midline showed that medical record formats greatly affect information completeness. Informants from medical record units in Hospitals C and D stated that medical staff using checklist medical record system completed forms more consistently compared to using blank forms. Checklists system medical record have been implemented in Hospitals A, C and D. As stated by an informant in Hospital D this system of medical record not only encourages completeness of medical records, but also encourages completeness of patient examination and treatment, especially for medical residents.
Midline observation showed that most hospital did not record their associated cause of maternal death. Hospital mortality data only rely on the existing records in the ward register. All patients who die in hospital are sent to the forensic department for the purpose of completing a medical certificate on the cause of death. The death certificate is then sent to the medical record unit and mortality data are recorded and reported monthly. Medical record unit just recorded the women who died while pregnant or during delivery but not the specific cause of death. There was no special reporting system for maternal or infant mortality. Not all of the study hospitals reported total deaths to the provincial health office. Most likely the reported mortality data does not correspond to the actual number of deaths. This needs to be the concern of all parties, so that actual number of death will be recorded. A study conducted by IMMPACT in Banten Province in 2005 revealed that the routine method to identify maternal deaths discovered a higher mortality rate of up to two-thirds of the total number of actual deaths. The difference is due to misclassification against maternal mortality .
Patient Experience Perception on Medical Services: Effective communication is a core competence listed by the Medical Council of Indonesia . All hospitals except C and D decreased from the baseline to the midline period on this domain which included the doctor’s ability to speaking clearly to patients and families, and patient’s confidence in the doctors’ abilities. This could have been caused by several factors including an increase in the patient-to-physician ratio and the medical education curriculum. It is also possible that implementation of JKN has increased demand for hospital services without an increase in the capacity of the system to supply these services to the same quality. Further investigation is needed to determine this relationship.
Perceptions of nursing services: Almost all hospitals decreased in perceptions of the quality of nursing services from the baseline to the midline period. The exception was a slight increase (2%) in Hospital C. This domain included patient confidence in the ability of nurses and midwives, the responsiveness to patient needs and clinical information sharing. The decline may be due to the shortage of nurses [22,23]. For example, there was one nurse to every ten patients in Hospital. This was far lower than the MoH Guideline Number 340 on the Classification of Hospitals in 2010 . The ratio recommended there was 1:1 in Class A hospitals. Also, the nursing education system has done little to strengthen the quality of nursing services in recent years . The MoH has tried to improve the quality of health workers using accreditation of health and medical education institutions and implementing competency tests of all health professional including nurses.
Patient Satisfaction The patient satisfaction domain includes patient involvement in treatment decisions, the quality of discharge instructions and whether or not the patient would recommend the hospital to a family member. Satisfaction in JCI hospitals increased while the two other hospital groups decreased. It was stated by key informants that JCI hospitals focused on considering the patient as the customer who must be provided with good service.
64 HAPIE Midline Assessment Otherwise, patient satisfaction decreased generally from baseline to midline. One reason 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). This means that military and civil servants are now essentially receiving the same services as the poor and nearpoor, a situation that those of the former group, at a higher social-economic level, may see as objectionable. This was a matter voiced by some of the informants.
Accreditation Process Role of Accreditation Team Observation showed that the success of hospitals achieving accreditation depends on many factors including the culture and attitudes towards work, leadership, and the readiness of designated team in the hospitals to implement changes necessary to achieve accreditation. Among the nine study hospitals, five (C, E, F, G, H and I) did not experience consistent changes since the baseline survey, while three hospitals (A, B, and D) showed improvement in many aspects of their operations. The improved hospitals all had active accreditation team who were eagerly pursuing implementation of plans of action towards accreditation while the top management was giving the necessary support and authority. In the other six hospitals this was either not as strong or lacking completely.
Leadership Leadership is an important component needed to implement change during the accreditation process.
Some informants in hospitals that were successfully accredited by JCI and KARS emphasized the role of top management in this process. An informant stated: “The top level management has a great responsibility on tasks to be done by his/ her staff, and they are aware of all regulations and possible obstacles…. so that the process can run well.” Commitment from top management is critical in developing policies and implementing them. Another element required by top level management is financial commitment since significant resources are needed to drive the process of change. Most hospitals spent their budget for in-house training in areas including basic life support, emergency and fire safety, infection control and hand hygiene.
Some hospitals also sent their staff for benchmarking to other hospitals. The objective of benchmarking is to learn from other hospitals, which already improve their accreditation level such as Sanglah and Cipto Hospitals.
New Version of Accreditation (KARS 2012) The GoI revised the hospital accreditation instrument, now called 2012 KARS version. This instrument is based almost entirely on JCI instruments, with the additional instruments related to Millennium Development Goals (4 and 5, especially related to hospital services in an effort to reduce maternal deaths) . In this midline study, Hospitals A, B, and D experienced both JCI and KARS accreditation, since it is required that hospitals achieve 2012 KARS accreditation prior to JCI.
Informants from these hospitals noted differences between KARS and JCI surveyors, both in the information gathered and the way the surveyors collect that information through observation or examining documents. Informants from Hospitals A, B, and D noted the difference between the JCI and KARS surveyors in the way they examine nosocomial infections, smoking areas around the hospital, and standards of laboratory equipment. The inconsistency of KARS surveyors was a major concern mentioned by informants from all hospitals. As one informant stated: "To be honest we are really confused. Because according to one surveyor, it should be like this. We're going back to the reference…. But then another surveyor tells us the different thing."
Accreditation Process and Hospital Staff Attitudes Informants in five hospitals (A, B, D, E and G) noted that the accreditation process had changed the attitudes of hospital personnel, especially those whose job were directly related to patient services.
Hand hygiene, and cross-checking patient identity before issuing medication are now practiced more routinely than before. More personnel realized that they need to record what they do as well as what they fail to do. Hospital management encouraged medical and non-medical staff to practice their work according to available standard operating procedures and to practice self- assessment. Most HAPIE Midline Assessment 65 informants stated that changing hospital personnel’s mindset, including focusing more on patient safety, was not easy and required considerable time and cost to achieve it.
Hospital Budget for Accreditation Similar to information from the baseline, in this midline we found that in all hospitals there was a budget for improving facilities or equipment in their annual financial plan. However, nothing was specifically labeled for achieving accreditation even though some renovation and procurement of equipment were directly related to plan for accreditation. Only fund for surveyor visits were usually written clearly as cost of accreditation. It was therefore not possible to report the cost of hospital on all
accreditation related activities. As one informant stated:
“What we have is a routine activity budget including those for special programs. We were a bit confused when our medical director asked that we should make a special budget for JCI accreditation. We cannot do that because in our financial system there is no line item that is suitable for that activity.” (Informant from Planning and Budget unit).
Implementation of National Health Insurance (JKN) Perception of Hospital Personnel on JKN Interviews with hospital managers reveal that most believe JKN is an excellent program and they strongly supported its policies. In JKN, patient should present first to the Primary Health Facility (PPK 1) – the Community Health Center or a participating clinic. This facility completes the initial screening, and only cases presenting with problem that cannot be handled by this facility will be referred to the PPK 2 (district government hospital or participating hospital). If the cases cannot be handled by PPK 2, then they are referred to PPK 3 . All study hospitals are PPK 3, where all the medical specialist and sub-specialist are available. These hospitals now only treat cases with complication. Since the
system has just started, its effectiveness and efficiency remains to be seen. As one informant put it:
"JKN is an ideal program, but the implementation is still far from perfect."
Impact of JKN on Hospitals’ Patients JKN was implemented by BPJS on January 1, 2014 seven months before this midline data collection.
According to Indonesian legislation, JKN is compulsory for all Indonesian. The poor and near-poor have their premium paid by government so they are eligible for health services provided by all government and participating private hospitals In MOH’s order on health care referral system , tertiary hospitals – those in which subspecialists are available to deliver patient clinical care – can be accessed by patients with government insurance only if they have a referral letter and meet other requirements. For childbirth, the participating hospitals in this study generally only admitted women identified as high-risk pregnancies. This was more the case in the midline compared to the baseline because this referral system was reinforced by the implementation of JKN. Consequently, fewer deliveries occurred in the midline at the participating tertiary hospitals.
Implementation of JKN appears to have had a differential effect on the nine participating hospitals.
One is the significant change in caseloads and case-mixes in certain parts of the hospital. For example, one hospital that was providing services for approximately 100-120 deliveries per month in its maternity ward had a decrease in bed occupancy of more than 50% due to the new referral system mandated by JKN. Other hospitals decreased by 20 to 40% in obstetric cases. The changes varied depending on the proportion of patients covered by JKN. The number of patients with government insurance increased sharply with JKN implementation. At baseline, the proportion of Jamkesmas (preJKN government supported insurance for the poor and near-poor) patients was around 30%, but in the midline proportion of JKN patients was more than 50%. In some hospitals the proportion up to 80of the total patients. At baseline, the highest proportion of patients paid with out of pocket, and the proportion with government insurance was generally below 50%.
Another impact of JKN implementation 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 66 HAPIE Midline Assessment 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.
Impact of JKN on Hospital Finance 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 presented 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. A greater impact arose when some suppliers stopped providing medicine or goods because the hospital failed to pay balances for several months.