Final Report: Hospital Accreditation Process Impact …...FINAL REPORT Hospital accreditation...

FIN A L REPORT

Hospital Accreditation Process Impact Evaluation

MAY 2018

This final report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Edward Broughton of URC and Anhari Achadi, Kamaludin Latief, Fitri Nandiaty, Tika Rianty, Sri Wahyuni, Eskaning Arum Pawestri, and Akhir Riyanti of the Center for Family Welfare, Faculty of Public Health, Universitas Indonesia. The work described was conducted under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is made possible by the generous support of the American people through USAID and its Office of Health Systems.

FINAL REPORT

Hospital accreditation process impact evaluation

MAY 2018

Edward Broughton, University Research Co., LLC Anhari Achadi, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Kamaludin Latief, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Fitri Nandiaty, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Tika Rianty, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Sri Wahyuni, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Eskaning Arum Pawestri, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia Akhir Riyanti, Center for Family Welfare, Faculty of Public Health, Universitas Indonesia

DISCLAIMER

The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Acknowledgements

We thank the Ministry of Health, Government of Indonesia for their support of the Hospital Accreditation Process Impact Evaluation (HAPIE) study. We greatly appreciate the assistance from the directors and staff of the nine participating hospitals: Rumah Sakit Umum Pusat (RSUP) Dr. M. Djamil, RSUP Fatmawati, Rumah Sakit Hasan Sadikin, RSUP Dr. Mohammad Hoesin, RSUP Prof. Dr. R.D. Kandou, RSUP Dr. Kariadi, RSUP Persahabatan Rumah Sakit Umum Daerah Dr. Saiful Anwar and RSUP Dr. Sarjito. We are grateful for the support and guidance from Rachel Cintron, Zohra Balsara and Edhie Rahmat of USAID.

This report was prepared by University Research Co., LLC (URC) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC.

For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected].

Recommended citation

Broughton E, Achadi A, Latief K, Nandiaty F, Rianty T, Wahyuni S, Pawestri EA, Riyanti A. 2018. Hospital accreditation process impact evaluation. Final Report. Published by the USAID ASSIST Project. Chevy Chase, MD: University Research Co., LLC (URC).

Indonesia hospital accreditation final report i

TABLE OF CONTENTS

List of Tables and Figures ....................................................................................................................... i

Acronyms .............................................................................................................................................. xix

Executive Summary .................................................................................................................................... xx

Foreword on the Organization of this Report ............................................................................................ xxiii

I. Comparisons among Hospital Groups ................................................................................................... 1

Chapter 1. Hospital Review .................................................................................................................... 3

Chapter 2. Organizational Audit ........................................................................................................... 13

Chapter 3. Clinical Review ................................................................................................................... 19

Chapter 4. Key Informant Interviews .................................................................................................... 32

II. Findings from Individual Hospitals ....................................................................................................... 39

Chapter 1. Hospital A ........................................................................................................................... 39

Chapter 2. Hospital B ........................................................................................................................... 68

Chapter 3. Hospital C ........................................................................................................................... 96

Chapter 4. Hospital D ......................................................................................................................... 124

Chapter 5. Hospital E ......................................................................................................................... 152

Chapter 6. Hospital F .......................................................................................................................... 180

Chapter 7. Hospital G ......................................................................................................................... 208

Chapter 8. Hospital H ......................................................................................................................... 235

Chapter 9. Hospital I ........................................................................................................................... 262

III. Policy Implications and Recommendations ....................................................................................... 289

List of Tables and Figures

Table 1. Hospital grouping by accreditation type and phase ........................................................................ 7 Table 2. Discharge dates for patient charts included in review .................................................................. 20 Table 3. Number of Sample Size ................................................................................................................ 20 Table 4. Laceration, Apgar score, and birth weight recorded in normal delivery before and after JKN implementation ............................................................................................................................................ 21 Table 5. Medical examination recorded in normal delivery between pre- and post-accreditation hospitals .................................................................................................................................................................... 22 Table 6. Respiratory symptoms and immunization recording in pneumonia before and after JKN implementation ............................................................................................................................................ 22 Table 7. Recording of physical examination for pneumonia between before and after JKN ...................... 23 Table 8. Respiratory symptoms and immunization status recording for pneumonia patients for pre- and post-accreditation ........................................................................................................................................ 23 Table 9. Physical examination recorded in pneumonia between pre- and post-accreditation ................... 24 Table 10. Cardiac enzymes examinations and ECG in AMI patients between before and after JKN ........ 24 Table 11. Medical history recorded in AMI patient charts before and after JKN implementation ............... 25 Table 12. Medication at discharge recorded in AMI patients between before and after JKN ..................... 26

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Table 13. Cardiac enzymes and ECG recording in AMI, pre- and post-accreditation ................................ 26 Table 14. Medical history recorded for AMI patients’ charts, pre- and post-accreditation .......................... 27 Table 15. Medication at discharge recorded in AMI Patient charts, pre- and post-accreditation ............... 28 Table 16. Surgery and antibiotic prophylactic recording for hip fracture patient, before and after JKN implementation ............................................................................................................................................ 28 Table 17. Mobilization after surgery recorded for hip fracture patient charts, before and after JKN implementation ............................................................................................................................................ 29 Table 18 Surgery and antibiotic prophylaxis recording for hip fracture patients, pre- and post-accreditation .................................................................................................................................................................... 29 Table 19. Mobilization after surgery recorded for hip fracture patients, pre- and post-accreditation ......... 29 Table 20. Hospital-reported basic performance indicators, Hospital A, 2011 to 2015................................ 39 Table 21. Method of payment for normal delivery patients by phase, Hospital A vs 8 other hospitals ...... 47 Table 22. Condition of normal delivery patients by phase, Hospital A vs. 8 other hospitals ...................... 49 Table 23. Age category distribution of pneumonia patients by phase, Hospital A vs. 8 other hospitals .... 50 Table 24. Sex distribution of pneumonia patients by phase, Hospital A vs. 8 other hospitals ................... 50 Table 25. Method of payment of pneumonia patients by phase, Hospital A vs. 8 other hospitals ............. 51 Table 26. Pneumonia patient condition at discharge by phase, Hospital A vs. 8 other hospitals .............. 51 Table 27. Methods of payment recorded of AMI patients by phase, Hospital A vs. 8 other hospitals ........ 54 Table 28. AMI patient condition recorded at discharge by phase, Hospital A vs. 8 other hospitals ........... 54 Table 29. Method of payment of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 60 Table 30. Patients’ condition of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 60 Table 31. Characteristic of patient interview respondents by phase, Hospital A vs. 8 other hospitals ....... 62 Table 32. Method of payment of patient interviewed by phase, Hospital A vs. 8 other hospitals ............... 63 Table 33. Hospital-reported basic performance indicators, Hospital B, 2011-2015 ................................... 68 Table 34. Method of payment for normal delivery patients by phase, Hospital B vs. 8 other hospitals ..... 75 Table 35. Percentage of normal delivery patients’ condition by phase, Hospital B vs. 8 other hospitals ... 76 Table 36. Age category distribution for pneumonia patients by phase, Hospital B vs. 8 other hospitals ... 77 Table 37. Sex distribution for pneumonia patients by phase, Hospital B vs. 8 other hospitals .................. 78 Table 38. Method of payment for pneumonia patients by phase, Hospital B vs. 8 other hospitals ............ 78 Table 39. Pneumonia patients’ condition at discharge by phase, Hospital B vs. 8 other hospitals ............ 79 Table 40. Method of payment for AMI patients by phase, Hospital B vs. 8 other hospitals ....................... 82 Table 41. Patient condition at discharge for AMI patients by phase, Hospital B vs. 8 other hospitals ....... 82 Table 42. Method of payment for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 88 Table 43. Patients’ condition for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 88 Table 44. Characteristic of patient interview respondents by phase, Hospital B vs. 8 other hospitals ....... 90 Table 45. Method of payment for patients interviewed by phase, Hospital B vs. 8 other hospitals ............ 91 Table 46. Hospital-reported basic performance indicators, Hospital C, 2011-2015 ................................... 96 Table 47. Method of payment for normal delivery patients by phase, Hospital C vs. 8 other hospitals ... 103 Table 48. Condition of normal delivery patients by phase, Hospital C vs. 8 other hospitals .................... 104 Table 49. Age category distribution for pneumonia patients by phase, Hospital C vs. 8 other hospitals . 106 Table 50. Sex distribution for pneumonia patients by phase, Hospital C vs. 8 other hospitals ................ 106 Table 51. Method of payment for pneumonia patients by phase, Hospital C vs. 8 other hospitals .......... 107 Table 52. Condition of pneumonia patients at discharge by phase, Hospital C vs. 8 other hospitals ...... 107 Table 53. Method of payment recorded for AMI patients by phase, Hospital C vs. 8 other hospitals ...... 110 Table 54. Patient condition at discharge for AMI patients by phase, Hospital C vs. 8 other hospitals ..... 111

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Table 55. Method of payment of hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 116 Table 56. Condition of hip/femoral neck fracture patients at discharge by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 116 Table 57. Characteristic of patient interview respondents by phase, Hospital C vs. 8 other hospitals .... 118 Table 58. Method of payment for patients interviewed by phase, Hospital C vs. 8 other hospitals ......... 119 Table 59. Hospital-reported basic performance indicators, Hospital D, 2011 to 2015 ............................. 124 Table 60. Method of payment for normal delivery patients by phase, Hospital D vs. 8 other hospitals ... 132 Table 61. Percentage of normal delivery patients’ condition at discharge by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 133 Table 62. Age distribution of pneumonia patients by phase, Hospital D vs. 8 other hospitals ................. 134 Table 63.Sex distribution of pneumonia patients by phase, Hospital D vs. 8 other hospitals .................. 134 Table 64. Method of payment for pneumonia patients by phase, Hospital D vs. 8 other hospitals .......... 135 Table 65. Condition of pneumonia patients at discharge by phase, Hospital D vs. 8 other hospitals ...... 135 Table 66. Method of payment recorded for AMI patients by phase, Hospital D vs. 8 other hospitals ...... 138 Table 67. Recorded condition at discharge for AMI patients by phase, Hospital D vs. 8 other hospitals 139 Table 68. Method of payment for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 144 Table 69. Condition of hip/femoral neck fracture patients at discharge by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 144 Table 70. Characteristics of patients interviewed by phase, Hospital D vs. 8 other hospitals .................. 146 Table 71. Method of payment of patients interviewed by phase, Hospital D vs. 8 other hospitals ........... 147 Table 72. Hospital-reported basic performance indicators, Hospital E, 2011 to 2015.............................. 152 Table 73. Method of payment for normal delivery patients by phase, Hospital E vs. 8 other hospitals ... 160 Table 74. Mother’s condition at discharge for normal delivery patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 161 Table 75. Age category for pneumonia patients by phase, Hospital E vs. 8 other hospitals .................... 162 Table 76. Sex for pneumonia patients by phase, Hospital E vs. 8 other hospitals ................................... 162 Table 77. Method of payment for pneumonia patients by phase, Hospital E vs. 8 other hospitals .......... 163 Table 78. Patient condition at discharge for pneumonia patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................................. 164 Table 79. Method of payment recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ...... 167 Table 80. Patient condition at discharge recorded for AMI patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 167 Table 81. Method of payment for hip/femoral neck-fracture patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 173 Table 82. Patient’s condition for hip/femoral neck-fracture patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 173 Table 83. Characteristics of patients interviewed by phase, Hospital E vs. 8 other hospitals .................. 175 Table 84. Method of payment of patients interviewed by phase, Hospital E vs. 8 other hospitals ........... 176 Table 85. Hospital-reported basic performance indicators, Hospital F, 2011 to 2015 .............................. 180 Table 86. Method of payment for normal delivery patients by phase, Hospital F vs. 8 other hospitals .... 188 Table 87. Mother’s condition for normal delivery patients by phase, Hospital F vs. 8 other hospitals ..... 189 Table 88. Age category for pneumonia patients by phase, Hospital F vs. 8 other hospitals .................... 190 Table 89. Sex of pneumonia patients by phase, Hospital F vs. 8 other hospitals .................................... 190 Table 90. Method of payment for pneumonia patients by phase, Hospital F vs. 8 other hospitals .......... 191 Table 91. Patient condition at discharge for pneumonia patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................................. 192 Table 92. Method of payment for AMI patients by phase, Hospital F vs. 8 other hospitals ...................... 195

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Table 93. Patient condition at discharge for AMI patients by phase, Hospital F vs. 8 other hospitals ..... 195 Table 94. Method of payment for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 200 Table 95. Patient’s condition at discharge for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals ........................................................................................................................................... 201 Table 96. Characteristics of patients interviewed by phase, Hospital F vs. 8 other hospitals .................. 203 Table 97. Method of payment of patients interviewed by phase, Hospital F vs. 8 other hospitals ........... 203 Table 98. Hospital-reported basic performance indicators, Hospital G, 2011 to 2014 ............................. 208 Table 99. Method of payment of normal delivery patients by phase, Hospital G vs. 8 other hospitals .... 216 Table 100. Condition of normal delivery patients by phase, Hospital G vs. 8 other hospitals .................. 217 Table 101. Age distribution of pneumonia patients by phase, Hospital G vs. 8 other hospitals ............... 218 Table 102. Sex distribution of pneumonia patients by phase, Hospital G vs. 8 other hospitals ............... 218 Table 103. Method of payment of pneumonia patients by phase, Hospital G vs. 8 other hospitals ......... 219 Table 104. Pneumonia patients’ condition at discharge by phase, Hospital G vs. 8 other hospitals ....... 220 Table 105. Methods of payment of AMI patients by phase, Hospital G vs. 8 other hospitals .................. 223 Table 106. Patient condition at discharge of AMI patients by phase, Hospital G vs. 8 other hospitals .... 223 Table 107. Method of payment of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 228 Table 108. Condition at discharge of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 229 Table 109. Characteristics of patient interview respondents by phase, Hospital G vs. 8 other hospitals 231 Table 110. Method of payment for patient interviewed by phase, Hospital G vs. 8 other hospitals ......... 231 Table 111. Hospital-reported basic performance indicators, Hospital H, 2011 to 2015 ........................... 236 Table 112. Method of payment of normal delivery patients by phase, Hospital H vs. 8 other hospitals .. 242 Table 113. Condition of normal delivery patients by phase, Hospital H vs. 8 other hospitals .................. 243 Table 114. Age distribution of pneumonia patients by phase, Hospital H vs. 8 other hospitals ............... 245 Table 115. Sex of pneumonia patients by phase, Hospital H vs. 8 other hospitals .................................. 245 Table 116. Method of payment of pneumonia patients by phase, Hospital H vs. 8 other hospitals ......... 245 Table 117. Pneumonia patients’ condition at discharge by phase, Hospital H vs. 8 other hospitals ........ 246 Table 118. Methods of payment for AMI patients by phase, Hospital H vs. 8 other hospitals ................. 249 Table 119. Patient condition at discharge for AMI patients by phase, Hospital H vs. 8 other hospitals ... 250 Table 120. Method of payment of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 255 Table 121. Condition of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals ... 255 Table 122. Characteristics of patients interviewed by phase, Hospital H vs. 8 other hospitals ................ 257 Table 123. Method of payment of patients interviewed by phase, Hospital H vs. 8 other hospitals ......... 258 Table 124. Hospital-reported basic performance indicators, Hospital I, 2011 to 2015 ............................. 262 Table 125. Method of payment of normal delivery patients by phase, Hospital I vs. 8 other hospitals .... 269 Table 126. Condition of normal delivery patients by phase, Hospital I vs. 8 other hospitals .................... 270 Table 127. Age distribution of pneumonia patients by phase, Hospital I vs. 8 other hospitals ................. 272 Table 128. Sex of pneumonia patients by phase, Hospital I vs. 8 other hospitals ................................... 272 Table 129. Method of payment of pneumonia patients by phase, Hospital I vs. 8 other hospitals ........... 272 Table 130. Condition at discharge of pneumonia patients by phase, Hospital I vs. 8 other hospitals ...... 273 Table 131. Method of payment of AMI patients by phase, Hospital I vs. 8 other hospitals ...................... 276 Table 132. Condition at discharge of AMI patients by phase, Hospital I vs. 8 other hospitals ................. 276 Table 133. Method of payment of hip/femoral neck fracture patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 282 Table 134. Patients’ condition for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 282

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Table 135. Characteristics of patient interview respondents by phase, Hospital I vs. 8 other hospitals .. 284 Table 136. Method of payment of patients interviewed by phase, Hospital I vs. 8 other hospitals .......... 284 Figure 1. Hospital review, overall performance, before and after JKN ......................................................... 7 Figure 2. Hospital governance, patient orientation, and human resources before and after JKN ................ 8 Figure 3. Clinical practice and patient care, healthcare-associated infections, and transfusion before and after JKN ....................................................................................................................................................... 8 Figure 4. Facility management, medication safety, surgery procedures and anesthesia, and documentation and records before and after JKN Implementation .............................................................. 8 Figure 5. Overall hospital review performance by hospital accreditation ..................................................... 9 Figure 6. Hospital governance, patient orientation and human resources by hospital accreditation type ... 9 Figure 7. Facility management and medication safety by hospital accreditation type ................................ 10 Figure 8. Clinical practice and patient care, healthcare-associated infections, and transfusion by hospital accreditation type ........................................................................................................................................ 10 Figure 9. Surgery, procedures and anesthesia, and documentation and records by hospital accreditation process ........................................................................................................................................................ 10 Figure 10. Total score across 10 criteria, before and after JKN implementation, all hospitals ................... 15 Figure 11. Total scores of 10 keys OA criteria by hospital category across all departments ..................... 15 Figure 12. Total score across 10 OA criteria by accreditation process, Obstetric Department .................. 16 Figure 13. Total score across 10 OA criteria by accreditation process, Pediatric Department .................. 16 Figure 14. Total score across 10 OA criteria by accreditation process, Internal Medicine Department ..... 16 Figure 15. Total score across 10 OA criteria by accreditation process, Surgery Department .................... 17 Figure 16. Timeline for accreditation of Hospital A ..................................................................................... 39 Figure 17. Bed occupancy rate, Hospital A, by phase ................................................................................ 40 Figure 18. Average length of stay, Hospital A, by phase ............................................................................ 40 Figure 19. Bed turnover interval, Hospital A, by phase .............................................................................. 41 Figure 20. Bed turnover, Hospital A, by phase ........................................................................................... 41 Figure 21. Hospital governance by phase, Hospital A vs. 8 other hospitals ............................................... 42 Figure 22. Patient orientation by phase, Hospital A vs. 8 other hospitals .................................................. 42 Figure 23. Human resource by phase, Hospital A vs. 8 other hospitals ..................................................... 43 Figure 24. Clinical practice and patient care performance by phase, Hospital A vs. 8 other hospitals ...... 43 Figure 25. Healthcare-associated infection performance by phase, Hospital A vs. 8 other hospitals ........ 43 Figure 26. Transfusion by performance phase, Hospital A vs. 8 other hospitals ....................................... 44 Figure 27. Facilities management by performance phase, Hospital A vs. 8 other hospitals ...................... 44 Figure 28. Medication safety performance by phase, Hospital A vs. 8 other hospitals .............................. 44 Figure 29. Surgery, interventional procedures, and anesthesia performance by phase, Hospital A vs. 8 other hospitals ............................................................................................................................................. 45 Figure 30. Documentation and records performance by phase, Hospital A vs. 8 other hospitals .............. 45 Figure 31. Key organizational audit criteria in Obstetric Department, Hospital A vs. 8 other hospitals ...... 46 Figure 32. Key organizational audit criteria in Pediatric Department, Hospital A vs. 8 other hospitals ...... 46 Figure 33. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital A vs. 8 other hospitals ............................................................................................................................................. 46 Figure 34. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 47 Figure 35. Average length of stay for normal delivery patients by phase, Hospital A vs. 8 other hospitals .................................................................................................................................................................... 48 Figure 36. Age of normal delivery patients by phase, Hospital A vs. 8 other hospitals .............................. 48 Figure 37. Laceration recorded of vaginal delivery patients by phase, Hospital A vs. 8 other hospitals .... 49

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Figure 38. Apgar score recorded for normal delivery newborns by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 49 Figure 39. Birth weight recorded for normal delivery newborns by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 50 Figure 40. Mean age in months of pneumonia patients by phase, Hospital A vs. 8 other hospitals .......... 50 Figure 41. Lengths of stay of pneumonia patients by phase, Hospital A vs. 8 other hospitals .................. 51 Figure 42. Respiratory symptom recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 52 Figure 43. Immunization recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals ..... 52 Figure 44. Respiratory rate recorded pneumonia patients by phase, Hospital A vs. 8 other hospitals ...... 52 Figure 45. Temperature recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals ...... 53 Figure 46. Pulse recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals ................. 53 Figure 47. Average age of AMI patients by phase, Hospital A vs. 8 other hospitals .................................. 54 Figure 48. Length of stay of AMI patients by phase, Hospital A vs. 8 other hospitals ................................ 54 Figure 49. Cardiac enzymes examination recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 55 Figure 50. ECG examination recorded for AMI patients by phase, Hospital A vs. 8 other hospitals .......... 55 Figure 51. Oral beta-adrenergic recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ..... 55 Figure 52. Statins recorded of AMI patients by phase, Hospital A vs. 8 other hospitals ............................ 56 Figure 53. Aspirin prescription recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ....... 56 Figure 54. Previous AMI history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ..... 57 Figure 55. Angina pectoris history recorded of AMI patients by phase, Hospital A vs. 8 other hospitals... 57 Figure 56. Hypertension history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ..... 57 Figure 57. Hypercholesterolemia history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 58 Figure 58. Cerebrovascular accident history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 58 Figure 59. Heart failure history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals ....... 58 Figure 60. Diabetic history for AMI patients by phase, Hospital A vs. 8 other hospitals............................. 59 Figure 61. Mean age for hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals .... 59 Figure 62. Length of stay for hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals .................................................................................................................................................................... 60 Figure 63. Surgery of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals ........ 61 Figure 64. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 61 Figure 65. Mobilization after surgery of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 61 Figure 66. Thromboembolic of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals ...................................................................................................................................................... 62 Figure 67. Mean age of patient interviewed by phase, Hospital A vs. 8 other hospitals ............................ 63 Figure 68. Length of stay of interviewed patients by phase, Hospital A vs. 8 other hospitals .................... 63 Figure 69. Patients’ confidence in doctors by phase, Hospital A vs. 8 other hospitals .............................. 64 Figure 70. Patients’ confidence in nursing care by phase, Hospital A vs. 8 other hospitals ...................... 64 Figure 71. Patient experience at hospital by phase, Hospital A vs. 8 other hospitals ................................ 64 Figure 72. Patient satisfaction with hospital facilities by phase, Hospital A vs. 8 other hospitals .............. 65 Figure 73. Patient satisfaction with all services at hospital by phase, Hospital A vs. 8 other hospitals ..... 65 Figure 74. Timeline for accreditation of Hospital B ..................................................................................... 68 Figure 75. Bed occupancy rate for Hospital B by phase ............................................................................. 69 Figure 76. Average length of stay for Hospital B by phase ......................................................................... 69

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Figure 77. Hospital governance by phase, Hospital B vs. 8 other hospitals ............................................... 70 Figure 78. Patient orientation by phase, Hospital B vs. 8 other hospitals .................................................. 70 Figure 79. Human resource by phase, Hospital B vs. 8 other hospitals ..................................................... 70 Figure 80. Clinical practice and patient care performance by phase, Hospital B vs. 8 other hospitals ...... 71 Figure 81. Healthcare-associated infection performance by phase, Hospital B vs. 8 other hospitals ........ 71 Figure 82. Transfusion performance by phase, Hospital B vs. 8 other hospitals ....................................... 71 Figure 83. Facilities management performance by phase, Hospital B vs. 8 other hospitals ...................... 72 Figure 84. Medication safety performance by phase, Hospital B vs. 8 other hospitals .............................. 72 Figure 85. Surgery, interventional procedures and anesthesia performance by phase, Hospital B vs. 8 other hospitals ............................................................................................................................................. 72 Figure 86. Documentation and records performance by phase, Hospital B vs. 8 other hospitals .............. 73 Figure 87. Key organizational audit criteria in Obstetric Department, Hospital B vs. 8 other hospitals ...... 73 Figure 88. Key organizational audit criteria in Pediatric Department, Hospital B vs. 8 other hospitals ...... 74 Figure 89. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital B vs. 8 other hospitals ............................................................................................................................................. 74 Figure 90. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 74 Figure 91. Average length of stay for normal delivery patients by phase, Hospital B vs. 8 other hospitals 75 Figure 92. Age of normal delivery patients by phase, Hospital B vs. 8 other hospitals .............................. 76 Figure 93. Laceration recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals ... 76 Figure 94. Apgar score recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals 77 Figure 95. Birth-weight recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals . 77 Figure 96. Mean age in months for pneumonia patients by phase, Hospital B vs. 8 other hospitals ......... 78 Figure 97. Length of stay for pneumonia patients by phase, Hospital B vs. 8 other hospitals ................... 79 Figure 98. Respiratory symptom recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 79 Figure 99. Immunization recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals ..... 80 Figure 100. Respiratory rate recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals .................................................................................................................................................................... 80 Figure 101. Temperature recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals .... 80 Figure 102. Pulse recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals ............... 81 Figure 103. Average age for AMI patients by phase, Hospital B vs. 8 other hospitals ............................... 81 Figure 104. Length of stay for AMI patients by phase, Hospital B vs. 8 other hospitals ............................ 81 Figure 105. Cardiac enzymes examination recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 83 Figure 106. ECG examination recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ........ 83 Figure 107. Oral beta-adrenergic recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ... 83 Figure 108. Statin recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ........................... 84 Figure 109. Aspirin prescription recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ..... 84 Figure 110. Previous AMI history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ... 84 Figure 111. Angina pectoris history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals 85 Figure 112. Hypertension history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ... 85 Figure 113. Hypercholesterolemia history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 85 Figure 114. Cerebrovascular accident history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 86 Figure 115. Heart failure history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ..... 86 Figure 116. Diabetic history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals ........... 86 Figure 117. Mean age for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals . 87

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Figure 118. Length of stay for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 87 Figure 119. Surgery for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals ..... 88 Figure 120. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals ............................................................................................................................................. 89 Figure 121. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals ............................................................................................................................................. 89 Figure 122. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals ...................................................................................................................................................... 89 Figure 123. Mean age of patients interviewed by phase, Hospital B vs. 8 other hospitals ........................ 90 Figure 124. Length of stay for patients interviewed by phase, Hospital B vs. 8 other hospitals ................. 91 Figure 125. Patient satisfaction with medical services by phase, Hospital B vs. 8 other hospitals ............ 91 Figure 126. Patient satisfaction with nursing care by phase, Hospital B vs. 8 other hospitals ................... 92 Figure 127. Patient satisfaction with hospital facilities by phase, Hospital B vs. 8 other hospitals ............ 92 Figure 128. Patient satisfaction with all services at hospital by phase, Hospital B vs. 8 other hospitals ... 92 Figure 129. Patient experience at hospital by phase, Hospital B vs. 8 other hospitals .............................. 93 Figure 130. Timeline for accreditation of Hospital C ................................................................................... 96 Figure 131. Bed occupancy rate for Hospital C by phase .......................................................................... 97 Figure 132. Average length of stay for Hospital C by phase ...................................................................... 97 Figure 133. Bed turn over interval for Hospital C by phase ........................................................................ 97 Figure 134. Hospital governance by phase, Hospital C vs. 8 other hospitals ............................................ 98 Figure 135. Patient orientation by phase, Hospital C vs. 8 other hospitals ................................................ 98 Figure 136. Human resource by phase, Hospital C vs. 8 other hospitals ................................................... 99 Figure 137. Clinical practice and patient care performance by phase, Hospital C vs. 8 other hospitals .... 99 Figure 138. Healthcare-associated infection performance by phase, Hospital C vs. 8 other hospitals ...... 99 Figure 139. Transfusion performance by phase, Hospital C vs. 8 other hospitals ................................... 100 Figure 140. Facilities management performance by phase, Hospital C vs. 8 other hospitals .................. 100 Figure 141. Medication safety performance by phase, Hospital C vs. 8 other hospitals .......................... 100 Figure 142. Surgery, interventional procedures, and anesthesia performance by phase, Hospital C vs. 8 other hospitals ........................................................................................................................................... 101 Figure 143. Documentation and records performance by phase, Hospital C vs. 8 other hospitals .......... 101 Figure 144. Key organizational audit criteria in Obstetric Department, Hospital C vs. 8 other hospitals . 102 Figure 145. Key organizational audit criteria in Pediatric Department, Hospital C vs. 8 other hospitals .. 102 Figure 146. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital C vs. 8 other hospitals ........................................................................................................................................... 102 Figure 147. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital C vs. 8 other hospitals .................................................................................................................................................... 103 Figure 148. Average length of stay for normal delivery patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................................. 104 Figure 149. Age of normal delivery patients by phase, Hospital C vs. 8 other hospitals .......................... 104 Figure 150. Laceration recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................................. 105 Figure 151. Apgar score recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................................. 105 Figure 152. Birth weight recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................................. 105 Figure 153. Mean age in months for pneumonia patients by phase, Hospital C vs. 8 other hospitals ..... 106 Figure 154. Length of stay for pneumonia patients by phase, Hospital C vs. 8 other hospitals ............... 107

Indonesia hospital accreditation final report ix

Figure 155. Respiratory symptoms recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 108 Figure 156. Immunization recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals . 108 Figure 157. Respiratory rate recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 108 Figure 158. Temperature recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals .. 109 Figure 159. Pulse recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals ............. 109 Figure 160. Average age of AMI patients by phase, Hospital C vs. 8 other hospitals .............................. 110 Figure 161. Length of stay for AMI patients by phase, Hospital C vs. 8 other hospitals .......................... 110 Figure 162. Cardiac enzymes examination recorded for AMI patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 111 Figure 163. ECG examination recorded for AMI patients by phase, Hospital C vs. 8 other hospitals ..... 111 Figure 164. Oral beta-adrenergic recorded for AMI patients by phase, Hospital C vs. 8 other hospitals. 112 Figure 165. Statin recorded for AMI patients by phase, Hospital C vs. 8 other hospitals ........................ 112 Figure 166. Aspirin prescription recorded for AMI patients by phase, Hospital C vs. 8 other hospitals ... 112 Figure 167. Previous AMI history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals. 113 Figure 168. Angina pectoris history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 113 Figure 169. Hypertension history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals . 113 Figure 170. Hypercholesterolemia history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 114 Figure 171. Cerebrovascular accident history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 114 Figure 172. Heart failure history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals .. 114 Figure 173. Diabetic history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals ......... 115 Figure 174. Mean age of hip/femoral neck-fracture patients by phase, Hospital C vs. 8 other hospitals. 115 Figure 175. Length of stay of hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 116 Figure 176. Surgery for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals ... 117 Figure 177. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals ........................................................................................................................................... 117 Figure 178. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals ........................................................................................................................................... 117 Figure 179. Thromboembolic for hip/femoral neck-fracture patients by phase, Hospital C vs. 8 other hospitals .................................................................................................................................................... 118 Figure 180. Mean age of patients interviewed by phase, Hospital C vs. 8 other hospitals ...................... 119 Figure 181. Length of stay of patients interviewed by phase, Hospital C vs. 8 other hospitals ................ 120 Figure 182. Patient satisfaction with medical services by phase, Hospital C vs. 8 other hospitals .......... 120 Figure 183. Patient satisfaction with nursing care by phase, Hospital C vs. 8 other hospitals ................. 120 Figure 184. Patient satisfaction with hospital facilities by phase, Hospital C vs. 8 other hospitals .......... 121 Figure 185. Patient satisfaction with all services at hospital by phase, Hospital C vs. 8 other hospitals . 121 Figure 186. Patient experience at hospital by phase, Hospital C vs. 8 other hospitals ............................ 121 Figure 187. Timeline for accreditation of Hospital D ................................................................................. 124 Figure 188. Bed occupancy rate, Hospital D, by phase ............................................................................ 125 Figure 189. Average length of stay, Hospital D, by phase ........................................................................ 125 Figure 190. Bed turnover interval, Hospital D, by phase .......................................................................... 125 Figure 191. Bed turnover, Hospital D, by phase ....................................................................................... 126 Figure 192. Net death rate, Hospital D, by phase ..................................................................................... 126 Figure 193. Hospital governance by phase, Hospital D vs. 8 other hospitals .......................................... 127

x Indonesia hospital accreditation final report

Figure 194. Patient orientation by phase, Hospital D vs. 8 other hospitals .............................................. 127 Figure 195. Human resource by phase, Hospital D vs. 8 other hospitals ................................................. 127 Figure 196. Clinical practice and patient care by phase, Hospital D vs. 8 other hospitals ....................... 128 Figure 197. Healthcare-associated infection by phase, Hospital D vs. 8 other hospitals ......................... 128 Figure 198. Transfusion by phase, Hospital D vs. 8 other hospitals......................................................... 128 Figure 199. Facilities management by phase, Hospital D vs. 8 other hospitals ....................................... 129 Figure 200. Medication safety performance by phase, Hospital D vs. 8 other hospitals .......................... 129 Figure 201. Surgery, interventional procedures, and anesthesia by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 129 Figure 202. Documentation and records by phase, Hospital D vs. 8 other hospitals ............................... 130 Figure 203. Key organizational audit criteria in Obstetric Department, Hospital D vs. 8 other hospitals . 130 Figure 204. Key organizational audit criteria in Pediatric Department, Hospital D vs. 8 other hospitals .. 131 Figure 205. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital D vs. 8 other hospitals ........................................................................................................................................ 131 Figure 206. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital D vs. 8 other hospitals .................................................................................................................................................... 131 Figure 207. Average length of stay for normal delivery patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 132 Figure 208. Mean age for normal delivery patients by phase, Hospital D vs. 8 other hospitals ............... 132 Figure 209. Laceration recorded of normal delivery patients by phase, Hospital D vs. 8 other hospitals 133 Figure 210. Apgar score recorded for normal delivery newborns by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 133 Figure 211. Birth weight score recorded for normal delivery patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 134 Figure 212. Mean age in months of pneumonia patients by phase, Hospital D vs. 8 other hospitals ...... 134 Figure 213. Length of stay for pneumonia patients by phase, Hospital D vs. 8 other hospitals ............... 135 Figure 214. Respiratory symptoms recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 136 Figure 215. Immunization recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals . 136 Figure 216. Temperature recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals .. 136 Figure 217. Respiratory rate recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 137 Figure 218. Pulse recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals ............. 137 Figure 219. Mean age of AMI patients by phase, Hospital D vs. 8 other hospitals .................................. 138 Figure 220. Length of stay for AMI patients by phase, Hospital D vs. 8 other hospitals .......................... 138 Figure 221. Cardiac enzymes examination recorded for AMI patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 139 Figure 222. ECG examination recorded for AMI patients by phase, Hospital D vs. 8 other hospitals ..... 139 Figure 223. Oral beta-adrenergic recorded for AMI patients by phase, Hospital D vs. 8 other hospitals. 140 Figure 224. Statins recorded for AMI patients by phase, Hospital D vs. 8 other hospitals ....................... 140 Figure 225. Aspirin prescription recorded for AMI patients by phase, Hospital D vs. 8 other hospitals ... 140 Figure 226. Previous AMI history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals. 141 Figure 227. Angina pectoris history recorded of AMI patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 141 Figure 228. Hypertension history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals . 141 Figure 229. Hypercholesterolemia history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 142 Figure 230. Cerebrovascular accident history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 142

Indonesia hospital accreditation final report xi

Figure 231. Heart failure history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals .. 142 Figure 232. Diabetic history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals ......... 143 Figure 233. Mean age for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals 143 Figure 234. Length of stay for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 144 Figure 235. Surgery of hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals .... 145 Figure 236. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 145 Figure 237. Mobilization after surgery of hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals ........................................................................................................................................... 145 Figure 238. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals .................................................................................................................................................... 146 Figure 239. Mean age of patient interviewed by phase, Hospital D vs. 8 other hospitals ........................ 147 Figure 240. Length of stay of interviewed patients by phase, Hospital D vs. 8 other hospitals ................ 147 Figure 241. Patient satisfaction with medical services by phase, Hospital D vs. 8 other hospitals .......... 148 Figure 242. Patient satisfaction with nursing care by phase, Hospital D vs. 8 other hospitals ................. 148 Figure 243. Patient satisfaction with medical decisions and clarity of discharge instruction by phase, Hospital D vs. 8 other hospitals ................................................................................................................ 148 Figure 244. Patient satisfaction with hospital facilities by phase, Hospital D vs. 8 other hospitals .......... 149 Figure 245. Patient satisfaction with all services at hospital by phase, Hospital D vs. 8 other hospitals . 149 Figure 246. Timeline for accreditation of Hospital E ................................................................................. 152 Figure 247. Bed occupancy rate, Hospital E, by phase ............................................................................ 153 Figure 248. Average length of stay, Hospital E, by phase ........................................................................ 153 Figure 249. Emergency room death rate, Hospital E, by phase ............................................................... 153 Figure 250. Net death rate, Hospital E, by phase ..................................................................................... 154 Figure 251. Pre-operative waiting time, Hospital E, by phase .................................................................. 154 Figure 252. Hospital governance by phase, Hospital E vs. 8 other hospitals ........................................... 155 Figure 253. Patient orientation by phase, Hospital E vs. 8 other hospitals .............................................. 155 Figure 254. Human resource by phase, Hospital E vs. 8 other hospitals ................................................. 155 Figure 255. Clinical practice and patient care by phase, Hospital E vs. 8 other hospitals ....................... 156 Figure 256. Healthcare-associated infection by phase, Hospital E vs. 8 other hospitals ......................... 156 Figure 257. Transfusion by phase, Hospital E vs. 8 other hospitals ......................................................... 156 Figure 258. Facilities management by phase, Hospital E vs. 8 other hospitals ....................................... 157 Figure 259. Medication safety by phase, Hospital E vs. 8 other hospitals ............................................... 157 Figure 260. Surgery, interventional procedures, and accompanying anesthesia by phase, Hospital E vs. 8 other hospitals ........................................................................................................................................ 157 Figure 261. Documentation and records by phase, Hospital E vs. 8 other hospitals ............................... 158 Figure 262. Key organizational audit criteria in Obstetric Department, Hospital E vs. 8 other hospitals .. 158 Figure 263. Key organizational audit criteria in Pediatric Department, Hospital E vs. 8 other hospitals .. 159 Figure 264. Key organizational audit criteria in internal Medicine/Cardiology Department, Hospital E vs. 8 other hospitals ........................................................................................................................................ 159 Figure 265. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital E vs. 8 other hospitals .................................................................................................................................................... 159 Figure 266. Length of stay for normal delivery patients by phase, Hospital E vs. 8 other hospitals ........ 160 Figure 267. Mean age for normal delivery patients by phase, Hospital E vs. 8 other hospitals ............... 160 Figure 268. Laceration recorded for normal delivery patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 161 Figure 269. Apgar score recorded for normal delivery newborns by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 161

xii Indonesia hospital accreditation final report

Figure 270. Birth weight recorded for normal delivery newborns by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 162 Figure 271. Mean age for pneumonia (months) patients by phase, Hospital E vs. 8 other hospitals ...... 163 Figure 272. Length of stay for pneumonia patients by phase, Hospital E vs. 8 other hospitals ............... 163 Figure 273. Respiratory symptom recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 164 Figure 274. Immunization recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals . 164 Figure 275. Temperature recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals .. 165 Figure 276. Respiratory rate recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 165 Figure 277. Pulse recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals ............. 165 Figure 278. Average age for AMI patients by phase, Hospital E vs. 8 other hospitals ............................. 166 Figure 279. Length of stay for AMI patients by phase, Hospital E vs. 8 other hospitals ......................... 167 Figure 280. Cardiac enzymes examination recorded for AMI patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 168 Figure 281. ECG examination recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ...... 168 Figure 282. Oral beta-adrenergic recorded for AMI patients by phase, Hospital E vs. 8 other hospitals . 168 Figure 283. Statin recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ......................... 169 Figure 284. Aspirin recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ....................... 169 Figure 285. Previous AMI recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ............ 169 Figure 286. Angina pectoris recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ......... 170 Figure 287. Hypertension recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ............. 170 Figure 288. Hypercholesterolemia history recorded for AMI patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 170 Figure 289. Cerebrovascular disease recorded for AMI patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 171 Figure 290. Heart failure recorded for AMI patients by phase, Hospital E vs. 8 other hospitals .............. 171 Figure 291. Diabetic history recorded for AMI patients by phase, Hospital E vs. 8 other hospitals ......... 171 Figure 292. Age for hip/femoral neck-fracture (mean) patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 172 Figure 293. Length of stay for hip/femoral neck-fracture patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 172 Figure 294. Surgery for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals ... 173 Figure 295. Antibiotic prophylactic of hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 174 Figure 296. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals ........................................................................................................................................... 174 Figure 297. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals .................................................................................................................................................... 174 Figure 298. Mean age of patients interviewed by phase, Hospital E vs. 8 other hospitals ...................... 175 Figure 299. Length of stay of patients interviewed by phase, Hospital E vs. 8 other hospitals ................ 176 Figure 300. Patient satisfaction with medical services by phase, Hospital E vs. 8 other hospitals .......... 176 Figure 301. Patient satisfaction with nursing care by phase, Hospital E vs. 8 other hospitals ................. 177 Figure 302. Patient satisfaction with hospital facilities by phase, Hospital E vs. 8 other hospitals .......... 177 Figure 303. Patient satisfaction of patient interviewed by phase, Hospital E vs. 8 other hospitals .......... 177 Figure 304. Patient experience at hospital by phase, Hospital E vs. 8 other hospitals ............................ 178 Figure 305. Timeline for accreditation of Hospital F ................................................................................. 180 Figure 306. Hospital F bed occupancy rate by phase .............................................................................. 181 Figure 307. Percentage of deaths in the emergency room, Hospital F, by phase.................................... 181

Indonesia hospital accreditation final report xiii

Figure 308. Net death rate, Hospital F, by phase ..................................................................................... 181 Figure 309. Waiting time for prescription drug service, Hospital F, by phase .......................................... 182 Figure 310. Hospital governance by phase, Hospital F vs. 8 other hospitals ........................................... 182 Figure 311. Patient orientation by phase, Hospital F vs. 8 other hospitals ............................................... 183 Figure 312. Human resource by phase, Hospital F vs. 8 other hospitals ................................................. 183 Figure 313. Clinical practice and patient care by phase, Hospital F vs. 8 other hospitals ....................... 183 Figure 314. Healthcare-associated infection by phase, Hospital F vs. 8 other hospitals ......................... 184 Figure 315. Transfusion by phase, Hospital F vs. 8 other hospitals ......................................................... 184 Figure 316. Facilities management by phase, Hospital F vs. 8 other hospitals ........................................ 184 Figure 317. Medication safety by phase, Hospital F vs. 8 other hospitals ................................................ 185 Figure 318. Surgery, interventional procedures, and accompanying anesthesia by phase, Hospital F vs. 8 other hospitals ........................................................................................................................................ 185 Figure 319. Documentation and records by phase, Hospital F vs. 8 other hospitals ............................... 185 Figure 320. Key organizational audit criteria in Obstetric Department, Hospital F vs. 8 other hospitals .. 186 Figure 321. Key organizational audit criteria in Pediatric Department, Hospital F vs. 8 other hospitals .. 186 Figure 322. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital F vs. 8 other hospitals ........................................................................................................................................ 187 Figure 323. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital F vs. 8 other hospitals .................................................................................................................................................... 187 Figure 324. Length of stay for normal delivery patients by phase, Hospital F vs. 8 other hospitals ......... 188 Figure 325. Age for normal delivery patients by phase, Hospital F vs. 8 other hospitals ......................... 188 Figure 326. Laceration recorded for normal delivery patients by phase, Hospital F vs. 8 other hospitals 189 Figure 327. Apgar score recorded for normal delivery newborns by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 189 Figure 328. Birth weight recorded for normal delivery newborns by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 190 Figure 329. Mean age for pneumonia (months) patients by phase, Hospital F vs. 8 other hospitals ....... 191 Figure 330. Length for stay for pneumonia patients by phase, Hospital F vs. 8 other hospitals .............. 191 Figure 331. Respiratory symptom recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 192 Figure 332. Immunization recorded for pneumonia in patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 192 Figure 333. Respiratory rate recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 193 Figure 334. Temperature recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals .. 193 Figure 335. Pulse recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals .............. 193 Figure 336. Mean age for AMI patients by phase, Hospital F vs. 8 other hospitals ................................. 194 Figure 337. Length of stay for AMI patients by phase, Hospital F vs. 8 other hospitals ........................... 194 Figure 338. Cardiac enzymes examination for AMI patients by phase, Hospital F vs. 8 other hospitals . 195 Figure 339. ECG examination for AMI patients by phase, Hospital F vs. 8 other hospitals ..................... 196 Figure 340. Oral beta-adrenergic recorded for AMI patients by phase, Hospital F vs. 8 other hospitals . 196 Figure 341. Statin recorded for AMI patients by phase, Hospital F vs. 8 other hospitals ......................... 196 Figure 342. Aspirin recorded for AMI patients by phase, Hospital F vs. 8 other hospitals ....................... 197 Figure 343. Previous AMI history recorded for AMI patients by phase, Hospital F vs. 8 other hospitals . 197 Figure 344. Angina pectoris recorded for AMI patients by phase, Hospital F vs. 8 other hospitals ......... 197 Figure 345. Hypertension recorded for AMI patients by phase, Hospital F vs. 8 other hospitals ............. 198 Figure 346. Hypercholesterolemia history recorded for AMI patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 198

xiv Indonesia hospital accreditation final report

Figure 347. Cerebrovascular disease recorded for AMI patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 198 Figure 348. Heart failure recorded for AMI patients by phase, Hospital F vs. 8 other hospitals .............. 199 Figure 349. Diabetic history recorded for AMI patients by phase, Hospital F vs. 8 other hospitals ......... 199 Figure 350. Mean age for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals 200 Figure 351. Length of stay for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 200 Figure 352. Surgery for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals ... 201 Figure 353. Antibiotic prophylactic for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 201 Figure 354. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals ........................................................................................................................................... 202 Figure 355. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals .................................................................................................................................................... 202 Figure 356. Mean age of patients interviewed by phase, Hospital F vs. 8 other hospitals ....................... 203 Figure 357. Length of stay of patients interviewed by phase, Hospital F vs. 8 other hospitals ................ 204 Figure 358. Patient satisfaction with medical services by phase, Hospital F vs. 8 other hospitals .......... 204 Figure 359. Patient satisfaction with nursing care by phase, Hospital F vs. 8 other hospitals ................. 204 Figure 360. Patient satisfaction with hospital facilities by phase, Hospital F vs. 8 other hospitals ........... 205 Figure 361. Overall satisfaction of patients interviewed by phase, Hospital F vs. 8 other hospitals ........ 205 Figure 362. Patient experience at hospital by phase, Hospital F vs. 8 other hospitals ............................ 205 Figure 363. Timeline for accreditation of Hospital G ................................................................................. 208 Figure 364. Bed occupancy rate for Hospital G by phase ........................................................................ 209 Figure 365. Average length of stay for Hospital G by phase .................................................................... 209 Figure 366. Bed turn over interval for Hospital G by phase ...................................................................... 209 Figure 367. Bed turn over for Hospital G by phase .................................................................................. 210 Figure 368. Hospital governance by phase, Hospital G vs. 8 other hospitals .......................................... 210 Figure 369. Patient orientation by phase, Hospital G vs. 8 other hospitals .............................................. 211 Figure 370. Human resource by phase, Hospital G vs. 8 other hospitals ................................................ 211 Figure 371. Clinical practice and patient care performance by phase, Hospital G vs. 8 other hospitals.. 211 Figure 372. Healthcare-associated infection performance by phase, Hospital G vs. 8 other hospitals ... 212 Figure 373. Transfusion performance by phase, Hospital G vs. 8 other hospitals ................................... 212 Figure 374. Facilities management performance by phase, Hospital G vs. 8 other hospitals .................. 212 Figure 375. Medication safety performance by phase, Hospital G vs. 8 other hospitals .......................... 213 Figure 376. Surgery, interventional procedures, and anesthesia performance by phase, Hospital G vs. 8 other hospitals ........................................................................................................................................... 213 Figure 377. Documentation and records performance by phase, Hospital G vs. 8 other hospitals ......... 213 Figure 378. Key organizational audit criteria in Obstetric Department, Hospital G vs. 8 other hospitals . 214 Figure 379. Key organizational audit criteria in Pediatric Department, Hospital G vs. 8 other hospitals.. 214 Figure 380. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital G vs. 8 other hospitals ........................................................................................................................................ 215 Figure 381. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital G vs. 8 other hospitals .................................................................................................................................................... 215 Figure 382. Average length of stay of normal delivery patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 216 Figure 383. Age of normal delivery patients by phase, Hospital G vs. 8 other hospitals ........................ 216 Figure 384. Laceration recorded for normal delivery patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 217

Indonesia hospital accreditation final report xv

Figure 385. Apgar score recorded for normal delivery newborns by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 217 Figure 386. Birth weight recorded for normal delivery newborns by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 218 Figure 387. Mean age in months of pneumonia patients by phase, Hospital G vs. 8 other hospitals ...... 219 Figure 388. Length of stay of pneumonia patients by phase, Hospital G vs. 8 other hospitals ................ 219 Figure 389. Respiratory symptoms recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 220 Figure 390. Immunization recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals 220 Figure 391. Respiratory rate recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 221 Figure 392. Temperature recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals . 221 Figure 393. Pulse recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals ............. 221 Figure 394. Average age of AMI patients by phase, Hospital G vs. 8 other hospitals ............................. 222 Figure 395. Length of stay of AMI patients by phase, Hospital G vs. 8 other hospitals ........................... 222 Figure 396. Cardiac enzymes examination recorded for AMI patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 223 Figure 397. ECG examination recorded for AMI patients by phase, Hospital G vs. 8 other hospitals ..... 224 Figure 398. Oral beta-adrenergic recorded for AMI patients by phase, Hospital G vs. 8 other hospitals 224 Figure 399. Statins recorded for AMI patients by phase, Hospital G vs. 8 other hospitals ...................... 224 Figure 400. Aspirin prescription recorded for AMI patients by phase, Hospital G vs. 8 other hospitals ... 225 Figure 401. Previous AMI history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals 225 Figure 402. Angina pectoris history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 225 Figure 403. Hypertension history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals 226 Figure 404. Hypercholesterolemia history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 226 Figure 405. Cerebrovascular accident history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals ........................................................................................................................................... 226 Figure 406. Heart failure history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals .. 227 Figure 407. Diabetic history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals ......... 227 Figure 408. Mean age of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals. 228 Figure 409. Length of stay of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 228 Figure 410. Surgery for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals ... 229 Figure 411. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals ........................................................................................................................................ 229 Figure 412. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals ........................................................................................................................................ 230 Figure 413. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals .................................................................................................................................................... 230 Figure 414. Mean age of patient interviewed by phase, Hospital G vs. 8 other hospitals ....................... 231 Figure 415. Length of stay of patients interviewed by phase, Hospital G vs. 8 other hospitals .............. 232 Figure 416. Patient satisfaction with medical services by phase, Hospital G vs. 8 other hospitals .......... 232 Figure 417. Patient satisfaction was nursing care by phase, Hospital G vs. 8 other hospitals ................ 232 Figure 418. Patient satisfaction with hospital facilities by phase, Hospital G vs. 8 other hospitals .......... 233 Figure 419. Patient satisfaction with all services, Hospital G vs. 8 other hospitals .................................. 233 Figure 420. Patient experience at hospital by phase, Hospital G vs. 8 other hospitals ............................ 233 Figure 421. Timeline for accreditation of Hospital H ................................................................................. 235

xvi Indonesia hospital accreditation final report

Figure 422. Waiting time for prescription drug service by phase, Hospital H ........................................... 236 Figure 423. Hospital governance by phase, Hospital H vs. 8 other hospitals .......................................... 236 Figure 424. Patient orientation by phase, Hospital H vs. 8 other hospitals .............................................. 237 Figure 425. Human resources by phase, Hospital H vs. 8 other hospitals ............................................... 237 Figure 426. Clinical practice and patient care performance by phase, Hospital H vs. 8 other hospitals .. 237 Figure 427. Healthcare-associated infection performance by phase, Hospital H vs. 8 other hospitals .... 238 Figure 428. Transfusion by performance phase, Hospital H vs. 8 other hospitals ................................... 238 Figure 429. Facilities management by performance phase, Hospital H vs. 8 other hospitals .................. 238 Figure 430. Medication safety performance by phase, Hospital H vs. 8 other hospitals .......................... 239 Figure 431. Surgery, interventional procedures, and anesthesia performance by phase, Hospital H vs. 8 other hospitals ........................................................................................................................................ 239 Figure 432. Documentation and records performance by phase, Hospital H vs. 8 other hospitals .......... 239 Figure 433. Key organizational audit criteria in Obstetric Department, Hospital H vs. 8 other hospitals . 240 Figure 434. Key organizational audit criteria in Pediatric Department, Hospital H vs. 8 other hospitals .. 240 Figure 435. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital H vs. 8 other hospitals ........................................................................................................................................ 241 Figure 436. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital H vs. 8 other hospitals .................................................................................................................................................... 241 Figure 437. Average length of stay of normal delivery patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 242 Figure 438. Mean age of normal delivery patients by phase, Hospital H vs. 8 other hospitals ................ 242 Figure 439. Laceration recorded for normal delivery patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 243 Figure 440. Apgar score recorded for normal delivery newborns by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 244 Figure 441. Birth weight recorded for normal delivery newborns by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 244 Figure 442. Mean age in months of pneumonia patients by phase, Hospital H vs. 8 other hospitals ...... 245 Figure 443. Length of stay of pneumonia patients by phase, Hospital H vs. 8 other hospitals ................ 246 Figure 444. Respiratory symptoms recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 246 Figure 445. Immunization recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals . 247 Figure 446. Respiratory rate recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 247 Figure 447. Temperature recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals .. 247 Figure 448. Pulse recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals ............. 248 Figure 449. Average age of AMI patients by phase, Hospital H vs. 8 other hospitals .............................. 249 Figure 450. Length of stay for AMI patients by phase, Hospital H vs. 8 other hospitals .......................... 249 Figure 451. Cardiac enzymes examination recorded for AMI patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 250 Figure 452. ECG examination recorded for AMI patients by phase, Hospital H vs. 8 other hospitals ..... 250 Figure 453. Oral beta-adrenergic recorded for AMI patients by phase, Hospital H vs. 8 other hospitals. 251 Figure 454. Statins recorded for AMI patients by phase, Hospital H vs. 8 other hospitals ....................... 251 Figure 455. Aspirin prescription recorded for AMI patients by phase, Hospital H vs. 8 other hospitals ... 251 Figure 456. Previous AMI history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals. 252 Figure 457. Angina pectoris history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 252 Figure 458. Hypertension history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals . 252

Indonesia hospital accreditation final report xvii

Figure 459. Hypercholesterolemia history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 253 Figure 460. Cerebrovascular accident history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals ........................................................................................................................................... 253 Figure 461. Heart failure history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals .. 253 Figure 462. Diabetic history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals ........ 254 Figure 463. Mean age of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals . 254 Figure 464. Length of stay of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 255 Figure 465. Surgery of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals .... 256 Figure 466. Antibiotic prophylaxis given to hip/femoral neck fracture by phase, Hospital H vs. 8 other hospitals .................................................................................................................................................... 256 Figure 467. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals ........................................................................................................................................ 256 Figure 468. Use of thromboembolism in hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals ........................................................................................................................................... 257 Figure 469. Mean age of patients interviewed by phase, Hospital H vs. 8 other hospitals ...................... 258 Figure 470. Length of stay of patients interviewed by phase, Hospital H vs. 8 other hospitals ................ 258 Figure 471. Patient satisfaction with medical services by phase, Hospital H vs. 8 other hospitals .......... 259 Figure 472. Patient satisfaction with nursing care by phase, Hospital H vs. 8 other hospitals ................. 259 Figure 473. Patient satisfaction with hospital facilities by phase, Hospital H vs. 8 other hospitals .......... 259 Figure 474. Patient satisfaction with all services by phase, Hospital H vs. 8 other hospitals ................... 260 Figure 475. Patient experience at hospital by phase, Hospital H vs. 8 other hospitals ............................ 260 Figure 476. Timeline for accreditation of Hospital I .................................................................................. 262 Figure 477. Bed occupancy rate for Hospital I by phase .......................................................................... 263 Figure 478. Average length of stay for Hospital I by phase ...................................................................... 263 Figure 479. Hospital governance by phase, Hospital I vs. 8 other hospitals ............................................ 264 Figure 480. Patient orientation by phase, Hospital I vs. 8 other hospitals ................................................ 264 Figure 481. Human resources by phase, Hospital I vs. 8 other hospitals ................................................ 264 Figure 482. Clinical practice and patient care performance by phase, Hospital I vs. 8 other hospitals ... 265 Figure 483. Healthcare-associated infection by performance phase, Hospital I vs. 8 other hospitals ..... 265 Figure 484. Transfusion by performance phase, Hospital I vs. 8 other hospitals ..................................... 265 Figure 485. Facilities management by performance phase, Hospital I vs. 8 other hospitals ................... 266 Figure 486. Medication safety performance by phase, Hospital I vs. 8 other hospitals ........................... 266 Figure 487. Surgery, interventional procedures, and anesthesia performance by phase, Hospital I vs. 8 other hospitals ........................................................................................................................................ 266 Figure 488. Documentation and records performance by phase, Hospital I vs. 8 other hospitals ........... 267 Figure 489. Key organizational audit criteria in Obstetric Department, Hospital I vs. 8 other hospitals ... 267 Figure 490. Key organizational audit criteria in Pediatric Department, Hospital I vs. 8 other hospitals ... 268 Figure 491. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital I vs. 8 other hospitals ........................................................................................................................................ 268 Figure 492. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital I vs. 8 other hospitals .................................................................................................................................................... 268 Figure 493. Average length of stay of normal delivery patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 269 Figure 494. Mean age of normal delivery patients by phase, Hospital I vs. 8 other hospitals .................. 270 Figure 495.Laceration recorded for normal delivery patients by phase, Hospital I vs. 8 other hospitals . 270 Figure 496. Apgar score recorded for normal delivery newborn by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 271

xviii Indonesia hospital accreditation final report

Figure 497. Birth weight recorded for normal delivery newborns by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 271 Figure 498. Mean age in months of pneumonia patients by phase, Hospital I vs. 8 other hospitals ........ 272 Figure 499. Length of stay of pneumonia patients by phase, Hospital I vs. 8 other hospitals .................. 273 Figure 500. Respiratory symptom recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 273 Figure 501. Immunization recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals .. 274 Figure 502. Respiratory rate recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 274 Figure 503. Temperature recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals ... 274 Figure 504. Pulse recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals ............... 275 Figure 505. Average age of AMI patients by phase, Hospital I vs. 8 other hospitals ............................... 275 Figure 506. Length of stay of AMI patients by phase, Hospital I vs. 8 other hospitals ............................. 276 Figure 507. Cardiac enzymes examination recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 277 Figure 508. ECG examination recorded for AMI patients by phase, Hospital I vs. 8 other hospitals ....... 277 Figure 509. Oral beta-adrenergic recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .. 277 Figure 510. Statin recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .......................... 278 Figure 511. Aspirin prescription recorded for AMI patients by phase, Hospital I vs. 8 other hospitals..... 278 Figure 512. Previous AMI history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .. 278 Figure 513. Angina pectoris history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 279 Figure 514. Hypertension history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .. 279 Figure 515. Hypercholesterolemia history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 279 Figure 516. Cerebrovascular accident history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals ........................................................................................................................................... 280 Figure 517. Heart failure history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals .... 280 Figure 518. Diabetic history for AMI patients by phase, Hospital I vs. 8 other hospitals .......................... 280 Figure 519. Mean age of hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals .. 281 Figure 520. Length of stay for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 281 Figure 521. Surgery for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals .... 282 Figure 522. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 283 Figure 523. Mobilization after surgery for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals ........................................................................................................................................... 283 Figure 524. Thromboembolic for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals .................................................................................................................................................... 283 Figure 525. Mean age of patients interviewed by phase, Hospital I vs. 8 other hospitals ........................ 284 Figure 526. Length of stay of interviewed patients by phase, Hospital I vs. 8 other hospitals ................. 285 Figure 527. Patient satisfaction with medical services by phase, Hospital I vs. 8 other hospitals ........... 285 Figure 528. Patient satisfaction with nursing care by phase, Hospital I vs. 8 other hospitals .................. 285 Figure 529. Patient satisfaction with hospital facilities by phase, Hospital I vs. 8 other hospitals ............ 286 Figure 530. Patient satisfaction with all services at hospital by phase, Hospital I vs. 8 other hospitals ... 286 Figure 531. Patient experience at hospital by phase, Hospital I vs. 8 other hospitals ............................. 286

Indonesia hospital accreditation final report xix

Acronyms

ACE Angiotensin converting enzyme

AMI Acute myocardial infarction

ASSIST USAID Applying Science to Strengthen and Improve Systems Project

BPJS Badan Penyelenggara Jamanin Sosial (Social Security Administrator)

CPD Continuous professional development

CPR Cardiopulmonary resuscitation

EBM Evidence-based medicine

ECG Electrocardiogram

ER Emergency room

GOI Government of the Republic of Indonesia

HAPIE Hospital Accreditation Process Impact Evaluation

HCI USAID Health Care Improvement Project

HR Human resources

IAP International Accreditation Program

ICU Intensive care unit

IDR Indonesian rupiah (currency)

INA-CBG Indonesian diagnosis-based group capitation system

INN International non-proprietary names

ISO International Organization for Standardization

ISQua International Society for Quality in Health Care

JCI Joint Commission International

JKN Jaminin Kesehatan Nasional (National Health Insurance)

KARS Komisi Akreditasi Rumah Sakit (Indonesian accreditation system)

LOS Length of stay

M&E Monitoring and evaluation

MOH Ministry of Health

NDR Net death rate

NICE National institute for health and care excellence

NICU Newborn intensive care unit

NR Not recorded

OA Organizational audit

OOP Out of pocket

PBI Penerima Bantuan Iuran (BPJS members whose premiums are paid on their behalf)

PICU Pediatric intensive care unit

QI Quality improvement

RSUP Rumah Sakit Umum Pusat (general hospital)

TOI Turn-over interval

UI Universitas Indonesia

URC University Research Co., LLC

USAID United States Agency for International Development

USD United States dollar (currency)

WHO World Health Organization

xx Indonesia hospital accreditation final report

EXECUTIVE SUMMARY

Introduction

This is the third and final report for the Hospital Accreditation Process Impact Evaluation (HAPIE). The study began in 2011 as a study of changes in quality and safety in nine hospitals undergoing either national accreditation through Komisi Akreditasi Rumah Sakit (KARS) or both national and international accreditation through Joint Commission International (JCI).

The study was funded by the United States Agency for International Development (USAID) as part of its country assistance to Indonesia’s health sector. USAID commissioned the study initially through the USAID Health Care Improvement Project (HCI), which ended in 2014; the study was completed under HCI’s follow-on project, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, both projects managed by University Research Co., LLC (URC). URC collaborated with the Center for Family Welfare, Faculty of Public Health, Universitas Indonesia, to design and implement the study.

Data were collected in 2012, 2014, and 2016 for the baseline, midline, and end-line, respectively. The overall questions the study sought to address were:

1. Were there changes in the hospitals’ quality performance indicators throughout the study period?

2. If so, were there differences in changes between hospitals that underwent additional JCI accreditation versus those that underwent KARS accreditation alone?

During the study, Badan Penyelenggara Jamanin Sosial – Kesehatan (BPJS-K) began implementing the Jaminin Kesehatan Nasional (JKN) system in January of 2014. JKN is a single-payer health insurance mechanism that aims to cover all Indonesians for comprehensive health care by the end of 2019. It began having a substantive impact on the study hospitals from the start of its implementation, as a large and growing proportion of patients receiving care from the nine hospitals were covered by JKN.

The roll-out of JKN provided the opportunity to observe differences in hospital quality associated with it. We added this component to the analysis of changes in the care of patients in the hospitals and sought to answer the additional question:

3. If there was a change in hospital performance from before to after implementation of JKN, was there a difference in the changes in patient indicators between patients who had government insurance coverage compared to patients who did not?

Methods

Study Design

Quantitative methods were applied to determine hospital service quality and performance and included clinical chart review for four conditions (normal vaginal delivery, pediatric pneumonia, acute myocardial infarction, and hip fracture) and interviews with 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.

There were six components of the study:

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. Information was obtained from interviewing hospital managers, reviewing documents, and observing facilities and hospital staff activities.

Indonesia hospital accreditation final report xxi

An organizational audit was conducted to describe the quality of care at the unit/department level related to the four diagnoses listed above.

Patient medical records were reviewed from a sample taken at random for the diagnoses normal vaginal delivery, childhood pneumonia, acute myocardial infarction, and hip and femur factures. Charts were reviewed for elements such as completeness of clinical information, patient outcomes, and patient characteristics. A questionnaire captured patients' experiences with care during their inpatient stay.

Patients were asked about their experiences with the care they received during their inpatient stay using a quantitative questionnaire.

Interviews with chiefs of medical services, Hospital Accreditation Team members, finance managers, members of the Hospital Information System Unit, and members of the Health Insurance Unit aimed to understand the opinion and perspective of senior officials at participating hospitals, KARS, and BPJS of hospital accreditation and its progress. The interview asked about the accreditation process’s influence on the quality of care as well as changes in hospital policy in response to JKN.

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.

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 Ministry of Health. One JCI hospital delayed seeking JCI accreditation for a year. The midline categorization of hospitals reflects these changes.

Results

From the hospital review, generally there were improvements in indicators of hospital system quality from baseline to end-line data collection periods. Improvements were also seen in documentation, as expected because it is required for JKN. Comparing hospitals undergoing different accreditation processes, JCI-KARS facilities started at a higher level for hospital review indicators than KARS-only hospitals. Both groups improved by about the same degree so that by the end-line, JCI hospitals scored higher than KARS hospitals by about the same amount.

In the organizational audit, surgery/orthopedic departments were found to have lower starting points and less improvement compared to pediatric, perinatal, and cardiac care/internal medicine wards. Scores across the ten domains of the organizational audit improved both in JCI-KARS and KARS-only hospitals. It appeared that improvements were associated with requirements of the accreditation process more than by JKN implementation. Hospitals undergoing JCI-KARS accreditation generally had higher levels of compliance in organizational audit domains compared to KARS-only hospitals by the end-line.

Clinical records of patients receiving services from hospitals undergoing JCI-KARS accreditation appeared to improve more than those treated in KARS-only hospitals, especially provision of discharge medications for patients with acute myocardial infarction (AMI). There was little difference between changes among clinical records of BPJS patients compared to those with other methods of payment from before to after implementation of JKN. Substantive deficits remained in some chart review indicators across all hospitals, especially from patients diagnosed with AMI.

The pattern noted from discussions with key informants was that JCI accreditation was more thorough and undertaken with greater seriousness than KARS accreditation but that the latter was improving in terms of its consistency and rigor over the last year. Implementation of JKN initially placed financial and

xxii Indonesia hospital accreditation final report

logistical pressure on hospitals, more so on the KARS-only group, but these have been ameliorated recently through better coordination with BPJS.

Conclusions and Recommendations

The 2012 reforms in KARS appeared to improve KARS’ effectiveness as an accreditation program, but deficits in quality and safety were still observed in the nine study hospitals, indicating room for further improvement in the system. Improving the quality of training of inspectors and deploying them in higher numbers may help.

Our findings generally showed that hospitals undergoing additional JCI accreditation started at higher levels and showed greater improvements in quality measures compared to KARS-only hospitals. However, deficits also remained in their quality performance scores. JCI accreditation costs a substantial amount more than KARS, and it is unclear from results of this study that these expenditures are commensurate with the increase in performance above KARS accreditation alone.

Implementation of JKN during the study period changed hospital behavior in predictable ways. Financial concerns were clearly a powerful driver of changes in the hospitals. It is hoped there will be organizational scope for BPJS to begin considering how JKN can incentivize high quality care and base payments at least partially on health outcomes rather than solely on service volume. As a positive step in this direction, JKN established a Quality and Cost Control Team for this purpose in 2017.

Implementation of JKN has been a profound change to the Indonesian health system. BPJS could benefit from their monopsony power in this new system but should recognize that those benefits do not continue in perpetuity and should be used judiciously. Low reimbursements for expensive diagnoses and procedures will decrease quality of care and may lead hospitals to game the system. It is the function of the MOH and BPJS-K to determine the payment mechanism, rate and coverage. Caution is required in this as promising the population comprehensive coverage while paying too little for the services may have the perverse effects of decreasing investment in health care, stifling innovation, and making the health care professions less attractive for high-performing workers.

Development of the system by experimentation with reimbursement methods and incentives for quality services should be explored and utilized. Evidence from such experimentation can help develop the system to maximize societal benefits while providing broad and equitable coverage. In this way, Indonesia has the opportunity to build the world’s premiere universal health system for a middle-income country that provides high quality, comprehensive health care.

Indonesia hospital accreditation final report xxiii

FOREWORD ON THE ORGANIZATION OF THIS REPORT

This final report for the Hospital Accreditation Process Impact Evaluation (HAPIE) study is organized into three sections. Section I is comprised of four chapters that present quantitative data collected from the nine hospitals from baseline in 2012 and end-line in 2016. For Chapter 1. Hospital Review and Chapter 2. Organizational Audit, data were collected at the hospital or ward/department level for comparison by accreditation type. In chapters 3 and 4, data were collected at the patient level allowing comparisons between in-patients at JCI-KARS versus KARS-only hospitals and, separately, between in-patients with government/JKN insurance versus those with an alternative method of payment. Comparison by method of payment could not be used to attempt to isolate the effect of JKN implementation separate from accreditation, but where a distinction between the two different causes for change could be inferred from the data and observation, analysis was presented. Chapter 4. Key Informant Interviews presents findings from key informants from the nine hospitals as a group. Section I answers the main research questions stated in the introduction.

Section II presents findings from the nine individual hospitals from baseline through midline (2014) to end-line together with the timeline of accreditation events throughout this period. The results are presented this way because each hospital responded in unique ways to the major changes in the health system over the study period, and each has a nuanced story of the effects of accreditation and JKN implementation.

Section III presents the policy implications and recommendations arising from the study.

At the beginning of each chapter is a boxed Overview that summarizes the overall findings from the chapter.

Indonesia hospital accreditation final report 1

I. COMPARISONS AMONG HOSPITAL GROUPS

1. Introduction

This is the third and final report for the Hospital Accreditation Process Impact Evaluation (HAPIE). The study began in 2011, when the United States Agency for International Development (USAID) Mission in Indonesia commissioned the USAID Health Care Improvement (HCI) Project to conduct a study on the quality and safety of nine hospitals and measure any changes in quality and safety as the hospitals underwent accreditation – all nine through Komisi Akreditasi Rumah Sakit (KARS – the Indonesian accreditation system) and five additionally through the Joint Commission International (JCI) system. The study was completed under HCI’s follow-on project, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, both projects managed by University Research Co., LLC (URC). URC collaborated with the Center for Family Welfare, Faculty of Public Health, Universitas Indonesia, to design and implement the HAPIE study.

Baseline data were collected at the end of 2012, mid-line data were collected at the end of 2014, and end-line data were collected from the middle to end of 2016. The overall questions the study sought to address were:

1. Were there changes in the hospitals’ quality performance indicators throughout the period of the study?

2. If so, were there differences in the changes between hospitals that underwent the additional JKN accreditation versus those that underwent KARS accreditation alone?

Unknown at the time of the design of the study was that Badan Penyelenggara Jamanin Sosial – Kesehatan (BPJS-K) began implementing the Jaminin Kesehatan Nasional (JKN) system in January of 2014 as mandated by National Social Security Law [1,2]. This occurred after HAPIE baseline data had been collected. JKN is a single-payer health insurance mechanism that aims to cover all Indonesians for comprehensive health care by the end of 2019. It began having a substantive impact on the study hospitals from the beginning of its implementation, as a large and growing proportion of patients receiving care from those nine hospitals were covered by JKN.

Under JKN, government insurance mechanisms in place before January 2014 were merged into a single system and managed by BPJS-K from the first quarter of 2014. Insurance mechanisms 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 end of 2017, JKN covered 72% of the population of Indonesia and was working toward covering the whole Indonesian population by the end of 2019 [3,4].

The roll-out of JKN provided the opportunity to observe differences in hospital quality associated with it. We added this component to the analysis of changes in the care of patients in the hospitals by analyzing them as groups depending on their method of payment – those with government insurance (either JKN or its precursor insurance type) and those without government insurance (self-payers or the privately insured). This analysis was added to the comparison between patients receiving care at JCI-KARS hospitals versus those receiving care from KARS-only hospitals. Therefore, a third question was added to the two above:

3. If there was a change in hospital performance from before to after implementation of JKN, was there a difference in the changes in patient indicators between patients who had government insurance coverage compared to patients who did not?

2 Indonesia hospital accreditation final report

The HAPIE study was conducted in three phases:

Baseline (completed August 2013)

Midline (end of 2014)

End-line (current report)

2. Background

To ensure a satisfactory level of 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 (MOH) [5]. All hospitals are required to obtain accreditation through the KARS system every three years as mandated by the MOH and also as a requirement for participating in the JKN [2,6]. However, as of 2017, only 1,164 of the approximately 2,760 hospitals (42%) in the country had achieved such accreditation [7].

The KARS system offers three levels of accreditation – five 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 those used by the international hospital accreditation agency, Joint Commission International (JCI).

In 2011, the United States Agency for International Development (USAID) collaborated with the GOI to improve hospital service quality. It supported eight hospitals seeking international accreditation through JCI and funded technical assistance for restructuring and upgrading the KARS system to have the process approved by the International Society for Quality in Health Care (ISQua) “International Accreditation Program” (IAP – accreditation for the accreditors). In February 2015, KARS received provisional accreditation through ISQua [8]. Accreditation lasts for four years, so the next evaluation is due in 2019.

The period from 2013 to 2016 saw major changes in the Indonesian health system that had a substantive impact on hospitals. Changes will continue as JKN rolls out coverage to the remaining quarter of the population not covered by the end of 2017 and adapts its policies in response to how well they serve policy-holders and health care providers. This study provides information on the changes that nine Class-A hospitals have experienced over time that may inform BPJS; the Ministry of Health’s Directorate for accreditation and quality, KARS; and the hospitals in the coming years.

References

1. Law of the Republic of Indonesia Number 40 of 2004 Regarding National Social Security System. 2004.

2. Law of the Republic of Indonesia Number 24 of 2011 Regarding BPJS. 2011. 3. BPJS Kesehatan. Laporan pengelolaan program tahun 2016 & laporan keuangan tahun 2016

(auditan). 2017. 4. Population Census. Statistics Indonesia. Population of Indonesia: Result of the 2015 Intercensal.

2017. 5. Soepojo P, Koentjoro T, Utarini A. Benchmarking of Hospital Accreditation System in Indonesia and

Australia. Jurnal Manajemen Pelayanan Kesehatan. 2002:5(2): 93-101. 6. Law of the Republic of Indonesia Act No. 34/Menkes/2017. 2017. 7. Irfianti I. Evaluation of hospital accreditation in Indonesia by the Hospital Accreditation Commission

(KARS): Perceptions of hospitals and ISQua standards. Yogyakarta: Medical Faculty of Gadjah Mada University. 2011.

8. International Society for Quality in Health Care. What is the International Accreditation Program (IAP)? Dublin, Ireland. 2017.


Chapter 1. Hospital Review

Overview

The hospital review component examined differences over time in organizational structures and physical characteristics at each of the hospitals to determine if there was a difference from before to after implementation of JKN and whether there was a difference among hospitals that underwent KARS-only versus JCI-KARS accreditation in that period.

There were generally improvements in indicators of hospital system quality from baseline to end-line data collection periods. Improvements were also seen in documentation, which was expected because it is required for JKN. Comparing hospitals undergoing different accreditation processes, JCI-KARS facilities started at a higher level for hospital review indicators than KARS-only hospitals. Both groups improved by about the same amount so JCI remained at a higher level by the end-line.

1. Introduction

Hospital quality management systems have been found to be positively associated with clinical outcome indicators for patients receiving hospital care [1]. For this reason, we sought to determine what quality management systems existed in the nine participating hospitals and whether there were changes in those systems from 2012 to 2016. We also sought to determine if there were differences in these indicators between hospitals that underwent only KARS accreditation and those that underwent both KARS and JCI accreditation over the period.

The instrument used to collect data for this hospital review was developed for the SANITAS project, an initiative of the European Society for Quality in Healthcare. It was designed for self-assessment of organizational structures and physical characteristics of hospitals to measure elements considered necessary to promote quality of care. It was tested and validated in 2011 in nine European hospitals [2].

If implementation of JKN caused changes in hospital management, we would expect to see this in the analysis of all hospitals considered in toto with improvements in hospital review indicators from 2012 to 2016 after JKN had been implemented (from January 2014). It is expected that some indicators will be affected in all hospitals due to JKN because reimbursement under the system relies specifically on them. For example, the “documentation and records” domain would likely improve given that compliance with JKN documentation requirements is necessary for a hospital to be paid for the services it provides to patients covered by JKN. However, most indicators could not logically be linked to JKN implementation alone. If JCI-KARS accreditation was superior to KARS-only accreditation in improving hospital review indicators, we expect this would be evident in higher improvements in those indicators among the JCI-KARS facilities.

2. Methods

Data collection instrument

The hospital review data tool captured information on documentation of policies, practices, and physical capacity in ten criteria, with each criterion composed of several elements as listed below.

1) Hospital governance

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


o Policy covering emergency preparedness for both internal and external critical situation has been established and is available to all staff

o Medical laboratory and the diagnostic radiology is certified by International Organization for Standardization (ISO)

o Medical laboratory and radiology departments participate in formal external quality assurance

2) Patient orientation

The hospital has approved and implemented a policy for obtaining informed consent and retaining 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 a report on how complaints are

handled is published annually

3) Human resources

Hospitals have a mechanism to verify professional qualifications in line with national law [3] Clinical staff are given cardiopulmonary resuscitation (CPR) 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 hospital has a formal procedure by which clinical guidelines are agreed upon and implemented [3]

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 usage diagrams 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

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 Staff who handle food 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 staff who handle food 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

Blood for transfusions is stored in a designated lockable refrigerator There is continuous record of blood bank temperatures to ensure the blood bank is maintained

consistently at an appropriate temperature There are written guidelines concerning the prescription and administering of blood and blood

products

7) Hospital facilities management

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 exposure during

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) are routinely tested on full load All firefighting equipment is 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 containers are appropriate to each type of waste All staff who work in areas where clinical waste is handled are suitably trained and wear

protective clothing

8) Medication safety

The hospital should have a systematic procedure for reviewing the hospital formulary The hospital’s policy requires the use of international non-proprietary names (INNs) High-risk medicines are included among non-emergency 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 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

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 is 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 discharge. Discharge summary is available to all patients; case note retention policy in accordance with

current national guidelines.

Data collection

Collection of hospital review data occurred three times: 2012, 2014, and 2016. Specific timing for the individual hospitals is reported in Section II.

Data collectors from the core Universitas Indonesia (UI)-based research team visited each hospital in turn and requested to see evidence of each element in each domain listed above. For example, under the Hospital Governance domain, to score the element, “Management has established an annual safety action plan and receives annual reports,” a UI team member asked the point of contact provided by the hospital administrator for the written safety action plan annual report. The UI team member recorded their observations and later compared them to those made in other hospitals to ensure standardization of scoring using a 0-4 rating (0 for non-compliance with the standard and 4 for full compliance). Scores for each element in each domain were entered in an Excel spreadsheet on the same day as data collection.

Data analysis

For the grouped hospital data examining associations with accreditation status, scores were taken before and after the hospitals underwent either KARS-only or JCI-KARS accreditation. Given that facilities undertook JCI-KARS accreditation at different times over the four-year period, we did not include the midline data collected for these analyses. Two hospitals (C and E) that were originally designated for KARS accreditation opted late to undergo JCI accreditation and therefore began preparing late for it. These two hospitals were counted in the KARS-only group for the baseline but the JCI-KARS group for the end-line because they did eventually undergo JCI accreditation before the end-line data collection (Table 1). For comparison of all hospitals before and after implementation of JKN, the midline period was excluded from the grouped analyses because it occurred over a period when JKN was just starting its roll-out, but was not fully in operation at all hospitals.


Table 1. Hospital grouping by accreditation type and phase

Accreditation Hospital Pre-accreditation of JCI-KARS (3 hospitals) A, B, and D

Pre-accreditation of KARS-only (6 hospitals) C, E, F, G, H, and IPost accreditation of JCI-KARS (5 hospitals) A, B, C, D, E

Post accreditation of KARS-only (4 hospitals) F, G, H, I

Scoring

For each domain, the hospital was given an overall score comprised of a summation of their scores on each element divided by the maximum possible score (the number of elements multiplied by four) to give a percentage. These percentages were then pooled across all hospitals for the baseline and end-line periods to determine if there was a difference overall across the span of about five years.

We then compared the changes from baseline to end-line among JCI-KARS accreditation hospitals compared to KARS-only accreditation hospitals.

In Section II of this report, midline data were included in the analysis to demonstrate the changes or otherwise that had occurred in the individual hospitals and how that was associated with the phase and type of accreditation they were undergoing. (See Section II. Findings from Individual Hospitals.)

3. Results

Before versus after JKN implementation differences

There was general improvement from before to after implementation of JKN, averaged across all domains in all hospitals (Figure 1).

Figure 1. Hospital review, overall performance, before and after JKN

Medication safety, patient orientation, human resources, healthcare-associated infections, and medication safety all improved by more than 0.5 on the 0 to 4 scale, while other indicators improved less. The only exception to the overall improvement was transfusion services, which did not improve from their initially high level (Figures 2, 3, and 4).

2.9

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1.0

1.5

2.0

2.5

3.0

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Before JKN After JKN

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n score

Hospital Review


Figure 2. Hospital governance, patient orientation, and human resources before and after JKN

Figure 3. Clinical practice and patient care, healthcare-associated infections, and transfusion before and after JKN

Figure 4. Facility management, medication safety, surgery procedures and anesthesia, and documentation and records before and after JKN Implementation

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Clinical Practice and Patient Care Healthcare‐associated Infections Transfusion

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Facility Management Medication Safety Surgery, Procedures and Documentation andAnesthesia Records

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Hospital Governance Patient Orientation Human Resources

Hospital Review


JCI-KARS versus KARS-only differences

Considering all ten hospital review criteria aggregated according to accreditation type and before versus after the accreditation, both JCI-KARS and KARS-only hospitals showed a slight increase but JCI-KARS hospitals began from a higher base (Figure 5). This pattern was repeated for hospital governance, patient orientation, human resources (Figure 6), facility management and medication safety (Figure 7). Clinical practice and patient care and health care associated infections also showed this pattern, but blood transfusion scores decreased from before to after accreditation (Figure 8). One possible explanation for this is that temperature monitoring for blood storage compartments and locks on the units were not part of the KARS or JCI accreditation criteria, while they were part of the hospital review criteria for this study.

Surgery, procedures and anesthesia improved a similar degree in both hospital groups while KARS-only hospitals decreased in scores compared to a slight improvement in the JCI-KARS hospitals (Figure 9).

Figure 5. Overall hospital review performance by hospital accreditation

Figure 6. Hospital governance, patient orientation and human resources by hospital accreditation type

2.8

3.23.1

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Figure 7. Facility management and medication safety by hospital accreditation type

Figure 8. Clinical practice and patient care, healthcare-associated infections, and transfusion by hospital accreditation type

Figure 9. Surgery, procedures and anesthesia, and documentation and records by hospital accreditation process

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4. Discussion

Before and after JKN implementation

When considering hospitals together and comparing their performance before and after implementation of JKN, we see improvement in all criteria except for blood transfusion, which began at a high level and remained high to the end-line. This was expected given that some domains in the hospital review are directly related to reimbursement by JKN, and therefore if hospitals want full and prompt payment for the services they provide to patients covered by JKN, they will make changes to ensure maximal compliance with those indicators. Three domains particularly relevant to this are: patient orientation, clinical practice, and documentation and records. While we did see improvements of 0.9, 0.5, and 0.1 respectively in those domains; however, they were not outstanding among the ten total indicators, so we do not detect strong evidence that hospitals successfully emphasized improvement in these areas in response to JKN.

JCI versus non-JCI

Initial scores for the hospital review criteria were generally higher for hospitals selected to undergo JCI-KARS accreditation. The MOH deliberately selected hospitals perceived to have superior performance to be candidates for JCI accreditation, so this finding was expected. Because many of the hospitals began with high scores on certain criteria, there was less room for improvement. Also, if diminishing marginal returns to investment in health systems improvement applied here as in other cases, we would expect lower improvements in JCI-KARS hospitals [4]. However, we saw the same degree of improvement of around 10% in both the JCI-KARS and KARS-only hospitals.

The lowest scores overall were from the clinical practice and patient care domains for KARS-only hospitals, which started at an average score of 2.2 and only progressed to 2.4 at the end-line period. This is concerning because the six elements in this criterion are closely linked to standardization of clinical care and may therefore play an important role in clinical outcomes [5,6].

This is the result expected given that hospitals perceived by the MOH to be performing better among Class A public facilities were selected for the additional JCI accreditation candidacy. It is also consistent with the fact that JCI-KARS hospitals were allocated additional resources to prepare for accreditation. Most of these resources were designated for improving the physical facility, but some was used to improve management systems (see Chapter 4).

5. Conclusion

Findings show most hospitals started with a moderate level of compliance with hospital review indicators and there was generally showed improvement across indicators of hospital system quality from baseline to end-line periods. Given the implementation of JKN, such improvement was expected in hospital criteria directly tied to JKN requirements for reimbursement, and these were detected. However, there was no strong evidence that the cause of the improvements was implementation of JKN. There was also no substantive difference between improvements seen in hospitals undergoing JCI-KARS accreditation compared to those undergoing KARS-only accreditation.

References

1. Bruneau C, Cohen A, Shaw C, Manion R, Thompson A, Walshe K. DUQuE final summary report. 2014.

2. Harrington N. European Society for Quality in Healthcare. London: ESQH Annual Report. 2012. 3. Republic of Indonesia. Law on the provision of services in hospital. Number 254. Jakarta. 2002. 4. Chiu C, Johnson LF, Jamieson L, Larson BA, Meyer-Rath G. Designing an optimal HIV programme

for South Africa: Does the optimal package change when diminishing returns are considered? BMC Public Health. 2017;17(1):143.


5. Alkhenizan A, Shaw C. Impact of accreditation on the quality of healthcare services: a systematic review of the literature. Ann Saudi Med. 2011;31(4):407-16.

6. Shaw CD, Groene O, Botje D, Sunol R, Kutryba B, Klazinga N, et al. The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals. Int J Qual Health Care. 2014;26 Suppl 1:100-7.


Chapter 2. Organizational Audit

Overview

This component examined differences over time in organizational structures and physical characteristics in four units at the nine hospitals to determine if there was a difference from before to after implementation of JKN and whether there was a difference among hospitals that underwent KARS-only versus JCI-KARS accreditation in that period.

The four units selected for the organizational audit were: 1. pediatric, 2. delivery or perinatal, 3. intensive cardiac care or internal medicine, and 4. surgery or orthopedics. Diagnoses of interest – pediatric pneumonia, normal vaginal deliveries, acute myocardial infarction, and hip fractures – were selected for each unit to assess outcomes. Surgery/orthopedic departments were found to have lower starting points and less improvement compared to pediatric, perinatal, and cardiac care/internal medicine wards. Scoresacross the ten domains of the organizational audit improved both in JCI-KARS and KARS-only hospitals. It appeared that improvements were associated with requirements of the accreditation process more than by JKN implementation. Hospitals undergoing JCI-KARS accreditation generally had higher levels of compliance compared to KARS-only hospitals by the end-line period.

1. Introduction

The organizational audit evaluated aspects of quality at the unit/department level in the nine participating hospitals where treatment is provided for the four diagnoses of interest – pediatric wards (for pediatric pneumonia), delivery and perinatal ward (for normal vaginal deliveries), intensive cardiac care units or internal medicine wards (for acute myocardial infarction), and surgical (or orthopedic ward, where they existed) for hip fractures.

The data collection tool was designed to address questions such as: “Is there a designated coordinator for quality and safety within the specific clinical service?” and “Is there an adverse event reporting policy and system for the clinical area?” There were about 50 such questions posed for each clinical area. The assessment instrument was based on a validated instrument from a previous study of the quality of hospital care in clinical units, the DUQuE Project [1,2].

As noted in Chapter 1, quality management systems have been found to be positively associated with clinical outcome indicators [3-5], and it was for this reason that we sought evidence of quality management systems in the four units within the hospital.

As with the data collection instrument used for the hospital review in Chapter 1, the organizational audit (OA) instrument was designed for assessment of documents and evidence of processes considered important in developing and maintaining the quality of care for hospital inpatients. It was based on an instrument that was tested and validated in 2011 in nine European hospitals [6]. Modifications were made for the local context. The modified instrument was piloted in one Class-B hospital, which was not part of the main study, to determine its suitability for use in the study.

We expected baseline findings to show deficits, as with the hospital review, and that there would be measurable improvement at the midline and end-line periods due to accreditation under the updated KARS criteria (and JCI accreditation, where this was applied) and implementation of JKN.

2. Methods

Data collection

Primary data collectors from the UI research team visited each of the four units in all nine hospitals in turn. They approached the unit manager, department chief, or their representative to request to see evidence of elements in each of the ten domains listed below. For example, in the patient identification


domain, to score the element: “There is an established standard operating procedure for correct patient identification,” the team asked to see the written standard operating procedure. They also asked to observe evidence that it was being implemented at the ward level; for example, by seeing wrist bands and other identification signs on all patients. They then compared their observations to those made in other hospitals to ensure standardization of scoring using a 0, 2 and 4 rating (0 is non-compliant, 2 is partially compliant, and 4 is fully compliant). Scores for each element in each domain were recorded and entered onto an Excel spreadsheet.

We compared compliance with ten indicators in four units as follows: patient identification wrist bands in use for correct patient identification, updated nursing manual available, clinical reviews undertaken to update practice in line with evidence-based medicine, adverse events analyzed, no potassium chloride in general ward stocks, resuscitation equipment maintained in order, evidence-based medicine (EBM) guidelines in use, sharps disposal boxes safely in use, guidelines on hospital care available to patients, and resuscitation procedure posters visible. For each domain, the hospital unit was given an overall score that was then divided by the maximum possible score (the number of elements multiplied by four) to create a percentage compliance score.

Data analysis

The method for analysis was the same as for the hospital review. For grouped data, scores were taken at baseline and end-line. The midline period was excluded from the grouped analyses because it occurred over a period when JKN was just starting to be implemented but was not fully in operation at all hospitals. It also included a time when some hospitals involved in JCI accreditation had not yet gone through any part of that process while one hospital had done so.

We then used difference-in-differences analysis to determine if there was a difference in changes from baseline to end-line between hospitals that underwent JCI-KARS accreditation compared to those that underwent only KARS accreditation.

3. Results

Before versus after JKN implementation differences

Looking across all ten domains in the OA, there was improvement in all indicators except sharps disposal box safety. There were substantive improvements in “Guidelines available to patients” and “Resuscitation procedure posters”; two areas where hospitals initially scored quite poorly (Figure 10).


Figure 10. Total score across 10 criteria, before and after JKN implementation, all hospitals

JCI-KARS versus KARS-only differences

Considering all OA domains, there was an increase in both JCI-KARS and KARS-only hospitals, each of about the same magnitude. The JCI-KARS wards began from a higher baseline score (Figure 11).

Figure 11. Total scores of 10 keys OA criteria by hospital category across all departments

Scores in obstetric units was generally higher than in the other units before accreditation. The gains were about the same for both units in JCI-KARS and KARS-only hospitals (Figure 12).

0 10 20 30 40 50 60 70 80 90 100

Resuscitation procedure posters

Guidelines available to patients

Safe needle disposal boxes

Evidence‐based guidelines in use

Resuscitation equipment in order

No KCl in general ward stocks

Adverse events analysed

Regular clinical review EBM

Current nursing manual

Bracelet ID all patients

2012 2016

74

85

74

55

68

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Figure 12. Total score across 10 OA criteria by accreditation process, Obstetric Department

There was a major improvement among the JCI-KARS hospital in compliance with OA criteria in pediatric departments, but much less improvement in KARS-only hospitals (Figure 13).

Figure 13. Total score across 10 OA criteria by accreditation process, Pediatric Department

In hospitals that did not have a dedicated department for cardiac patients, we examined the internal medicine departments where patients with acute myocardial infarctions were routinely assigned. In all such departments, observing across all hospitals, there was again a similar pattern of improvement in both JCI-KARS and KARS-only hospitals, with the former starting from a higher baseline (Figure 14).

Figure 14. Total score across 10 OA criteria by accreditation process, Internal Medicine Department

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In surgical departments, those in KARS-only hospitals had a lower score and their improvement over the four-year period only brought them up to the level of JCI-KARS hospitals at baseline (Figure 15).

Figure 15. Total score across 10 OA criteria by accreditation process, Surgery Department

4. Discussion

All hospital units examined had over 70% compliance with indicators by the end-line, including having current nursing manuals, using identification bracelets for all patients, and having regular clinical reviews for evidence-based medicine. Almost all departments achieved compliance of 80% or above at the end-line on all indicators except for having resuscitation procedure posters and guidelines on hospital care and patients’ rights available to patients. For analyses of adverse events, it was generally recognized by the data collectors that the improvement from 65% to over 85% compliance was evident with better recording of events and more thorough and consistent follow-up.

The lowest scores in the OA were for not having resuscitation procedure posters and guidelines on hospital care and patients’ rights available to patients. For resuscitation procedures, all hospitals already had established “Code Blue” teams – clinicians specifically trained on effective resuscitation procedures available hospital-wide in cases where emergency resuscitation is required. The posters for resuscitation were not required for JCI or KARS accreditation, and it was therefore not considered a priority in hospital units generally.

Patient guidelines were available in some units in some hospitals, but were not universally distributed in all. There is a mandate in the implementation of JKN to provide patient-centered care and one might expect this to increase availability of patient guidelines. However, the data collection team considered the lower level of compliance on this indicator more a reflection on accreditation requirements than the JKN implementation.

Availability of nursing manuals, safety measures for potassium chloride, and use of patient identification bracelets are requirement for both JCI and KARS accreditation. During the study period, there was standardization of these indicators in preparation for accreditation. This is likely the reason for the improvements in these three indicators.

Some hospitals reported to the data collectors that sufficient resources were not available to procure standardized sharps safety disposal boxes. This was the reason given for there not being an overall improvement in that indicator from baseline to end-line.

Scores for surgical ward compliance with quality indicators were lowest among the four wards. It is because most hospitals had not fully developed the clinical standard in surgical wards and only one hospital had a specifically designated orthopedic ward. Orthopedic and surgical wards were observed by the data collectors to be less well developed in terms of basic operating procedures compared to other departments.

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5. Conclusion

In general, scores across the ten domains of the OA improved both in JCI-KARS and KARS only hospitals from baseline to end-line. It appeared that the improvements were the result of requirements of the accreditation process more than by JKN implementation. Hospitals undergoing JCI-KARS accreditation generally had higher levels of compliance compared to KARS-only hospitals by the end-line period.

References

1. Bruneau C, Cohen A, Shaw C, Manion R, Thompson A, Walshe K. DUQuE final summary report. 2014.

2. Groene O, Klazinga N, Wagner C, Arah OA, Thompson A, Bruneau C, et al. Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the 'Deepening our Understanding of Quality Improvement in Europe (DUQuE)' project. BMC Health Serv Res. 2010;10:281.

3. Groene O, Sunol R, Consortium DUP. The investigators reflect: what we have learned from the Deepening our Understanding of Quality Improvement in Europe (DUQuE) study. Int J Qual Health Care. 2014;26 Suppl 1:2-4.

4. Weed LL. The importance of medical records. Can Fam Physician. 1969;15(12):23-5. 5. Harrington N. ESQH Annual Report. European Society for Quality in Healthcare: London. 2012. 6. Shaw CD, Groene O, Botje D, Sunol R, Kutryba B, Klazinga N, et al. The effect of certification and

accreditation on quality management in 4 clinical services in 73 European hospitals. Int J Qual Health Care. 2014;26 Suppl 1:100-7.


Chapter 3. Clinical Review

Overview

We reviewed clinical charts for individual patients with one of four separate diagnoses at three points in time: baseline, midline, and end-line. As with the hospital review and organizational audit, we did analyses on grouped data before and after implementation of JKN and examined differences between changes over the same period between patient charts from hospitals that underwent JCI-KARS accreditation versus those undergoing KARS-only accreditation.

Findings: Clinical records of patients receiving services from hospitals undergoing JCI-KARS accreditation appeared to improve more than those treated in KARS-only hospitals, especially with regard to provision of discharge medications for patients with acute myocardial infarction (AMI). There was little difference between changes among clinical records of BPJS patients compared to those with other methods of payment from before to after implementation of JKN. Substantive deficits remain in some chart review indicators across all hospitals, especially for patients diagnosed with AMI.

1. Introduction

The content, completeness, and accuracy of individual patient clinical records are essential for the quality of medical care in the hospital setting. As such, they can serve as both an indicator of the quality of care and a facilitator of it [1]. We examined samples of these charts from the nine hospitals to evaluate the quality of care delivered for four different diagnoses.

We selected these four diagnoses for chart review because they involved diverse patient populations, were relatively common (to maximize the likelihood of having a large enough sample size in the time given), and because they are generally associated with a substantive burden of cases to the health system. Specifically, we chose acute myocardial infarction (AMI) because ischemic heart disease is the second leading cause of premature mortality in Indonesia [2]. The link between medical records for inpatient treatment of AMI and quality of care is well established [3]. We examined pediatric pneumonia because it is the second leading cause of death in children globally and a common cause of hospitalization for children in Indonesia [4]. Clinical charts have also been used to assess quality of care for this condition in other settings [5]. Uncomplicated (vaginal) childbirth was also selected for inclusion in chart reviews because chart reviews of normal deliveries are widely used as indicators of overall health system performance [6,7] and because many normal deliveries were attended to in these nine class A hospitals in 2012 when the study was initiated. However, when JKN was implemented in 2014, the hospitals began enforcing a policy of referring only pregnant women with complications to class A hospitals with much greater consistency than before. Therefore, the number of normal deliveries in these class A hospitals fell substantively in the midline and especially the end-line periods. Femoral neck fractures were also selected based on their relatively high prevalence; they are the second most common type of fracture among adults worldwide [2] and are usually treated surgically. It was expected that including this group of patients would capture the quality of care for surgery patients.

2. Method

Data collection tools

We developed four separate checklist tools for examining the clinical charts from patients with one of the four diagnoses. The tools were developed based on tools for clinical chart reviews used in the DUQuE study [8] and on the evidence-based standards of treatment for each condition as follows:

Acute myocardial infarction: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction [9].


Pediatric pneumonia: The World Health Organization’s case management for cough or difficult breathing in the pediatric ward [10] and the British Thoracic Society annual national pediatric pneumonia audit UK [11].

Normal deliveries: National Institute for Health and Care Excellence (NICE) Guideline 55 (for intrapartum care) [12] plus the Indonesian Ministry of Health Guideline of Normal Delivery Care for 2004 and 2008 [13,14].

Hip fracture: National Institute for Health and Care Excellence (NICE) Clinical Guideline 124 [15].

The tools were designed to capture whether specific evaluations, history-taking, and procedures were recorded in the medical records of sampled patients.

Sampling

A sample size of 30 was selected for each diagnosis. The dates of discharge for the selected medical records occurred within a year of the data collection period or slightly longer time, if it was required to capture an adequate sample size (Table 2). The UI data collectors obtained a list of all patients diagnosed with one of the four conditions and entered their names on a list in Excel database. They were then randomly ordered using the Excel random number generator and charts of the top 30 patients were selected for review (Table 3).

Table 2. Discharge dates for patient charts included in review

Vaginal delivery, AMI, pediatric pneumonia

Femoral neck fracture

Baseline July 2011 - June 2012 January 2011 - June 2012

Midline January 2013 - December 2013 July 2012 - December 2013

End-line July 2014 - June 2015 January 2014 - June 2015

Table 3. Number of Sample Size

Total

B M E

Vaginal Delivery 270 270 270

Pneumonia 270 269 270

AMI 270 273 270

HIP Fracture 145 235 232

Total 955 1047 1042

Data collection

The data collectors for the chart review were medical doctors and selected graduates from faculties of medicine of local universities. They could not be present or formers workers for the hospital in which they were collecting data. Two were recruited for each hospital. They were trained for three days on: the nature of the study and its protocol; the data collection process and instruments to be used; and research ethics and maintaining patient anonymity. Where possible, the same chart reviewers were used for all three data collection periods. This was the case for about 40% of data collectors. When other data collectors were hired, they underwent the same three-day training.

Once the charts were selected for inclusion in the study, the data collectors reviewed each chart in turn. It took the data collectors about two weeks to complete all chart reviews. The UI core team checked entries


on the checklists. Data from the checklists were then entered into databases for analyses by members of the UI core team.

Analysis

Data were analyzed for differences for all hospitals from before to after the implementation of JKN, and between JCI-KARS and KARS-only accreditation hospitals in the same manner described in Section I Chapter 1. For the payment method-based analyses, we separated the patients in the baseline period into those who had the types of coverage under BPJS that were first carried over into the JKN system from those patients who had non-BPJS coverage before JKN implementation. In this way, we could examine the difference-in-differences for BPJS and non-BPJS patients before and after implementation of JKN.

3. Results

This section presents the findings from the analysis of the chart review indicators from each of the four clinical areas in turn; first, by whether there was a change from before to after JKN and, second, by whether there was a difference between JCI–KARS accredited hospitals versus KARS-only accredited hospitals.

Delivery

Pre/post JKN

There was a statistically significant improvement in the recording of lacerations among BPJS patients compared to non-BPJS patients over the period. Birth weight and Apgar scores showed no such difference in improvements, but both indicators began at very close to full compliance at baseline (Table 4).

Table 4. Laceration, Apgar score, and birth weight recorded in normal delivery before and after JKN implementation

Variables Period Patients’ Medical Coverage

P Value Non BPJS BPJS n % n %

Laceration Before JKN 172/199 86 46/71 64 0.001*After JKN 67/81 82 165/189 87 0.321Difference -4% 23% Difference in difference 26% 0.001*

Apgar Score Within 5 Minutes

Before JKN 194/195 99 70/70 100 0.548After JKN 81/81 100 187/189 99 0.353Difference 1% -1% Difference in difference -2% 0.276

Birth Weight Before JKN 194/199 97 70/71 99 0.588After JKN 81/81 100 189/189 100 Difference 3% 1% Difference in difference -1% 0.582

*statistically significant

Pre/post accreditation

For the difference between changes in JCI-KARS and KARS-only accredited hospitals, there was a greater improvement in the JCI-KARS hospitals in overall medical examination recording but none of the other indicators, which started at a high level of compliance at baseline (Table 5).


Table 5. Medical examination recorded in normal delivery between pre- and post-accreditation hospitals

Variables Period Hospital Category

P Value KARS-only JCI-KARS n % N %

Medical Examination

Pre-accreditation 142/176 81 67/89 75 0.309Post- accreditation 147/180 82 84/90 93 0.010*Difference 1% 18% Difference in difference 17% 0.014 *

Laceration Pre-accreditation 145/180 81 73/90 81 0.913Post- accreditation 148/180 82 84/90 93 0.013*Difference 1% 12% Difference in difference 11% 0.120

Apgar Score Within 5 Minutes

Pre-accreditation 175/176 99 89/89 100 0.476Post- accreditation 178/180 98 90/90 100 0.316Difference -1% 0% Difference in difference 1% 0.692

Birth Weight Pre-accreditation 179/180 99 85/90 94 0.009*Post- accreditation 180/180 100 90/90 100 Difference 1% 6% Difference in difference 5% 0.008*


Pneumonia

Pre/post JKN

There was no difference between changes in the BPJS versus the non-BPJS patients from before to after implementation of JKN in the recording of elements of medical history for pneumonia (Table 6). There was also no significant difference for the recording of elements of the physical examination over the time periods and most began at a high level of compliance (Table 7).

Table 6. Respiratory symptoms and immunization recording in pneumonia before and after JKN implementation

Variables Time Patients’ Medical Coverage

P Value Non BPJS BPJSn % N %

Respiratory Symptoms

Before JKN 231/244 94 25/26 96 0.746After JKN 121/123 98 146/147 99 0.460Difference 4% 3%Difference in difference -1% 0.898

Immunization Before JKN 244/244 100 26/26 100 After JKN 102/123 83 129/147 88 0.261Difference -17% -12%Difference in difference 5% 0.419


Table 7. Recording of physical examination for pneumonia between before and after JKN


P Value Non-BPJS BPJSn % N %

Information of Basic Physical Examination

Before JKN 229/244 94 26/26 100 0.193After JKN 112/123 91 136/147 93 0.662Difference -3 -7%Difference in difference -4% 0.440

Temperature Before JKN 235/244 96 26/26 100 0.319After JKN 118/123 96 140/147 95 0.782Difference 0% -4%Difference in difference -4% 0.346

Respiratory Rate

Before JKN 241/244 99 26/26 100 0.570After JKN 118/123 96 140/147 95 0.782Difference -3% -5%Difference in difference -2% 0.625

Pulse Before JKN 237/244 97 26/26 100 0.382After JKN 115/123 93 141/147 96 0.371Difference -4% -4%Difference in difference 0% 0.923

Pre/post accreditation

For differences in medical history recording before and after the different accreditations for pediatric pneumonia patients, there was marked decrease among KARS-only accredited hospitals in recording immunization status (possibly related to a change in recording forms) with no difference detected in recording of respiratory symptoms (Table 8).

Table 8. Respiratory symptoms and immunization status recording for pneumonia patients for pre- and post-accreditation


P ValueKARS-only JCI-KARS n % n %

Respiratory Symptoms

Pre-accreditation 172/180 96 84/90 93 0.438Post-accreditation 179/180 99 88/90 97 0.218Difference 3% 4%Difference in difference 1% 0.861

Immunization Pre-accreditation 180/180 100 90/90 100 Post-accreditation 147/180 81 84/90 93 0.010*Difference -19% -7%Difference in difference 12% 0.010*


Hospitals that underwent KARS-only accreditation showed decreases in recording elements of physical examination while JCI-KARS accredited hospitals showed slight improvements in those indicators (Table 9).


Table 9. Physical examination recorded in pneumonia between pre- and post-accreditation


P Value KARS-only JCI-KARS n % N %

Information of Basic Physical Examination

Pre-accreditation 175/180 97 80/90 89 0.005*Post-accreditation 163/180 91 85/90 94 0.271Difference -7% 5% Difference in difference 12% 0.008*

Temperature Pre-accreditation 179/180 99 82/90 91 0.001*Post-accreditation 172/180 95 86/90 95 1.000Difference -4% 4% Difference in difference 8% 0.018*

Respiratory Rate

Pre-accreditation 178/180 99 89/90 99 1.000Post-accreditation 168/180 93 90/90 100 0.012*Difference -6% 1% Difference in difference 7% 0.025*

Pulse Pre-accreditation 176/180 98 87/90 97 0.588Post-accreditation 167/180 93 89/90 99 0.033*Difference -5% 2% Difference in difference 7% 0.040*


AMI

Pre/post JKN

There were no differences in improvement between BPJS and non-BPJS patients from before to after implementation of JKN. The levels of recording basic clinical findings were high and remained so for both groups (Table 10).

Table 10. Cardiac enzymes examinations and ECG in AMI patients between before and after JKN


P Value Non-BPJS BPJSN % N %

Cardiac enzymes examinations

Before JKN 153/166 92 93/104 89 0.440After JKN 66/70 94 187/200 93 0.816Difference 2% 4%Difference in difference 2% 0.693

ECG Before JKN 153/166 92 98/104 94 0.519After JKN 67/70 96 198/200 99 0.079Difference 4% 5%Difference in difference 1% 0.749

There were greater improvements overall in the non-BPJS patients with regard to recording of previous AMI and medical history, but all indicators for both groups showed improvements. Both groups of patient charts started at low levels of compliance in all indicators but recordings of hypertension and hypercholesterolemia (Table 11).


Table 11. Medical history recorded in AMI patient charts before and after JKN implementation


P ValueNon BPJS BPJS N % n %

Medical History Before JKN 3/166 2 2/104 2 0.945After JKN 11/70 16 14/200 7 0.030*Difference 14% 5% Difference in difference -9% 0.036*

Previous AMI Before JKN 34/166 20 24/104 23 0.613After JKN 33/70 47 57/200 29 0.004*Difference 27% 6% Difference in difference -21% 0.010*

Previous Angina Pectoris

Before JKN 47/166 28 34/104 33 0.445After JKN 48/70 68 125/200 63 0.362Difference 40% 30% Difference in difference -10% 0.235

Hypertension Before JKN 139/166 84 96/104 92 0.041*After JKN 69/70 99 199/200 100 0.436Difference 15% 7% Difference in difference -8% 0.095

Hypercholesterolemia Before JKN 103/166 62 66/104 63 0.815After JKN 57/70 81 158/200 79 0.664Difference 19% 16% Difference in difference -3% 0.646

Cerebrovascular Disease

Before JKN 21/166 12 12/104 12 0.786After JKN 29/70 41 81/200 41 0.892Difference 29% 29% Difference in difference 0% 0.981

Previous Heart Failure Before JKN 43/166 25 26/104 25 0.868After JKN 50/70 71 140/200 70 0.822Difference 46% 45% Difference in difference -1% 0.950

Diabetic Before JKN 112/166 67 64/104 62 0.319After JKN 65/70 92 191/200 96 0.391Difference 25% 34% Difference in difference 9% 0.218


For recording of basic information at discharge for AMI patients, there was also no statistically significant difference in improvements between BPJS and non-BPJS patient charts before and after JKN. Both BPJS and non-BPJS patient charts started with low levels of compliance and showed between 10% and 20% improvement (Table 12).


Table 12. Medication at discharge recorded in AMI patients between before and after JKN


P ValueNon BPJS BPJS n % n %

Medication at Discharge


Discharge on Oral Beta-Adrenergic Blocker


Discharge on Statin


Discharge on Aspirin/ Antiplatelet Agents



Pre/post accreditation process

ECG recordings improved move in KARS-only hospitals than JCI-KARS hospitals, with all hospitals reaching high compliance with this and the cardiac enzyme recording indicator (Table 13).

Table 13. Cardiac enzymes and ECG recording in AMI, pre- and post-accreditation


P Value KARS-only JCIKARS n % n %

Cardiac Enzymes Examinations

Pre-accreditation 162/180 90 84/90 93 0.364Post-accreditation 163/180 91 90/90 100 0.003*Difference 1% 7% Difference in difference 6% 0.204

ECG Pre-accreditation 162/180 90 89/90 99 0.007*Post-accreditation 177/180 98 88/90 98 0.750Difference 8% -1% Difference in difference -9% 0.011*


It was a mixed picture for recording of medical history for AMI, considering differences between JCI–KARS and KARS-only accredited hospitals. Recording of previous medical history of AMI, hypertension, and diabetes improved more in KARS-only hospitals while recording of previous cerebrovascular disease improved more in the JCI-KARS accreditation hospitals. Generally, improvements were seen in both hospital groups (Table 14).


Table 14. Medical history recorded for AMI patients’ charts, pre- and post-accreditation


P Value KARS-only JCI-KARS n % n %

Medical History Pre-accreditation 3/180 2 2/90 2 0.750Post-accreditation 14/180 8 11/90 12 0.235Difference 6% 10% Difference in difference 4% 0.347

Previous AMI Pre-accreditation 33/180 18 25/90 28 0.075Post-accreditation 64/180 35 26/90 29 0.273Difference 17% 1% Difference in difference -16% 0.046*

Previous Angina Pectoris

Pre-accreditation 54/180 30 27/90 30 1.000Post-accreditation 119/180 66 54/90 60 0.324Difference 36% 30% Difference in difference -6% 0.477

Hypertension Pre-accreditation 146/180 81 89/90 99 0.001*Post-accreditation 178/180 99 90/90 100 0.316Difference 18% 1% Difference in difference -17% 0.001*

Hypercholesterolemia Pre-accreditation 102/180 57 67/90 74 0.004*Post-accreditation 129/180 72 86/90 95 0.001*Difference 15% 21% Difference in difference 6% 0.443

Cerebrovascular Disease

Pre-accreditation 22/180 12 11/90 12 1.000Post-accreditation 53/180 29 57/90 63 0.001*Difference 17% 51% Difference in difference 34% 0.001*

Previous Heart Failure

Pre-accreditation 48/180 27 21/90 23 0.554Post-accreditation 126/180 70 64/90 71 0.851Difference 43% 47% Difference in difference 4% 0.587

Diabetic Pre-accreditation 102/180 56 74/90 82 0.001*Post-accreditation 168/180 93 88/90 98 0.121Difference 37% 16% Difference in difference -21% 0.002*


There was consistently greater improvement in recording of discharge medications in JCI-KARS accredited hospitals compared to KARS-only hospitals (Table 15).


Table 15. Medication at discharge recorded in AMI Patient charts, pre- and post-accreditation



Medication at Discharge


Discharge on Oral Beta-Adrenergic Blocker

Pre-accreditation 73/166 44 34/76 45 0.912Post-accreditation 88/152 58 55/82 67 0.169Difference 14% 22% Difference in difference 8% 0.382

Discharge on Statin


Discharge on Aspirin/Antiplatelet Agents



Hip fracture

Pre/post JKN

Antibiotic prophylactic recording improved more in BPJS patients after implementation of JKN compared to before (Table 16).

Table 16. Surgery and antibiotic prophylactic recording for hip fracture patient, before and after JKN implementation


P ValueNon-BPJS BPJS n % n %

Surgery Before JKN 56/96 58 37/49 76 0.0414After JKN 30/44 68 156/188 83 0.0267Difference 10% 8%

Difference in difference -2% 0.819

Antibiotic prophylactic Before JKN 46/56 82 19/37 52 0.0015After JKN 27/30 90 132/156 85 0.4432Difference 8% 33%

Difference in difference 25% 0.024*

Both BPJS and non-BPJS patient charts showed large improvements of about the same magnitude in recording of mobilization after surgery (Table 17).


Table 17. Mobilization after surgery recorded for hip fracture patient charts, before and after JKN implementation

Variable Time Patients’ Medical CoverageNon-BPJS BPJSn % n %

Mobilization after surgery

Before JKN 24/56 43 18/37 49 0.5828After JKN 22/30 73 131/156 84 0.1624Difference 30% 35%Difference in difference 5% 0.696

P Value

Pre/post accreditation process

There was statistically significantly improvement in recording of surgery and antibiotic prophylaxis among JCI-KARS accredited hospitals compared to KARS-only hospitals pre- and post-accreditation (Table 18).

Table 18 Surgery and antibiotic prophylaxis recording for hip fracture patients, pre- and post-accreditation



Surgery Pre-accreditation 48/65 74 45/80 56 0.028*Post-accreditation 98/141 70 88/91 96 0.001*Difference -4% 40%

Difference in difference 45% 0.001*

Antibiotic prophylactic Pre-accreditation 37/48 77 28/45 62 0.119Post-accreditation 77/98 79 82/88 93 0.005*Difference 2% 31%

Difference in difference 29% 0.003

There was a large improvement in both groups of hospitals from baseline to end-line in recording of mobilization after hip surgery (Table 19).

Table 19. Mobilization after surgery recorded for hip fracture patients, pre- and post-accreditation

Variable Period Hospital Category

P Value KARS-only JCI-KARS n % n %

Mobilization after surgery

Pre-accreditation 13/48 27 29/45 63 0.0003Post-accreditation 68/98 69 85/88 97 0.0001Difference 42% 32% Difference in difference -10% 0.316

4. Discussion

Overall, a mixed picture emerges from the chart reviews conducted for these four diagnoses. There is limited evidence of a difference from before to after JKN implementation among patient charts from those covered by BPJS compared to those not covered by BPJS in all indicators except recording of antibiotic prophylaxis for hip surgery patients. There was a decrease in BPJS patient chart compliance with respect to recording of AMI history, contrary to what was expected under the assumption that JKN


implementation would improve the quality of recording of patient medical and treatment histories. This could have been due to an increase in the average severity of the condition of the patients, adding to the degree of complexity of the medical charts.

Considering differences between JCI-KARS accredited hospitals and KARS-only hospitals, there was evidence of greater improvements in chart review indicators in the former for normal deliveries, pneumonia, AMI (clinical examination and discharge medications), and hip surgery. This finding supports the hypothesis that JCI-KARS accreditation facilitated greater improvements than KARS-only accreditation. It was noticed from observations during data collection in JCI-KARS accreditation hospitals that senior doctors supervised performance of residents more closely in response to JCI accreditation.

For surgeries, the use of the WHO Safe Surgery Checklist is included in both JCI and KARS accreditation standards. The finding of lower compliance in KARS-only hospitals with hip surgery indicators may indicate less rigorous application of accreditation under KARS evaluation.

It is noteworthy that the recording of history and discharge instructions for AMI started at a low level of compliance generally for all hospitals. While there were improvements, poor compliance remains a problem that may reflect low quality of care. An important quality of care indicator is whether those discharged from care following an admission for AMI were prescribed an ACE inhibitor, a beta blocker, aspirin and a statin – the standard evidence-based medications for management of that condition [16]. Not having this recorded in the medical record can be seen to indicate that this evidence-based medical practice was not followed or that the recording of patient treatment in the chart is unreliable. Both alternatives are a negative reflection on the quality of care provided for this, one of the most common causes of hospitalization in Indonesia [17].

5. Conclusion

JCI-KARS accreditation hospitals appeared to improve more than KARS-only hospitals, especially in AMI chart reviews. There was little difference between outcomes for BPJS and non-BPJS patients before and after implementation of JKN. Important quality deficits remained in several quality indicators.

References

1. Abdelrahman A, Abdelmageed A. Medical record keeping: clarity, accuracy, and timeliness are essential. BMJ Careers. 2014. 1(9).

2. Institute for Health Metrics and Evaluation, Global burden of disease: Indonesia. University of Washington: Seattle, Washington. 2017. Available at: http://www.healthdata.org/indonesia.

3. Mehta RH, et al. Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA. 2002. 287(10):1269-76.

4. Zhang S, et al. Cost of management of severe pneumonia in young children: systematic analysis. J Glob Health. 2016. 6(1):010408.

5. Palonen KP, et al. Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey. J Gen Intern Med. 2006. 21(3):226-30.

6. Hermida J, Broughton EI, Franco LM. Validity of self-assessment in a quality improvement collaborative in Ecuador. Int J Qual Health Care. 2011. 23(6):690-6.

7. Yan, LD, et al. Hypertension management in rural primary care facilities in Zambia: a mixed methods study. BMC Health Serv Res. 2017. 17(1):111.

8. Wagner C, Groene O, Thompson CA, Dersarkissian M, Klazinga NS, Arah OA, et al. DUQuE quality management measures: associations between quality management at hospital and pathway levels. Int J Qual Health Care. 2014. 26 Suppl 1:66-73.

9. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013. 61(4):e78-140.


10. World Health Organization. Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations: newborn conditions, dysentery, pneumonia, oxygen use and delivery, common causes of fever, severe acute malnutrition and supportive care. Geneva, Switzerland. 2012.

11. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community-acquired pneumonia in children: update 2011. Thorax. 2011. 66 Suppl 2:ii1-23.

12. National Institute for Health and Care Excellence, Intrapartum care for healthy women and babies: CG 190. London, UK. 2016.

13. Ministry of Health of Republic of Indonesia. Asuhan Persalinan Normal (Normal Delivery Care). Jakarta, Indonesia. 2004.

14. Ministry of Health of Republic of Indonesia. Clinical Practice of Normal Delivery. Jakarta, Indonesia. 2008.

15. National Institute for Health and Care Excellence, Hip fracture management: CG 124. London, UK. 2011.

16. Fornasini M, Yarzebski J, Chiriboga D, Lessard D, Spencer FA, Aurigemma P, et al. Contemporary trends in evidence-based treatment for acute myocardial infarction. Am J Med. 2010. 123(2):166-72.

17. Dharma S, Juzar DA, Firdaus I, Soerianata S, Wardeh AJ, Jukema JW. Acute myocardial infarction system of care in the third world. Neth Heart J. 2012. 20(6):254-9.


Chapter 4. Key Informant Interviews

Overview

The pattern noted from discussions with key informants was that JCI accreditation was more thorough and taken with greater seriousness than KARS accreditation but that the latter was improving in terms of its consistency and rigor over the last year. Implementation of JKN initially placed financial and logistical pressure on hospitals, more so on the KARS-only group, but these have been ameliorated recently through better coordination with BPJS.

1. Introduction

We conducted key informant interviews with hospital personnel directly involved in the accreditation process to collect information on changes that occurred in the nine hospitals undergoing accreditation from 2012 to 2016. Key informants included members of accreditation committees, hospital directors, medical department heads, chiefs of hospital units, and claims and insurance verification staff. Supporting information from hospital data was also used. Given that JKN was initially implemented in 2014 and was such an important factor in this study, we also interviewed BPJS officers based in the hospitals and local BPJS offices.

Questions for hospital staff centered on the process for accreditation including constraints, impacts, and its influence of service quality. Informants were also asked about information systems, procedures for inpatient and outpatient reporting, and performance indicators. Interviews with BPJS personnel were to assess implementation of JKN, including current collaboration systems with hospitals, trends in patient visits (diagnoses, severity level, regionalization, and payment method), claims mechanisms, and their opinion on the implication of JKN implementation for hospital service quality.

All participants gave informed consent and interviews were audio-recorded, then transcribed for analysis. Responses were coded and analyzed for common themes emerging on the topics listed above. The quotes presented are of some of the typical responses from several respondents.

2. Key findings and discussion

Human resources and leadership commitment

In response to accreditation, hospitals were more concerned with improving competencies of their human resources, including building clinical skills and continuous professional development (CPD) programs for medical staff. This was done through conducting training activities, planning human resource development and providing financial assistance for medical staff who wish to continue with higher education or a specialist program. CPD programs were organized according to the hospital’s needs and related to their Centers of Excellence. Training was organized for existing staff and new employees. Each individual unit was also required to prepare a human resource development plan for submission to the hospital’s Training and Development Unit to coordinate the needs of the unit with those of the hospital.

Three of the five JCI-KARS hospitals reported preparing their staff in accordance with human resources accreditation standards and guidelines in preparation for JKN implementation. This contrasts with the KARS-only hospitals, which generally had difficulty in filling the open positions for qualified staff in order to maintain the standards for Class-A hospital classification, as given by the central and local governments. The KARS-only hospitals reported problems with staff turnover and stated that some service providers lacked training and skills in key competencies, which negatively affected overall service performance.

“The key was to strengthen human resources in all aspects, from the composition [of the workforce] and their competencies [to] the numbers. We need to improve this issue.” (Hospital D: JCI-KARS group)


To overcome human resources limitations, some hospitals recruited additional short-term employees, rather than permanent staff, to give flexibility in the hospital budget for adjustments in workload according to the patient census. Such cost-cutting was thought to have negatively impacted service quality. Most JCI-KARS hospitals were in a better financial situation and able to afford qualified staff to deliver service according to standards.

“... impact has occurred in all aspects: services, human resources, infrastructure, financial efficiency and everything. In my opinion, the spirit continues and improvement has occurred in all aspects.” (Hospital D: JCI-KARS group)

Hospital service quality also depended on the leaders’ management and commitments and the support they received from all staff, especially during accreditation. In JCI-KARS hospitals, the leaders’ commitment persuaded staff members to stay committed to the strategic plan and achieve the expected outputs. In KARS-only hospitals, communication and coordination among management and staff was not optimal. It was reported that the lack of commitment from top management was a major obstacle to fulfillment of accreditation standards. Unclear guidance led to staff blaming each other for deficiencies in some KARS-only hospitals.

“The director position for the hospital is given from the central government. Huh? We are not involved in (this decision). That's what bothered me – I often criticized it. How was it? On the other hand, I was being asked to achieve a set of indicators. But I was given staff who I did not know at all. I had never collaborated with them previously… Their performance I did not know. Well, it became very difficult to manage. So, I think the selection of the director need to involve the hospital’s managers.” (Hospital F: KARS-only)

“Leader’s commitment, from the top level to lower levels, also includes strong monitoring and evaluation. [The hospital director] was very strong. For example, when he gave a task associated with an accreditation standard, he would follow-up and closely supervised each unit within the hospital.” (Hospital C: JCI-KARS)

“Well, the leaders have to understand the SOPs. I am sorry that many people do not know their job description. If they knew it very well, and complied [with] the standard, the system would be implemented well.” (Hospital H: KARS-only)

Work culture

In JCI-KARS hospitals, work culture changes were reportedly easily visible. An informant noted that due to accreditation, physicians were more open to accepting input and showed commitment to improving medical services. Culture changes were seen from the top management down to functional units. Punishment, such as remuneration downgrading and issuance of warning letters, was reportedly given to those who did not comply with hospital policies. In KARS-only hospitals, work culture changes due to the accreditation process were reported to be transient – not enduring beyond the inspection period. It was noted by informants that there was a less visible commitment from leaders.

“The ‘blaming culture’ exists in this hospital. That is why we do not improve more. Other people know it. Commitment and leadership from the top management is lacking.” (Hospital H: KARS-only)

Document completion for accreditation

Document assessments were conducted in both KARS and JCI accreditation processes. In JCI-KARS hospitals, documents were generally being maintained according to accreditation standards. In the KARS-only group, there were more efforts required to maintain standardization and there was reported to be a gap between the standards seen and those expected for accreditation.


One interesting finding was that despite KARS standards reportedly originating from JCI standards—and essentially replicating them—KARS had more rigorous requirements for documentation. For example, under KARS accreditation hospitals must prepare documents such as policies, manuals, and guidelines for certain operating standards. With the JCI accreditation there was no specific type of documentation required, as long at the document (whether policy, manual, or guidelines) fulfilled the standard by being up to date.

Clinical pathway and medical record

Developing clinical pathways was seen by hospitals as one possible way to improve the quality of care and reduce hospital costs in response to implementation of JKN. Hospitals had independent authority to determine for which cases they formulated and implemented clinical pathways. Some JCI-KARS hospitals had already developed pathways and applied them for several diagnoses. KARS-only hospitals were at an early stage of developing such pathways and were yet to implement them in a systematic way.

“Clinical pathway trial had been started before accreditation. Currently, we are in the stage of improving the quality of implementation and development. Implementation of clinical pathway by doctors will be included in the human resources performance assessment.” (Hospital D: JCI-KARS)

The medical record system is one of the main assessment domains for KARS and JCI accreditation. It has also gained in importance with JKN implementation because of its link with claims processing. All hospitals were reported to have implemented various changes in medical records systems. However, completion of clinical records of some hospitals remained low, particularly in the KARS-only group. This adversely affected accreditation scores and caused delays and rejection of payment for claims to BPJS for patient services. Some JCI-KARS hospitals already had well-functioning medical record systems, with adequate human resources and high work standards before JKN implementation, and this led to a higher proportion of medical records being completed appropriately.

“The constraint is incomplete medical record. Until the last moment we invite the doctors [to revise and complete medical records]. Usually medical records [department] is requested to open the records, then we find there are many medical records incomplete.” (Hospital F: KARS-only)

“Yes - the behavior. Now the completeness of medical records was not achieved. Medical records were not completed and consequently the claims [for payment from BPJS] were also low.” (Hospital H: KARS-only)

The respondents recognized that medical records and clinical pathways are important factors that can benefit both hospitals and patients and help determine whether the quality of service provided is in accordance with set standards. Individual decisions by service providers greatly affect the consistency of using clinical pathways and compliance with record completion. Responses from the key informants provided additional evidence supporting the results from the data extraction section of this study indicating that there were wide variations in the degree of completeness of medical records. In some JCI-KARS and KARS-only hospitals, medical record completeness is the responsibility of the doctor in charge, who may not be supervised or held accountable in this task. Though the hospital also placed case managers to monitor this process in hospital units, they only focused on the completeness of medical record not the quality. Furthermore, observation in some of the hospital units, especially those that did not have medical residents, showed that medical record completeness was more the responsibility of nurses.

“Many medical record are incomplete... The case manager should not only complete the medical record, but also bridge communication with the DPJP [doctor in charge] if there are any medical issues that need to be further confirmed. But what happens is still the opposite.” (Hospital H: KARS-only)


“The hospital also conducts open medical reviews and closed medical reviews to assess the quality of medical record completeness.” (Hospital D: JCI-KARS )

During accreditation, all hospitals revised their medical record forms to comply with the standard of medical record completeness and to be better accepted by clinical staff. Several hospitals visited other hospitals to learn about how to improve medical record documentation.

Remuneration

Referring to information from Hospitals B & D, by the end of 2017, nearly 90% of patients received financial coverage for hospital stays from JKN. The system has its package payment mechanism, whereby hospitals are reimbursed according to a formula based on the type of hospital, its location, and several other factors. It was reported that hospitals use this remuneration system to calculate reimbursement to staff. Remuneration patterns varied among hospitals, and it was reported by the JCI-KARS hospitals that they had implemented remuneration systems that were generally functioning well. The formulation involved functional medical staff and other managers according to the income that they were involved in generating and was designed to minimize the income gap among clinicians, which could lead to clinician dissatisfaction. In some KARS-only hospitals, because the system was not as well developed, there was dissatisfaction among staff over perceived inequities and the lack of transparency in remuneration decisions by hospital management.

“I think we are still looking for the ideal formula for remuneration. It is still long way to have a stable formula.” (Hospital B: JCI-KARS)

“How to manage clinicians? In here, remuneration is already performing well.” (Hospital D: JCI-KARS)

“Yes – in this hospital a good remuneration is given. We evaluate doctors according to their expertise. We approached them professionally, by involving hospital committees.” (Hospital D: JCI-KARS)

Ministry of Health’s support

All hospitals in the study are administered by the MOH except Hospital G, which is administered by the provincial government. To achieve accreditation status, each hospital allocated funds to improve facilities, infrastructure, compliance standards, and the quality of human resources. Hospitals also allocated resources directly for financing the accreditation itself, which covered costs of the mock survey and the assessors. The JCI-KARS group has budgeted more than US $148,000 for accreditation each, while KARS-only group budgeted approximately US $22,000 for KARS accreditation. Financing from the central government assisted all study hospitals by procuring medical equipment or paying for infrastructure renovation directly. However, only the eight MOH hospitals received direct assistance or financing for the accreditation process costs, including the cost of the mock surveys.

“Actually, MOH helped us by providing around [$148,000 USD]. Uh-huh. Well, now we are trying [paying] with our own efforts.” (Hospital A: JCI-KARS)

“For the mock survey, we were funded by MOH for [$110,000 USD]; mock and final surveys, around [148,000 USD]. If hospitals must pay themselves, who is willing to?” (Hospital B: JCI-KARS)

“We received MOH’s assistance for medical facilities...” (Hospital F: KARS-only)

Hospital reporting, monitoring & evaluation (M&E) from MOH

Annual reporting of quality performance indicators by hospitals was not yet standardized in all hospitals at the time of data collection. There was variability in the amount of information and the formulation of quality indicators, but all hospitals did have some form of annual reporting. By 2017, the MOH was still


encouraging hospitals to complete performance reporting regularly. Appreciation rewards were given to hospitals for compliance in reporting as one effort that had been implemented.

Several informants suggested that hospitals should be regularly monitored and evaluated from the MOH. Most felt that provision of this form of oversight had been minimal up to the end of 2017 and that it could be strengthened. It was stated that the MOH should serve as the authority to monitor and provide guidance based on findings, but this had not been done to a degree considered adequate by the time of data collection. There was in fact almost no objective feedback provided by the MOH on hospital performance.

Improvement strategy

Improvement efforts had been undertaken by all hospitals to pass accreditation and in response to JKN implementation. Generally, the JCI-KARS and KARS-only groups used different improvement strategies. The JCI-KARS group developed long-term strategies with the aim of sustaining improvements beyond the period of accreditation. These improvements were also implemented at the unit level; for example, improving medical records quality started with training the staff in the medical record department, updating SOPs ensuring adherence to the SOPs, and discussing with clinicians their part in the medical records process. Some hospital managers even punished clinicians who did not improve medical record completeness. It was generally reported that the improvement activities were more intensive and better organized in JCI-KARS group, and the results were much better there, than in the KARS-only group.

Informants from Hospital D mentioned that the names of doctors who had not completed the mandated medical records (pre-surgery assessment notes and completed surgery reports) were shared during a presentation at weekly meetings. Also, medical staff were sometimes called individually to ensure they completed the assessment forms. Other hospitals reported conducting regular medical record reviews.

“Well, they conduct regular closed medical record review and open medical record review. To some extent, it was difficult to encourage clinicians to comply with medical records completeness standard. But if we compare it with the past, current compliance is very much better.” (Hospital C: JCI-KARS)

Accreditation process

The quality of the KARS surveyors was a subject of discussion for all key informants. When compared to JCI surveyors, who were reportedly very consistent with their application of the quality standards, the KARS assessors varied greatly in theirs, depending on their interpretation of the content of the standard they were measuring. For this reason, the quality of JCI surveyors was rated much higher in terms of consistency, clarity, and the ability to understand the application of the measure in the hospital context.

“KARS assessed more of the documents preparation. That is the difference between KARS and JCI. JCI measured whole process, from the main problem into the solutions. They assessed from policies, SOPs, and they evaluated the implementation of those policies in very great detail.” (Hospital E: JCI-KARS)

“More detail, I mean JCI is more detail-oriented in the implementation and explanation... Meanwhile KARS really depends on the surveyor.” (Hospital C: JCI-KARS)

Sometimes there were inconsistencies between the findings of JCI-KARS surveyors. For example, in one hospital, a KARS accreditor assigned a high score for infection control indicators while a JCI surveyor found some aspects in infection control did not initially meet the accreditation standards and the deficiency needed to be rectified before accreditation was granted.

Both JCI and KARS have passed the “Accreditation of Accreditors” process conducted by the International Society for Quality in Health Care (ISQua). However, JCI accreditation reportedly focused more on the assessing implementation rather than document examination. JCI measured the


implementation of the SOPs or standards that have been developed by each hospital. The JCI assessment was reported to be straightforward but detailed and comprehensive. Coordination and integration among JCI surveyors was reported to be much better even though they came from different professional backgrounds and did the accreditation work only on an ad hoc basis.

KARS accreditation generally was reported to be more focused on the examination of documents and written SOPs and was considered weak in measuring the implementation of standards of care described in those documents. Some informants stated that in the beginning of KARS adoption of their updated standards (KARS version 2012), their implementation of accreditation was poor and the quality of their surveyors was considered lacking. However, in the more recent accreditations performed, there was reported to be an improvement. More attention was placed on implementation of the SOPs, and generally there was more rigor noted with the survey and greater consistency in the results seen by key informants in the hospitals. Measurement by KARS-only accreditors was still considered by all informants as more fragmented with some inconsistencies remaining between documentation and implementation of the standards. However, the improvements seen were appreciated.

“From the accreditation process, the integration among surveyors… JCI surveyors [each] have their own specialization – nurses, physician, administrator – but they integrate smoothly with each other. Not so with the KARS [surveyors]: They are not integrated and the implementation of KARS is relatively superficial.” (Hospital D: JCI-KARS)

Another consistent finding was the profound effect that implementation of JKN had on the operations in the hospital. It is logical that imposition of the massive single-payer universal health insurance system would affect health providers of all types, including hospitals. The main impacts on these hospitals appeared to be in several areas of operation. One is that hospitals were unprepared for the transition from the fee-for-service model to the INA-CBG (Indonesian diagnosis-based group capitation system). It was reported that payment for some diagnoses were not commensurate with the resources consumed to provide services to adequately treat patients with those diagnoses.

Another was the length of time taken for verification of the claims for reimbursement from BPJS. If the verification review found deficits in the medical records that failed to substantiate the claims for payment for treatment, there was an even greater delay until the problem could be rectified, if possible, before payment was completed. There was also the need for reallocation of resources in the hospital to improve the quality of medical records for better preparation of claims for submission to BPJS to improve reimbursement.

Another was a change in case mix at the hospital because JKN imposed a more rigorous referral system that generally meant that only the more serious cases were receiving services at the type A hospitals.

However, it was generally reported that implementation of JKN has increased the overall revenue of the hospitals once the initial issues with its start-up had been overcome. It has also increased the overall in-patient load.

3. Discussion

It was clear from all discussions with key informants from the hospitals that there was still a substantive difference between JCI-KARS accreditation despite the content being the same for most of the standards. JCI accreditation was seen to be more consistent and more rigorous in its application of the standards and the accreditors seemed better trained in conducting the assessments. This is consistent with recent findings that JCI accreditation is associated with better hospital performance than national accreditation alone [1]. However, informants who had more recent exposure to KARS accreditors stated uniformly that they seemed to have improved in their manner of conducting accreditation inspections. This is consistent with public comments made by the director of KARS at the HAPIE dissemination meeting, “Hospital


Services Quality in the JKN Era” (March 29, 2017) that there was improvement in the training of KARS accreditors and that more accreditors were being deployed.

It became apparent from key informant interviews that there was a difference in the responses of the hospitals to both accreditation and JKN implementation. It appeared that those in the JCI-KARS group were better prepared and had more engaged and activist leadership in the accreditation process and the changes required by that process than the those in the KARS-only group. It was not possible from this study to determine whether this was a result of the accreditation process or because of the non-randomized selection of hospitals to undergo additional JCI accreditation. The latter seems plausible as it was stated by the MOH in 2012 that the hospitals they chose to undergo JCI accreditation and the two hospitals the decided later to submit to the additional JCI accreditation elected to independently based on their perceived likelihood of success. The JCI hospitals did receive additional funds; not only for the fees associated with accreditation but also for other capital improvements.

Implementation of JKN had a profound impact on hospital operations. Details of individual hospital responses to implementation of JKN are reported in Section II of this report.

4. Conclusion

The pattern noted from discussions with key informants was that JCI accreditation was more thorough and taken on with more seriousness than KARS accreditation, but that the latter was improving over the last year in terms of consistency and rigor. Implementation of JKN initially placed financial and logistical pressure on hospitals, more so on the KARS-only group, but these have been ameliorated recently through better coordination with BPJS.

References

1. Um MH, Lyu ES, Lee SM, Park YK. International hospital accreditation and clinical nutrition service in acute care hospitals in South Korea: results of a nationwide cross-sectional survey. Asia Pac J Clin Nutr. 2018;27(1):158-66.


II. FINDINGS FROM INDIVIDUAL HOSPITALS

Chapter 1. Hospital A

1. Description

Hospital A is located in small, densely populated regional city in Java. The region has 43 public hospitals, 32 private, non-profit hospitals, 50 private, for-profit hospitals, and 4 hospitals owned by national companies (for employees and their families). There are also 61 specialty hospitals; for example, cardiac and cancer hospitals. Five of the region’s hospitals are type A hospitals, with three of those public facilities.

Hospital A is a type A national referral facility with 719 beds. It is a “center of excellence” and national referral hospital for patients with spinal diagnoses. It is primarily funded by the central MOH and is a satellite teaching hospital for some Indonesian universities, mostly for medical residents. The hospital was accredited by KARS in December 2012 and by JCI in October 2016 (Figure 16).

Figure 16. Timeline for accreditation of Hospital A

KARS 2007 ‐ 16 Service Accred (Jan)

2008KARS 2007 ‐16 Service Accred (Dec))

2010

• ISO‐OHSAS Accred (Dec)

2011

• Baseline Data Collection (Jan)

• KARS 2012 Accred (Jan)

• JCI Accred (Dec)

2013Midline Data

Collection (Mar)

2014Re‐accreditation of KARS 2012 (Dec)

2015

• End‐line Data Collection (June‐July)

• Re‐Accredited JCI (Oct)

2016

2. Results

Hospital-reported data

Hospital A showed little change in some indicators, such as emergency response time and pre-operative waiting times (Table 20). Other indicators, such as bed occupancy rate, average length of stay, and bed turn over interval, fluctuated from 2011 to 2015 (Figures 17-20).

Table 20. Hospital-reported basic performance indicators, Hospital A, 2011 to 2015

Variables MOH Standard*

Phase (Year) Baseline

(2011) Midline (2013)

End-line (2015)

Emergency response time (minutes)

< 5 < 5 < 5 < 5

% deaths in ER <2 2 3 3.2 Prescription drug service waiting time (minutes)

< 30 minutes 38 30 108

Pre-operative waiting time (days)

< 2 2 2 2


Figure 17. Bed occupancy rate, Hospital A, by phase

Note: MOH is standard is 60-80%; B: baseline; M: midline; E: end-line

Figure 18. Average length of stay, Hospital A, by phase

72.969.5

77.4

B (2011) M (2013) E (2015)

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Percentage

6.56.2

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Days

Note: MOH standard is 6-9 days


Figure 19. Bed turnover interval, Hospital A, by phase


Figure 20. Bed turnover, Hospital A, by phase

2.5

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Hospital review

Hospital A review results showed high scores at the beginning of the study compared to the other eight hospitals. The hospital governance score increased slightly in the midline, after JCI accreditation, then decreased slightly at end-line (Figure 21). Almost all domains increased from baseline to end-line, and almost all domains were higher for Hospital A than the mean scores of the other eight hospitals except for human resource at baseline (Figures 21-30). However, the human resource domain has increased greatly in the midline period and remained consistent at the end-line (Figure 23). It also had the highest maximum score compared to the other eight hospitals. It continuously improved patient orientation and was consistently higher than the other hospitals (Figure 22). Clinical practice, hospital-acquired infection, facility management, and medication safety all showed same pattern (Figures 24-27). For documentation and records, there was a slightly decrease at the end-line (Figure 30).

Hospital governance

Figure 21. Hospital governance by phase, Hospital A vs. 8 other hospitals

Patient orientation

Figure 22. Patient orientation by phase, Hospital A vs. 8 other hospitals

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Figure 23. Human resource by phase, Hospital A vs. 8 other hospitals

Clinical practice and patient care

Figure 24. Clinical practice and patient care performance by phase, Hospital A vs. 8 other hospitals

Healthcare-associated infection

Figure 25. Healthcare-associated infection performance by phase, Hospital A vs. 8 other hospitals

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Figure 26. Transfusion by performance phase, Hospital A vs. 8 other hospitals

Facilities management

Figure 27. Facilities management by performance phase, Hospital A vs. 8 other hospitals

Medication safety

Figure 28. Medication safety performance by phase, Hospital A vs. 8 other hospitals

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Surgery, interventional procedures, and accompanying anesthesia

Figure 29. Surgery, interventional procedures, and anesthesia performance by phase, Hospital A vs. 8 other hospitals

Documentation and records

Figure 30. Documentation and records performance by phase, Hospital A vs. 8 other hospitals

Organizational audit (4 department - average)

Based on 10 criteria assessments in the four departments, Hospital A demonstrated an increase in each successive phase. The orthopedic department showed an increase at end-line, while other departments improved from baseline to midline and were stable from midline to end-line (Figures 31-34).

The total scores for orthopedics, obstetric, and pediatric departments were higher than in the other eight other hospitals, while the internal medicine/cardiology unit was slightly lower. A higher score in the Orthopedic Department was expected as this hospital is a designated as a center of excellence for orthopedics.

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Figure 31. Key organizational audit criteria in Obstetric Department, Hospital A vs. 8 other hospitals

Figure 32. Key organizational audit criteria in Pediatric Department, Hospital A vs. 8 other hospitals

Figure 33. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital A vs. 8 other hospitals

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Figure 34. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital A vs. 8 other hospitals

Chart review (4 diagnoses)

Delivery

For vaginal delivery, most patients in A hospital had financial coverage from Jampersal (universal coverage for maternity care) in the baseline period. There was an increase in the proportion using Jamkesmas (insurance for those with low income) at the midline, but Jampersal still covered a high proportion. However, with BPJS implementation of JKN, most normal delivery patients were covered by JKN. In 2014, BPJS was implemented at all hospitals administered by the national government and at some private hospitals. The proportion using JKN in the end-line was higher for Hospital A than at all other hospitals in the study (Table 21).

The average length of stay did not change significantly over the study period (Figure 35).

Table 21. Method of payment for normal delivery patients by phase, Hospital A vs 8 other hospitals

A 8 hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 13.3 0.0 20.0 37.5 25.4 19.6Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0Government insurance 6.7 6.7 0.0 14.2 6.3 0.0Insurance for the poor/Jamkesmas 13.3 66.7 0.0 21.3 24.6 4.2Jampersal 66.7 26.7 0.0 25.0 33.3 0.0BPJS 80.0 68.8Others 0.0 0.0 0.0 0.0 0.0 5.0Do not know 0.0 0.0 0.0 1.7 10.4 2.5

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100

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Figure 35. Average length of stay for normal delivery patients by phase, Hospital A vs. 8 other hospitals

Figure 36. Age of normal delivery patients by phase, Hospital A vs. 8 other hospitals

The patients’ condition at discharge were recorded for a high proportion of patients in midline and end-line. However, there was a slightly decrease from midline to end-line (Table 22).

Completeness of medical records for normal deliveries was high for all three periods. Apgar score and birth weight, indicators reported on birth certificates, remained at 100% from baseline to end-line (Figures 37, 38, and 39).

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Table 22. Condition of normal delivery patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals

Baseline Midline End‐line Baseline Midline End‐line

Cured/improving 13.3 0.0 20.0 37.4 25.4 19.6Refer to other hospital 0.0 0.0 0.0 0.4 0.0 0.0Death 6.7 6.7 0.0 14.2 6.3 0.0Judicial discharge 13.3 66.6 0.0 21.3 24.6 7.1Other 66.7 26.7 0.0 25.0 33.3 0.0Transferred to outpatient 80.0 65.8Unknown 0.0 0.0 0.0 0.0 0.0 5.0

Figure 37. Laceration recorded of vaginal delivery patients by phase, Hospital A vs. 8 other hospitals

Figure 38. Apgar score recorded for normal delivery newborns by phase, Hospital A vs. 8 other hospitals

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Figure 39. Birth weight recorded for normal delivery newborns by phase, Hospital A vs. 8 other hospitals

Pneumonia of children under five years

The age and sex distribution of pediatric pneumonia cases did not vary substantially between hospitals or across phases of the study (Tables 23 and 24 and Figure 40).

Table 23. Age category distribution of pneumonia patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Age (months) Baseline Midline End-line Baseline Midline End-line< 1 3.3 3.3 6.7 1.7 20.2 15.01 - 11 60.0 56.7 53.3 54.2 48.3 37.912 - 23 23.3 13.3 26.7 25.8 18.1 26.724 - 35 6.7 26.7 3.3 11.7 7.6 11.736 - 47 6.7 0.0 3.3 5.4 4.2 6.748 - 59 0.0 0.0 6.7 1.3 1.7 2.1

Table 24. Sex distribution of pneumonia patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineMale 50.0 63.3 66.7 49.6 53.1 53.8Female 50.0 36.7 33.3 50.4 46.9 46.3

Figure 40. Mean age in months of pneumonia patients by phase, Hospital A vs. 8 other hospitals

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The trend in changes for method of payment for pneumonia patients was not different from that seen with vaginal delivery patients. Pneumonia patients were mostly covered by JKN, higher than in the eight other participating hospitals, while the proportion of out-of-pocket payers was still high (Table 25). Lengths of stay for pneumonia patients did not change significantly over the whole period (Figure 41).

Table 25. Method of payment of pneumonia patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals

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End-line

Out of pocket 36.8 20.0 26.7 61.6 52.6 33.8Commercial insurance 3.3 0.0 0.0 1.3 0.0 0.0Governance insurance 13.3 6.7 0.0 9.2 6.3 0.0Insurance for the poor 43.3 73.3 0.0 24.5 31.8 11.7Others, specified 3.3 0.0 0.0 1.3 1.3 2.5BPJS 0.0 0.0 73.3 0.0 0.0 50.7Do not know 0.0 0.0 0.0 2.1 8.0 1.3

Figure 41. Lengths of stay of pneumonia patients by phase, Hospital A vs. 8 other hospitals

The clinical chart review for pneumonia patients showed a marked increase in the proportion of those with an unknown condition at discharge (unrecorded) (Table 26). Medical history and basic physical examination did not change significantly across the three time periods (Figures 42-46).

Table 26. Pneumonia patient condition at discharge by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals


End-line

Cured/improving 40.0 80.0 60.0 70.4 59.4 67.5Refer to other hospital 3.3 3.3 0.0 0.8 1.3 0.0Death 13.3 13.3 10.0 5.0 12.6 12.5Not cured, judicial discharge 6.7 3.3 0.0 15.0 13.4 10.8Others 33.3 0.0 0.0 2.1 0.0 0.0Control and outpatient 0.0 0.0 0.0 0.0 1.7 0.8Unknown 3.3 0.0 30.0 6.7 11.7 8.3

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Figure 42. Respiratory symptom recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals

Figure 43. Immunization recorded for pneumonia patients by phase, Hospital A vs. 8 other

hospitals

Figure 44. Respiratory rate recorded pneumonia patients by phase, Hospital A vs. 8 other

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Figure 45. Temperature recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals

Figure 46. Pulse recorded for pneumonia patients by phase, Hospital A vs. 8 other hospitals

AMI

The average age of AMI patients did not vary much by phase (Figure 47). Lengths of stay for AMI patients appeared to decrease from baseline to end-line, from 12 days down to 8.9 (Figure 48). More than three quarters of patients were covered by JKN in the end-line period, after implementation by BPJS, a higher proportion than in the other eight hospitals (Table 27).

The proportion of patients reported to have died from AMI in hospital A deceased at end-line to 0. However, the proportion of patients who did not have their condition reported on discharge increased to more than one third at the end-line (Table 28).

Use of cardiac enzyme tests and electrocardiograms remained high across hospitals and phases (Figures 49 and 50). While there was improvement in oral beta-adrenergic prescription, it started from a very low baseline and was still prescribed to fewer than 50% of AMI patients at discharge at end-line (Figure 51). The proportion of patients who had prescriptions for an oral beta adrenergic, statin, and/or aspirin appeared to improve slightly from baseline to end-line. By end-line, more than 90% of AMI patients had received a prescription for statins and aspirin at discharge (Figures 52 and 53).

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Figure 47. Average age of AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 48. Length of stay of AMI patients by phase, Hospital A vs. 8 other hospitals

18

Table 27. Methods of payment recorded of AMI patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 26.7 6.7 20.0 37.9 35.8 16.7Commercial insurance 6.7 0.0 0.0 0.4 0.4 0.4Governance insurance 13.3 30.0 0.0 41.7 28.0 0.0Insurance for the poor 50.0 63.3 3.3 17.5 28.8 4.6Others 0.0 0.0 0.0 0.0 0.4 4.6BPJS 76.7 72.9Do not know 3.3 0.0 0.0 2.5 6.6 0.8

Table 28. AMI patient condition recorded at discharge by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 33.3 70.0 53.3 65.8 64.6 66.7Refer to other hospital 0.0 0.0 3.3 0.0 0.0 0.0Death 13.3 16.7 0.0 10.0 11.1 15.0Not cured, judicial discharge 6.7 13.3 6.7 12.5 5.8 5.8Others 36.7 0.0 0.0 4.2 1.7 0.0Control and outpatient 0.0 0.0 0.0 0.0 8.6 1.3Unknown 10.0 0.0 36.7 7.5 8.2 11.3

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Figure 49. Cardiac enzymes examination recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 50. ECG examination recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 51. Oral beta-adrenergic recorded for AMI patients by phase, Hospital A vs. 8 other

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Figure 52. Statins recorded of AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 53. Aspirin prescription recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figures 54-60 show medical history recording had improved from baseline to end-line. Most indicators were very low in baseline, such as recording previous history of AMI, angina pectoris, cerebrovascular, or heart failure (Figures 54, 55, 58, and 59). Some indicators, such as previous AMI (Figure 54) and health failure recorded (Figure 59), were still very low at end-line. Recording of other important aspects of a patient’s medical history, such as history of angina pectoris (Figure 55) or cerebrovascular accident (Figure 58), improved substantively from baseline to end-line, but overall there remained major deficits in the completeness of AMI patient medical chart records from this sample.

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Figure 54. Previous AMI history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 55. Angina pectoris history recorded of AMI patients by phase, Hospital A vs. 8 other

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Figure 56. Hypertension history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

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Figure 57. Hypercholesterolemia history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 58. Cerebrovascular accident history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

Figure 59. Heart failure history recorded for AMI patients by phase, Hospital A vs. 8 other hospitals

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Figure 60. Diabetic history for AMI patients by phase, Hospital A vs. 8 other hospitals

Hip/femoral neck fracture

We were only able to review 20 clinical charts for hip/femoral neck fracture patients during the baseline period of 1.5 years in Hospital A. The inclusion criteria were reviewed to ensure that all upper femoral fractures were included in the midline and end-line. There was an increase in the age of patients admitted for this diagnosis over the period from less than 40 to almost 70 years of age (Figure 61). The average length of stay of hip fracture patients did not show any significant change except decreasing variability (Figure 62). Almost all patients had their medical expenses covered by JKN by the end-line period, and this was higher in Hospital A than in the other eight hospitals (Table 29). The percentage of patients who had surgery increased from 35% at baseline to over 95% at end-line (Figure 63).

Figure 64 shows that antibiotic prophylaxis declined slightly while compliance with mobilization after surgery (Figure 65) was constantly high from baseline to end-line (100%), which was different compared to the other eight hospitals, which had low compliance at baseline and showed only slight improvement by the end-line. There was an increase in the use of thromboembolism prophylaxis over the study period (Figure 66).

Figure 61. Mean age for hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

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Figure 62. Length of stay for hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

Table 29. Method of payment of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 35.0 20.0 3.3 55.2 32.2 12.4Governance insurance 15.0 33.3 0.0 25.6 36.1 0.0Insurance for the poor 50.0 46.7 0.0 13.6 22.9 2.0BPJS 96.7 78.1Others 0.0 0.0 0.0 1.6 0.0 5.5Do not know 0.0 0.0 0.0 4.0 8.8 2.0

Table 30. Patients’ condition of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

A Hospital 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 60.0 86.7 70.0 62.4 61.5 65.4Refer to other hospital 0.0 0.0 0.0 0.0 0.0 0.5Death 0.0 0.0 3.3 4.0 2.0 3.5Not cured, judicial discharge 10.0 13.3 3.3 25.6 19.5 13.4Others 0.0 0.0 0.0 0.0 1.0 2.5Control and outpatient 0.0 0.0 0.0 0.8 10.7 0.5Unknown 30.0 0.0 23.3 7.2 5.4 14.4

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Figure 63. Surgery of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

Figure 64. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital A vs. 8 other hospitals

Figure 65. Mobilization after surgery of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

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Figure 66. Thromboembolic of hip/femoral neck fracture patients by phase, Hospital A vs. 8 other hospitals

Patient interviews

Most respondents for the patient interview in all three phases of the study were male, junior and high school graduates, and more than 40 years old (Table 31). At baseline, most patients were using Jamkesmas for financial coverage of their hospital stay, but after JKN implementation most were covered by this insurance program (Table 32). The average length of stay for patients varied from around 11 days at baseline to seven days at end-line (Figure 68).

Patients’ perception of the professional competence of doctors and nursing staff improved from 15% at baseline to 20% at end-line (Figures 69 and 70), while overall patient satisfaction showed no significant improvement over the study period.

There was no clear trend in the changes observed with regard to patient experiences with medical decisions, discharge instructions, hospital facilities, overall satisfaction, and whether they would recommend the facility over the study period, but all started from a reasonably high base (Figures 71-73).

Table 31. Characteristic of patient interview respondents by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 33.1 25 30.9 27.1 27.8 33.6Female 66.9 75 69.1 72.9 72.2 66.4

Education None or primary school 17.8 15.8 15.5 29.1 23.6 20.8Junior and high school 70.3 64.2 61.8 55.6 59.8 61.0Academy and university 11.9 20 22.8 15.3 16.7 18.2

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Figure 67. Mean age of patient interviewed by phase, Hospital A vs. 8 other hospitals

Table 32. Method of payment of patient interviewed by phase, Hospital A vs. 8 other hospitals

A 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 10.2 11.7 3.3 19.8 10.7 14.0Commercial insurance 1.7 0.0 0.0 1.3 0.4 0.2Government insurance 23.7 0.0 0.0 19.1 0.0 0.0Jampersal 17.0 0.0 0.0 16.2 0.0 0.0BPJS for the poor (PBI)/Jamkesmas 44.9 50.0 25.2 41.6 35.4 29.2BPJS pay for premium 20.8 43.9 32.7 31.7BPJS paid by the company 4.2 12.2 3.7 9.4BPJS for government employee (Askes, Asabri, etc.)

13.3 13.8 16.7 14.3

Other 2.5 0.0 1.6 1.9 0.2 1.2Do not know 0.0 0.0 0.0 0.1 0.2 0.0

Figure 68. Length of stay of interviewed patients by phase, Hospital A vs. 8 other hospitals

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Figure 69. Patients’ confidence in doctors by phase, Hospital A vs. 8 other hospitals

Figure 70. Patients’ confidence in nursing care by phase, Hospital A vs. 8 other hospitals

Figure 71. Patient experience at hospital by phase, Hospital A vs. 8 other hospitals

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Figure 72. Patient satisfaction with hospital facilities by phase, Hospital A vs. 8 other hospitals

Figure 73. Patient satisfaction with all services at hospital by phase, Hospital A vs. 8 other hospitals

3. Key informant interviews

Accreditation

Hospital A was reported by key informants to have shown a consistent commitment to KARS, JCI, and ISO accreditation from 2012 to 2016. The hospital was selected by the MOH in 2013 to undergo JCI accreditation. It was successful in achieving JCI accreditation status in 2015 due to the commitment of the staff and administration. Leaders there stated that they will maintain JCI accreditation even without material support from the MOH when the time for re-accreditation comes in 2018. Unlike the four other hospitals that underwent JCI accreditation in the study, this one was not classified an “academic medical center” and was not accredited as such.

Informants reported that initially when the decision was made to seek JCI accreditation, there was a strong human resource commitment to improve services in preparation. However, it was stated by informants that changes brought about by implementation of JKN in 2014 and 2015 had caused some diminution in the emphasis on patient safety and quality of care.

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The MOH provided 2 billion IDR ($150,000 USD) in 2013 to the hospital to pay JCI for the process of undergoing accreditation. This amount was approximately half the fee paid to JCI to undergo the accreditation process. The informants noted that KARS accreditation was less expensive than both JCI and the ISO 9000 accreditation, which they had also undergone until recently.

Informants from Hospital A reported that the productivity incentive system that existed in the hospital to encourage physicians to maintain a caseload above a target was possibly compromising medical service quality and possibly patient safety. Informants stated that neither JCI nor KARS accreditation procedures had been able to change this situation. Informants said that while accreditation had given the hospital tools to use to facilitate improvement, they had not become an embedded part of the working culture. It was also noted that there was inertia in the system, making implementation of change a difficult task. One informant stated, “A person is required to work quickly in some hospitals. This correlates with income, so that it will always be a circle between human resources, MOH, policy, BPJS, and [individual] reward and punishment.”

Key informants generally felt that JCI accreditation had a more profound impact of the operation of the hospital and the attitude of the staff than KARS accreditation. There was a greater emphasis in JCI on both patient safety and staff well-being. The results from the mock JCI survey were taken very seriously by the staff and incited a change in mindset, and this is what helped achieve the changes needed to be granted JCI accreditation. When JCI surveyors discovered deficits in hospital performance, they asked what actions had been taken by the hospital to correct the problem. If that action was included in the annual plan for the hospital, JCI generally approved of the action.

Key informants also reported that inspectors from KARS initially applied the accreditation standards inconsistently and that they were not as thorough as the JCI accreditors. However, in the final interview, the key informants said that the standard of KARS accreditation had improved to be more in line with the level of performance of the JCI accreditors. KARS was apparently working to improve the standards they apply to hospitals seeking their accreditation. They were also developing a system of accreditation to apply to Puskesmas (Pusat kesehatan masyarakat – government-mandated community health clinics).

In 2013, Hospital A used the consultation services offered for a fee by JCI to assist it with making changes to improve quality and safety to prepare for accreditation. However, this practice was not considered effective and was abandoned after the initial JCI accreditation was achieved. Throughout the period of study, Hospital A invited those responsible for supporting accreditation efforts in other successful hospitals to give advice and guidance on practices and systems to prepare for accreditation. Hospital A also sent senior staff to visit other accredited hospitals for insights into how other hospitals were going about improving systems of care to enhance quality and safety with the aim of accreditation. This was considered a more effective and efficient way to make improvements in the hospital compared to procuring the consultation services through JCI.

JKN implementation

Implementation of JKN clearly placed stress on the hospital’s financial administration. In 2014, at the beginning of the transition to JKN, all submitted claims for payment of services were verified and payment was forthcoming. However, once the system of BPJS was more established, new regulators with different verification processes began working in the hospital and there was some confusion in the hospital finance department regarding the requirements for full reimbursement for hospital services rendered to patients. Informants complained that BPJS was applying reimbursement levels for medical conditions that were inconsistent with standard practice – that diagnoses that require large amounts of resources to manage effectively were not reimbursed with adequate funds to provide those services. Disputed and disallowed claims led to delays in payment and sometimes non-payment of claims, leading to downward pressure on the hospital’s finances. Overall, the “Indonesia cost-based group” (INA-CBG: the schedule of payments allowed for specific diagnoses) reimbursement for orthopedic cases was considered lower than the labor


and materials required to treat those patients. This was a concern in Hospital A given that 85% of their patients were covered by JKN at end-line.

Key informants also stated that there was pressure from competition from nearby hospitals, both public and private. To improve the quality of care in a competitive environment, Hospital A was still working with its remuneration system to ensure it had the financial resources to retain medical staff and maintain increased quality performance. The hospital needed to manage its finances with great care as JKN expanded implementation in 2014 and beyond.

Informants generally stated that improvements had been made since the first year of JKN implementation, but there were still issues of orienting all staff to the new requirements of documentation for reimbursement by JKN.

Conclusion

Overall, key informants from Hospital A were positive about their accreditation experience: they thought it was a beneficial process and that it had improved the quality of care delivered at the hospital. They reported that the quality of the KARS accreditation process had shown improvement over the period. Implementation of JKN had caused some difficulties in the hospital, especially in the first year, but this had stabilized somewhat by end-line.


Chapter 2. Hospital B

1. Description

Hospital B is located in a special region in Java. It is the highest level of referral hospital and a type A teaching hospital. It has 23 medical staff groups with 29 installations inside. There are 813 beds and 3,015 total staff. Hospital B is recognized with the followings centers of excellence: integrated heart center, integrated cancer, kidney transplant, and homecare.

Hospital B is fully funded by the MOH. It was accredited by KARS (2012 version) in April 2014 and by JCI as one of the first Academic Medical Hospital in Indonesia and Southeast Asia in August of the same year (Figure 74).

Figure 74. Timeline for accreditation of Hospital B

KARS 2007 ‐ 16 Service Accred 2008

• ISO 9001:2008 (Feb)

• Main teaching Hosp accreditation (March)

2011

• Baseline Data Collection (Nov)

• KARS 2007 ‐ 16 Service Accred (Jan)

2012

• KARS 2012 Accred (Apr)

• Midline Data Collection (May)

• JCI Accred (Aug)

2014

• End‐line Data Collection (March)2016

Future Plan to be re‐accredited by

JCI & KARS2017

2. Results


Overall, Hospital B showed improvement in most performance indicators even though it still did not meet some predetermined national standards, such as net death rate (NDR), waiting times for prescription drug service, and pre-operative waiting times (Table 33). Length of stay (LOS) and turn-over interval (TOI) were also longer in end-line (Figures 75 and 76).

Table 33. Hospital-reported basic performance indicators, Hospital B, 2011-2015

Phase (Year) MOH

Variables Standard* Baseline Midline End-line

(2011) (2013) (2015) TOI (days) 1 – 3 2.1 2.0 2.9

Bed turn-over rate (times) 40 – 50 39.9 38.6 33.0 Emergency response time

< 5 < 5 5 5 (minutes) Proportion of death in ER (%) < 2 NR 0.8 0.6

Net death ratio (%) < 25 20 58 74.1 Waiting times for prescription < 30

< 30 30.0 40.5 drug service (minutes) minutesPost-operative death rate 3 NR 2.6 1.9 Pre-operative waiting times

< 2 1.4 2.4 2.7 (days)

NR: not recorded


Figure 75. Bed occupancy rate for Hospital B by phase

Note: MOH standard = 60-80%

Figure 76. Average length of stay for Hospital B by phase

Note: MOH standard = 6-9 days

Hospital review

Hospital B had generally higher scores at baseline compared to the other eight hospitals (Figures 77 – 86). From baseline to end-line, scores increased slightly almost in all domains. There was a modest dip in midline for human resource, transfusion, documentation, and records performance (Figure 79, 82, and 86). Then both of human resource and documentation and records performance improved from midline to end-line with the other domains. However, there was a leveling off from midline to end-line for transfusion, facilities management, and medication safety domains (Figure 82, 83, 84). In summary, most domains in Hospital B increased gradually through baseline to end-line, and they were generally higher than the mean scores for the other eight hospitals.

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Figure 77. Hospital governance by phase, Hospital B vs. 8 other hospitals

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Figure 78. Patient orientation by phase, Hospital B vs. 8 other hospitals

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Figure 79. Human resource by phase, Hospital B vs. 8 other hospitals

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Figure 80. Clinical practice and patient care performance by phase, Hospital B vs. 8 other hospitals


Figure 81. Healthcare-associated infection performance by phase, Hospital B vs. 8 other hospitals

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Figure 82. Transfusion performance by phase, Hospital B vs. 8 other hospitals

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Figure 83. Facilities management performance by phase, Hospital B vs. 8 other hospitals

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Figure 84. Medication safety performance by phase, Hospital B vs. 8 other hospitals

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Figure 85. Surgery, interventional procedures and anesthesia performance by phase, Hospital B vs. 8 other hospitals

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Figure 86. Documentation and records performance by phase, Hospital B vs. 8 other hospitals


Organizational audit scores rose significantly from baseline to end-line in all four departments for Hospital B. However, in the midline performance was variable. Scores for internal medicine/cardiology and orthopedic/surgical departments rose moderately from baseline to midline (Figure 89 and 90) while obstetric department remained stable (Figure 87). A significant change occurred in pediatric department where the midline percentage rose sharply from 56% in baseline to 95% in midline (Figure 88). Overall, almost all departments had higher scores than the mean of the eight other hospitals.

Figure 87. Key organizational audit criteria in Obstetric Department, Hospital B vs. 8 other

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Figure 88. Key organizational audit criteria in Pediatric Department, Hospital B vs. 8 other hospitals

Figure 89. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital B vs. 8 other hospitals

Figure 90. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital B vs. 8 other hospitals

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In Hospital B, normal delivery patients who use out-of-pocket method payments dropped steadily from 56.7% at baseline to 20% at end-line. After implementation of JKN early in 2014, more than half of the patients in Hospital B were covered by BPJS. Insurance for the poor decreased gradually. This is a similar pattern to the eight other hospitals. There were no patients in our sample in Hospital B who were covered by commercial insurance. The average of length of stay for normal delivery patients in Hospital B was stable from baseline to midline. Thereafter, it fell slightly in the end-line (Figure 91).

Table 34. Method of payment for normal delivery patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals Baseline Midline End-line Baseline Midline End-line

Out of pocket 56.7 33.3 20.0 32.1 21.3 19.6Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0Government insurance 20.0 20.0 0.0 12.5 4.6 0.0Insurance for the poor 23.3 16.7 13.3 20.0 30.8 5.4Jampersal 0.0 30.0 0.0 33.3 32.9 0.0BPJS 66.7 67.5Other 0.0 0.0 0.0 0.0 0.0 5.0Do not know 0.0 0.0 0.0 1.7 10.4 2.5

Figure 91. Average length of stay for normal delivery patients by phase, Hospital B vs. 8 other hospitals

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Figure 92. Age of normal delivery patients by phase, Hospital B vs. 8 other hospitals

There were few patients in Hospital B (3.3%) who were referred to other hospitals and a similar proportion chose judicial discharge. Almost all patients were discharged with improving or resolved condition in all three periods (Table 35).

The proportion of normal deliveries for which lacerations were recorded increased slightly through all period (Figure 93). The proportion of Apgar score and birth weight recorded reached 100% in end-line (Figures 94 and 95).

Table 35. Percentage of normal delivery patients’ condition by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals

Baseline Midline End-line Baseline Midline End-line

Cured/improving 100.0 93.4 100.0 86.7 85.5 83.7

Refer to other hospital 0.0 3.3 0.0 0.0 0.8 0.0

Death 0.0 0.0 0.0 0.0 0.0 0.0

Judicial discharge 0.0 3.3 0.0 0.4 2.1 4.6

Other 0.0 0.0 0.0 4.6 0.4 0.0

Control and outpatient 0.0 0.0 0.0 0.0 0.8 0.0

Unknown 0.0 0.0 0.0 8.3 10.4 11.7

Figure 93. Laceration recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals

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Figure 94. Apgar score recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals

Figure 95. Birth-weight recorded for normal delivery patients by phase, Hospital B vs. 8 other hospitals


Table 36. Age category distribution for pneumonia patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals Age (months) Baseline Midline End-line Baseline Midline End-line

< 1 3.3 6.7 6.7 1.7 19.8 15.0

1 - 11 46.7 76.7 56.7 55.8 45.7 37.5

12 - 23 30.0 10.0 20.0 25.0 18.5 27.5

24 - 35 3.3 3.3 13.3 12.1 10.5 10.4

36 - 47 10.0 3.3 3.3 5.0 3.8 6.7

48 - 59 6.7 0.0 0.0 0.4 1.7 2.9

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Table 37. Sex distribution for pneumonia patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Male 40.0 56.7 60.0 50.8 54.0 54.6

Female 60.0 43.3 40.0 49.2 46.0 45.4 Figure 96. Mean age in months for pneumonia patients by phase, Hospital B vs. 8 other hospitals

The largest proportion of pneumonia patients used out-of-pocket payment for their hospital charges in baseline and midline; however, the proportion dropped sharply in end-line when more than half were covered by BPJS. This was similar to findings in other participating hospitals (Table 38). Length of stay for pneumonia patients in Hospital B showed fluctuations over all periods. After rising slightly from baseline to midline, there was a slight drop between midline and end-line (Figure 97).

Table 38. Method of payment for pneumonia patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Out of pocket 73.3 73.4 36.7 57.0 46.0 32.5

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Figure 97. Length of stay for pneumonia patients by phase, Hospital B vs. 8 other hospitals

Most of pneumonia patients’ condition was reported to have improved or been resolved by discharge across the three time periods. There was a marked rise in deaths in the midline phase (30%) compared to a very small proportion at the baseline and end-line (3.3%). Meanwhile, judicial discharge in Hospital B rose steadily from 0% in baseline and midline to 13.3 percent in end-line (Table 39).

There were no significant changes for the completeness of recording of medical history or basic physical examination over all periods (Figure 98 – 102).

Table 39. Pneumonia patients’ condition at discharge by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


End-line

Cured/improving 93.4 70.0 80.1 63.7 60.6 65.0


Death 3.3 30.0 3.3 6.3 10.5 13.3Not cured, judicial discharge 0.0 0.0 13.3 15.7 13.8 9.2

Other 0.0 0.0 0.0 6.3 0.0 0.0


Unknown 3.3 0.0 3.3 6.7 11.7 11.7

Figure 98. Respiratory symptom recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals

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Figure 99. Immunization recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals

Figure 100. Respiratory rate recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals

Figure 101. Temperature recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals

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Figure 102. Pulse recorded for pneumonia patients by phase, Hospital B vs. 8 other hospitals

AMI

Figure 103. Average age for AMI patients by phase, Hospital B vs. 8 other hospitals

Length of stay for AMI patients increased from 6 days at baseline to 8 days at end-line. This is the opposite to other participating hospitals, which decreased gradually over three time periods (Figure 104).

Figure 104. Length of stay for AMI patients by phase, Hospital B vs. 8 other hospitals

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Most AMI patients were covered by governance insurance in baseline and midline. Almost three quarters of patients were covered by JKN by the end-line period after its implementation by BPJS (Table 40).

Most patients were reported to have improved or resolved conditions at discharge over all three time periods. There was no significant change in the proportion of patient death. The proportion of patients who chose judicial discharge in Hospital B dropped from 6.7% at baseline to zero percent in midline and end-line. In the other eight hospitals, patients who did not have their condition reported on discharge almost doubled from baseline to end-line (Table 41).

Table 40. Method of payment for AMI patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Out of pocket 36.7 30.0 23.3 36.7 32.9 16.3




Others 0.0 0.0 0.0 0.0 0.4 4.6

BPJS 73.4 73.3

Do not know 0.0 0.0 0.0 2.9 6.6 0.8

Table 41. Patient condition at discharge for AMI patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Cured/improving 73.3 80.0 76.7 60.7 63.4 63.7


Death 20.0 20.0 23.3 9.2 10.7 12.1

Not cured, judicial discharge 6.7 0.0 0.0 12.5 7.4 6.7

Others 0.0 0.0 0.0 8.8 1.7 0.0


Unknown 0.0 0.0 0.0 8.8 8.2 15.8

The proportion of patients who had cardiac enzymes examination and statin recorded increased slightly from baseline to end-line. Both started from more than 80% compliance in baseline (Figure 105 and 108). ECG examination recording already had high, high levels of compliance at baseline and remained high throughout all periods (Figure 106). Oral beta-adrenergic prescription recording for AMI patients rose slightly in midline and dropped slightly by the end-line (Figure 107). Aspirin prescription recorded for AMI patients started with perfect values and stayed the same to the end-line (Figure 109).

Figure 110-115 shows the proportions of medical histories recorded for AMI patients. The majority had no significant changes except for hypercholesterolemia, cerebrovascular, and diabetic history, which improved about one third from baseline to end-line (Figures 111, 112 and 114). Recording of heart failure had a marked increase, starting from a very low proportion and then increasing to almost three quarters by the end-line (Figure 115). Recording of both previous AMI and angina pectoris had a low proportion in the beginning; there was a slight drop in recording of previous AMI and a slight increase in recording of angina pectoris by end-line (Figure 110 and 111). Hypertension recording was at maximum level at baseline, then fell slightly at midline, then returned to a maximum level by end-line (Figure 112).


Figure 105. Cardiac enzymes examination recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 106. ECG examination recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 107. Oral beta-adrenergic recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

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Figure 108. Statin recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 109. Aspirin prescription recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 110. Previous AMI history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

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Figure 111. Angina pectoris history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 112. Hypertension history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 113. Hypercholesterolemia history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

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Figure 114. Cerebrovascular accident history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 115. Heart failure history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

Figure 116. Diabetic history recorded for AMI patients by phase, Hospital B vs. 8 other hospitals

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Lengths of stay for hip/femoral neck fracture patients was longer at end-line than at baseline and midline, and overall was shorter than other participating hospitals (Figure 118).

The pattern of change for methods of payment was similar to the three cases above, with most clients covered by BPJS. Total BPJS coverage was 81.8% in Hospital B and 80.4% in all other participating hospitals at end-line (Table 42).

The proportion of patients reported to have been discharged with improving or resolved conditions increased to be highest at midline then decreased slightly to the end-line. Few patients were referred to other hospital in end-line (3.0%), while patients who were not reported with resolved condition or who chose judicial discharge decreased by more than half from baseline to end-line (Table 43).

Compliance with surgery improved from 73% in baseline to 97% in midline and end-line. This percentage was much higher than the eight other hospitals (Figure 119). Antibiotic prophylaxis compliance started low (30%) then increased sharply to 100% in midline and end-line (Figure 120). Compliance of mobilization after surgery rose gradually from 45% to 69% to 91% in baseline, midline and end-line, respectively (Figure 121). Thromboembolic compliance had no significant changes from baseline to midline and end-line, while there was a slight increase across the other eight hospitals (Figure 122).

Figure 117. Mean age for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals

Figure 118. Length of stay for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals

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Table 42. Method of payment for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Out of pocket 43.3 33.4 18.2 54.7 30.2 10.1



BPJS 81.8 80.4

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Do Not Know 0.0 0.0 0.0 4.4 8.8 2.0

Table 43. Patients’ condition for hip/femoral neck-fracture patients by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals


Cured/improving 66.7 100.0 87.9 60.8 59.4 62.3Referred to other hospital 0.0 0.0 3.0 0.0 0.0 0.0


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Figure 119. Surgery for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals

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Figure 120. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals

Figure 121. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals

Figure 122. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital B vs. 8 other hospitals

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Patient interviews

Most interviewed patients in Hospital B were female, more than 30 years old, and with junior and high school education (Table 44). The largest proportion of patients used insurance for the poor/Jamkesmas before 2014 and JKN after 2014 (Table 45). The length of stay for interviewed patients dropped in midline, then it rose in end-line (Figure 124).

The proportion of patients interviewed who were satisfied with medical services started high (79%), increased (98%) in midline, then decreased slightly (86%) in the end-line (Figure 125). Satisfaction with nursing care was 76% in baseline, then it improved steadily in midline to 90% and remained stable in end-line (Figure 126). Figures 127 and 128 show the percentage of patients’ satisfaction in hospital facilities and in all services at hospital, respectively. Overall, satisfaction with both facilities and services was reported by more than 85% of patients over all periods of the study. An unexpected finding was that while satisfaction with hospital facilities and services was above 85%, overall patient experience remained at around 60%, suggesting patients were weighting experiences other than facilities and services in their overall judgement (Figure 129).

Table 44. Characteristic of patient interview respondents by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 18.0 21.7 35.2 29.0 28.2 33.0Female 82.0 78.3 64.8 71.0 71.8 67.0

Education None or primary school 30.3 30.0 17.6 27.6 21.8 20.5Junior and high school 52.5 52.5 58.4 57.8 61.2 61.5Academy and University 17.2 17.5 24.0 14.6 17.0 18.0

Figure 123. Mean age of patients interviewed by phase, Hospital B vs. 8 other hospitals

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Table 45. Method of payment for patients interviewed by phase, Hospital B vs. 8 other hospitals

B 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 15.6 6.7 8.8 19.2 11.4 13.3Commercial insurance 3.3 0.8 0.8 1.0 0.3 0.1Government insurance 21.3 0.0 0.0 19.4 0.0 0.0Jampersal 9.8 0.0 0.0 17.1 0.0 0.0BPJS for the poor (PBI)/Jamkesmas 49.2 39.2 29.6 41.2 36.8 28.7BPJS pay for premium 30.0 26.4 31.5 33.9BPJS paid by the company 0.8 16.8 4.1 8.8BPJS for government employee (Askes, Asabri, etc)

21.7 16.8 15.8 13.9

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Figure 124. Length of stay for patients interviewed by phase, Hospital B vs. 8 other hospitals

Figure 125. Patient satisfaction with medical services by phase, Hospital B vs. 8 other hospitals

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Figure 126. Patient satisfaction with nursing care by phase, Hospital B vs. 8 other hospitals

Figure 127. Patient satisfaction with hospital facilities by phase, Hospital B vs. 8 other hospitals

Figure 128. Patient satisfaction with all services at hospital by phase, Hospital B vs. 8 other

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Figure 129. Patient experience at hospital by phase, Hospital B vs. 8 other hospitals


Accreditation

Hospital B is a highly regarded hospital that is often considered a benchmark for other type A hospitals undergoing JCI accreditation. According to the informants, almost all personnel, including cafeteria and office clerical staff, received four compulsory trainings on accreditation compliance. The hospital faced some constraints during the accreditation process, including behavior and work culture of medical personnel and hospital staff; behavior of patients and visitors (for example, difficulty in changing their smoking habits within hospital areas); financial support to adhere to the JCI standard; seniority issues; and difficulty emphasizing the importance of accreditation.

Also, it was reported that there were inconsistencies in the findings by JCI and KARS surveyors. For example, KARS accreditors granted a high score in infection control while JCI surveyors found some aspects in infection control did not initially meet the accreditation standards.

Hospital B allocated 20% of their budget to the JCI accreditation process and related improvements. Most was spent on facility improvements to meet the JCI standards for patient safety and to meet service quality standards. They spent approximately 150 million USD for the final JCI survey and around 110 million USD for the JCI mock survey, which was funded by the Ministry of Health. With the increase in the overall budget due to the cost of accreditation, it was expected that the hospital tariff would also increase. However, implementation of JKN resulted in the hospital not being able to independently set their own tariff because of the set JKN tariff package.

Hospital B was thought to be functioning well in overall services and in the qualification level of their human resources before JCI accreditation. An effective medical record filing system had been established previously. However, the completeness of the medical records was the individual responsibility of each department, and therefore there were some inconsistencies across the hospital. Previously, it was reported that doctors rarely completed medical records as expected.

Accreditation reportedly contributed to improvements in many aspects of services. For example, doctors, nurses, and the customer service unit were more amenable to patients’ needs because they were trained to provide more patient-centered services. An informant said that the hospital management and patients met annually to discuss and resolve complaints and that since this process had been initiated, patients’ complaints were slightly reduced.

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With regard to facilities, canteens in Hospital B had been renovated and an old one had been closed after its assessment showed it was not meeting appropriate standards. Also, there was a plan to renovate a non-standard ER in Hospital B.

JKN implementation

JKN implementation had a positive effect for both patients and the hospital staff. It has driven Hospital B to find and establish the remuneration system that works within the JKN system. Furthermore, it also has affected the income of specialists so that medical staff remuneration has become more equal. Previously, their earnings varied widely as patients could choose their doctors freely, resulting in more popular doctors earning much more.

JKN implementation has encouraged more people, including the poor, to seek treatment because financial coverage is guaranteed. Hospital B, as the highest level of referral hospital, only accepts patients with end-level severity, which has affected the caseload at the hospital. However, the system has not been fully implemented as of the end of 2017. Hospitalization for referred cancer chemotherapy patients ranked first among other cases, followed by heart disease patients. Over the study period, outpatient visits declined as less severely ill patients were referred to other hospitals by the new system. Meanwhile, the wait time for inpatient services was still high, especially for elective procedures and for emergency patients.

There was a higher number of BPJS premium (non-PBI) patients compared to patients with BPJS for the poor (PBI). Hospital B had a problem with the number of beds, which were mostly designated for the PBI patients (third-class). Non-PBI patients were usually at least in the second-class. Consequently, there were long waiting times for high-demand beds and many patients were provided hospital beds in the wrong class. To solve this problem, more beds should be designated for second and first classes. The bed occupancy rate at Hospital B was high because it is a national reference hospital and therefore provides services for patients from many regions. However, LOS was also high because of delays in visitation by doctors and sometimes delays in the scheduling of surgeries for various reasons.

All hospitals rely on BPJS income for their operational funding. One benefit of JKN implementation for hospital was the perceived certainty and punctuality of payment from BPJS to the hospital in contrast to the out-of-pocket (OOP) patients, who sometimes paid in installments. For Hospital B, data from the last 10 years showed that 80% patients paid out-of-pocket payment for their hospital care. Since implementation of JKN, the OOP patient proportion has dropped to about 10-20%. Overall, hospital income has increased every year in at least the past five years. However, Hospital B had an operating deficit of about $420,000 – $560,000 USD every month from BPJS payment had not covered the full cost of care.

Claims for JKN patients totaled 221-295 million USD per month in 2017, including medication, hospitalization, outpatient care, and medical equipment. There were pending claims, but not of a magnitude to affect liquidity. One pending batch of claims totaled around 589 million USD in 2015. These outstanding claims were caused by the differences in patient classification coding between the hospital coders and the BPJS verifiers. Constraints in the claim process still existed at Hospital B in mid-2017, including (1) medical record flow, which was different from the other hospitals because double encoding occurred: first with the medical record unit and then with the insurance coders; (2) the encoded diagnosis used was sometimes one not approved by BPJS; (3) around 20% of the documents related to the claims were incomplete; and (4) Hospital B did not provide medical records unless specifically requested by BPJS as agreed in the MOU between Hospital B and BPJS. A substantial part of the constraint was due to BPJS itself because of their limitation of verification personnel.

According to informants, there were several INA-CBGs’ tariffs that were considered unreasonable, such as the tariffs for liver transplants and separation of conjoined twins, according to hospital data. For example, payment for a liver transplant from BPJS was limited to about $15,000 USD while its actual cost


is many times that amount. Other reimbursements from BPJS considered inadequate were several procedures in perinatology and burn treatment. Also, the total cost of care for patients with a cerebrovascular accident and cases with antiviral drugs was much greater than the INA-CBGs package, determining BPJS payment, accounted for. Informants from Hospital B expected that tariffs for those unreasonable reimbursements would be adjusted by BPJS to decrease the risk of future deficits.

Conclusion

Result from the HAPIE study found that most indicators assessed were higher at baseline in Hospital B compared to the baseline average of the other eight hospitals and we observed improvement in most indicators from baseline to end-line. Hospital B began with a good score for overall services, qualification of human resources, and quality of medical facilities, which were better than most other hospitals in the study. Accreditation was considered to bring favorable impacts to Hospital B, especially for work performance because staff were trained adhere to the accreditation standard. However, there was still room for improvement in medical record completion and other indicators.

Regarding JKN implementation, the majority of patients are now covered by the national insurance; a change from the predominantly OOP payment method most patients used before 2014. Hospital revenue did not change dramatically with this change. However, the hospital did face financial difficulties and many elements of the transactions between the hospital and BPJS need to be strengthened, such as diagnostic and charge coding and the promptness in submitting claim documents.


Chapter 3. Hospital C

1. Description

There are 328 hospitals in the province where Hospital C is located as of June 2017; seventy public/government hospitals and 258 private hospitals. Among them, nine are type A hospitals, administered by the MOH, and the other 249 are run by the local government or are private. By accreditation status, only 28.7% of hospitals were already accredited by KARS in this province.

Hospital C is a type A teaching facility established in 1956 on the island of Java. It is a top-level referral for tertiary health services in the province and national center of excellence in nuclear medicine. In 2016, it was reported to have 996 beds and provide a wide range of services comprising 20 medical specialties and 125 sub-specialists. Examples of other specialty services are: integrated cardiac medicine, oncology, infectious diseases, minimally invasive surgery, and kidney transplant.

The hospital was accredited by KARS in 2014 and by JCI as an Academic Medical Center in 2016. The hospital underwent JCI mock surveys in both 2013 and 2015 (Figure 130).

Figure 130. Timeline for accreditation of Hospital C

KARS 2007 ‐16 Service Accred (Jun)

2011 Baseline Data Collection (Nov)2012

• MOCK Survey of JCI Accred (Jan)

• ISO Accred

2013

• Midline Data Collection (Mar)

• Mock Survey of KARS 2012 Accred (Jul)

• KARS 2012 Accred (Jul)

2014 Mock Survey of JCI Accred (Aug)2015

• JCI Accred (April)

• End‐line Data Collection (July ‐ Aug)

2016

2. Results


Some hospital-reported indicators showed improvement from baseline to end-line, such the emergency room death ratio and the post-operative death ratio. However, at end-line some performance indicators still did not meet MOH standards, such as the net death ratio, waiting times for prescriptions, and the bed occupancy ratio (Table 46 and Figures 131-133).

Table 46. Hospital-reported basic performance indicators, Hospital C, 2011-2015

Variables MOH

Standard*

Phase (Year) Baseline

(2011)Midline (2013)

End-line (2015)

Emergency response time (minutes)

< 5 < 5 5 < 5

Percentage of deaths in ER (%) <2 16.6 2.3 2.5 Net death rate (%) < 25 34.9 39.5 47.9 Waiting time for prescription drug service (minutes)

< 30 minutes

NR < 30 44.2

Post-operative death rate 3 NR 0.7 0.1


Figure 131. Bed occupancy rate for Hospital C by phase

Note = MOH standard is 60-80%

Figure 132. Average length of stay for Hospital C by phase

Note = MOH standard is 6-9 days

Figure 133. Bed turn over interval for Hospital C by phase

Note = MOH standard is 1-3 days

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Hospital review

Some hospital review variables have been stable since the baseline, such as hospital governance, clinical practice and patient care performance, facilities management, and surgery and anesthesia (Figures 134, 137, 140 and 142). From baseline to end-line, most variables increased after JCI accreditation except for documentation and records (Figure 134-143). Overall, Hospital C’s performance was at or above the average of the other eight hospitals.

Hospital governance

Figure 134. Hospital governance by phase, Hospital C vs. 8 other hospitals

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Figure 135. Patient orientation by phase, Hospital C vs. 8 other hospitals

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Figure 136. Human resource by phase, Hospital C vs. 8 other hospitals


Figure 137. Clinical practice and patient care performance by phase, Hospital C vs. 8 other hospitals


Figure 138. Healthcare-associated infection performance by phase, Hospital C vs. 8 other hospitals

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Figure 139. Transfusion performance by phase, Hospital C vs. 8 other hospitals


Figure 140. Facilities management performance by phase, Hospital C vs. 8 other hospitals

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Figure 141. Medication safety performance by phase, Hospital C vs. 8 other hospitals

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Figure 142. Surgery, interventional procedures, and anesthesia performance by phase, Hospital C vs. 8 other hospitals


Figure 143. Documentation and records performance by phase, Hospital C vs. 8 other hospitals


Overall, Hospital C improved after JCI accreditation in all departments. Significant improvement was seen in the cardiology/internal medicine department (Figure 146). Obstetric and pediatric departments did not improve significantly, but were operating at a high level since the baseline (Figures 144 and 145). Orthopedic/surgical departments experienced increases of about 15% from baseline to end-line (Figure 147).

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Figure 144. Key organizational audit criteria in Obstetric Department, Hospital C vs. 8 other hospitals

Figure 145. Key organizational audit criteria in Pediatric Department, Hospital C vs. 8 other hospitals

Figure 146. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital C vs. 8 other hospitals

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Figure 147. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital C vs. 8 other hospitals


Delivery

Length of stay for delivery patients in Hospital C decreased at the end-line and remained below the average of eight other hospitals (Figure 148). Almost all patients were cured or were reported to have resolution of their medical conditions prior to discharge; no patients were referred to other hospitals at discharge and no deaths were recorded (Table 48). Lacerations, Apgar score, and birth weight were recorded for more than 90% of deliveries from baseline to end-line, but there was a decrease of 10% for laceration recorded in the end-line (Figures 150-152).

Table 47. Method of payment for normal delivery patients by phase, Hospital C vs. 8 other hospitals

C 8 hospitals

Baseline MidlineEnd-line

Baseline Midline End-line

Out of pocket 36.7 26.7 50.0 34.5 22.1 15.8 Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0 Government insurance 6.7 3.3 0.0 14.2 6.7 0.0 Insurance for the 23.3 10.0 0.0 20.0 31.6 7.1 poor/Jamkesmas Jampersal 33.3 60.0 0.0 29.2 29.2 0.0 BPJS 13.3 74.2 Other 0.0 0.0 36.7 0.0 0.0 0.4 Do not know 0.0 0.0 0.0 1.7 10.4 2.5

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Figure 148. Average length of stay for normal delivery patients by phase, Hospital C vs. 8 other hospitals

Figure 149. Age of normal delivery patients by phase, Hospital C vs. 8 other hospitals

Table 48. Condition of normal delivery patients by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals


Cured or improving 96.7 100.0 93.3 87.1 84.6 84.6

Referred to other hospital 0.0 0.0 0.0 0.0 1.3 0.0

Death 0.0 0.0 0.0 0.0 0.0 0.0


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Unknown 0.0 0.0 0.0 8.3 10.4 11.7

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Figure 150. Laceration recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals

Figure 151. Apgar score recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals

Figure 152. Birth weight recorded for normal delivery patients by phase, Hospital C vs. 8 other hospitals

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In the baseline period, most cases of pneumonia in Hospital C were found in the 12- to 23-month-old age group while at end-line, there was a higher proportion in the one- to 11-month-old cohort. In the eight other hospitals, most cases were in the one- to 11-month-old age group (Table 49).

Table 49. Age category distribution for pneumonia patients by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals Age (months) Baseline Midline

End-line Baseline Midline

End-line

< 1 0.0 6.7 23.3 2.1 19.8 12.9 1 - 11 33.3 36.7 26.7 57.5 50.8 41.3 12 - 23 40.0 33.3 23.3 23.7 15.5 27.1 24 - 35 16.7 20.0 16.7 10.4 8.4 10.0 36 - 47 10.0 3.3 10.0 5.0 3.8 5.8 48 - 59 0.0 0.0 0.0 1.3 1.7 2.9

Table 50. Sex distribution for pneumonia patients by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals


End-line

Male 46.7 46.7 50.0 50.0 55.2 55.8

Female 53.3 53.3 50.0 50.0 44.8 44.2

Figure 153. Mean age in months for pneumonia patients by phase, Hospital C vs. 8 other hospitals

Length of stay for pneumonia patients increased up to the end-line. It decreased on average in the other eight hospitals, although not significantly (Figure 154). Deaths of patients diagnosed with pneumonia in Hospital C occurred in 10% of cases sampled at end-line, but the case fatality rate was higher on average among the eight other hospitals across all three time periods (Table 52). Physical examination data, such as respiratory rate, temperature, and pulse, was recorded for in over 95% of cases since baseline (Figures 157-159) and was similarly high for recording of patient history data, respiratory symptoms, and immunization (Figures 155 and 156).

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Table 51. Method of payment for pneumonia patients by phase, Hospital C vs. 8 other hospitals

C 8 hospitals

Baseline MidlineEnd-line

Baseline Midline End-line

Out of pocket 70.0 60.0 30.0 57.5 47.7 33.3Commercial insurance 0.0 0.0 0.0 1.7 0.0 0.0Government insurance 6.7 6.7 0.0 10.0 6.3 0.0Insurance for the poor/Jamkesmas 16.6 30.0 13.3 27.9 37.2 10.0BPJS 40.0 55.0Other 6.7 3.3 16.7 0.8 0.8 0.4Do not know 0.0 0.0 0.0 2.1 8.0 1.3

Figure 154. Length of stay for pneumonia patients by phase, Hospital C vs. 8 other hospitals

Table 52. Condition of pneumonia patients at discharge by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals




Death 0.0 0.0 10.0 6.6 14.2 12.5


Other 0.0 0.0 0.0 6.3 0.0 0.0


Unknown 0.0 0.0 0.0 7.1 11.7 12.1

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Figure 155. Respiratory symptoms recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals

Figure 156. Immunization recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals

Figure 157. Respiratory rate recorded for pneumonia patients by phase, Hospital C vs. 8 other

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Figure 158. Temperature recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals

Figure 159. Pulse recorded for pneumonia patients by phase, Hospital C vs. 8 other hospitals

AMI

For AMI cases, most of the indicator variables, such as cardiac enzymes, ECG, statin, aspirin, angina pectoris, hypertension and diabetic history, were at a high level in the baseline (Figures 162, 163, 165, 166, 168, 169 and 173). Almost all variables improved in the end-line period except aspirin administration, which decreased slightly (Figure 166), and the variables of statin prescription and the recording of angina pectoris (Figure 165 and 168), which remained the same from baseline to end-line; 90% and 87%, respectively. Recording of cerebrovascular accident history was low at baseline and increased over the period but only up to 40% compliance. A similar trend, though with slightly lower average proportions, was also seen in the eight other hospitals (Figure 171).

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Figure 160. Average age of AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 161. Length of stay for AMI patients by phase, Hospital C vs. 8 other hospitals

Table 53. Method of payment recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

C 8 hospitals Baseline Midline End-line Baseline Midline End-line Out of pocket 36.7 0.0 33.4 36.7 36.6 15.0Commercial insurance 0.0 0.0 0.0 1.3 0.4 0.4Government insurance 40 10 0.0 38.3 30.5 0.0Insurance for the poor/Jamkesmas 23.3 90 0.0 20.8 25.5 5.0BPJS 33.3 78.4Other 0.0 0.0 33.3 0.0 0.4 0.4Do not know 0.0 0.0 0.0 2.9 6.6 0.8

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Table 54. Patient condition at discharge for AMI patients by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals




Death 10.0 16.7 6.7 10.3 11.1 14.2


Other 0.0 0.0 0.0 8.8 1.7 0.0


Unknown 0.0 3.3 0.0 8.8 7.8 15.7

Figure 162. Cardiac enzymes examination recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 163. ECG examination recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

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Figure 164. Oral beta-adrenergic recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 165. Statin recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 166. Aspirin prescription recorded for AMI patients by phase, Hospital C vs. 8 other

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Figure 167. Previous AMI history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 168. Angina pectoris history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 169. Hypertension history recorded for AMI patients by phase, Hospital C vs. 8 other

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Figure 170. Hypercholesterolemia history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 171. Cerebrovascular accident history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

Figure 172. Heart failure history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals

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Figure 173. Diabetic history recorded for AMI patients by phase, Hospital C vs. 8 other hospitals


For orthopedic surgery cases, patients with fractures mostly received surgery once the JKN system was implemented (Table 55). There was a change in the average age of patients diagnosed with hip/femoral neck fractures in Hospital C, from an average of around 38 years to above 55 years from baseline to end-line, which followed a similar trend to the other eight hospitals (Figure 174). Length of stay for hip/femoral neck fracture in Hospital C increased from baseline to end-line, but still remained below the average for the eight other hospitals (Figure 175).

For recording of patients’ condition at discharge, the proportion of patients reported with resolution of their primary complaint increased in the end-line, whereas the proportion of judicial discharge of patients decreased. This trend was similar to that of the other eight hospitals (Table 56).

The proportion of patients who received surgery decreased in the midline and end-line phases, but the recording of antibiotic prophylaxis increased significantly (Figures 176-177). Provision of thromboembolic therapy in cases of hip/femoral neck fracture was under 30% in Hospital C and in the other eight hospitals (Figure 179).

Figure 174. Mean age of hip/femoral neck-fracture patients by phase, Hospital C vs. 8 other hospitals

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Figure 175. Length of stay of hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals

Table 55. Method of payment of hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals

C 8 hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 62.5 26.6 20.7 51.8 31.2 9.9Government insurance 12.5 40.0 0.0 24.8 35.2 0.0Insurance for the poor/Jamkesmas 12.5 16.7 6.9 19.0 27.3 1.0BPJS 37.9 86.6Other 12.5 0.0 34.5 0.7 0.0 0.5Do not know 0.0 16.7 0.0 3.7 6.3 2.0

Table 56. Condition of hip/femoral neck fracture patients at discharge by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals




Death 0.0 6.7 6.9 3.7 1.0 3.0


Other 0.0 0.0 0.0 0.0 1.0 2.5


Unknown 0.0 6.7 0.0 11.0 4.4 17.7

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Figure 176. Surgery for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals

Figure 177. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals

Figure 178. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital C vs. 8 other hospitals

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Figure 179. Thromboembolic for hip/femoral neck-fracture patients by phase, Hospital C vs. 8 other hospitals

Patient interviews

The characteristics of the respondents in the patient interviews from all three phases are listed in Table 57. Most respondents were 40 years of age or older, female, and junior and high school graduates. At baseline, most patients were using Jamkesmas for the method of payment, but after JKN implementation, most of patients were covered by this system. The proportion of patients with JKN for the poor was higher than other methods of payment (Table 60). The average length of stay varied between seven to nine days from baseline to end-line (Figure 181).

Patients’ positive perceptions of medical services fluctuated from baseline to end-line, starting at 51% at baseline, then increasing in the midline period to 95%, before dropping to 80% at the end-line (Figure 182). A similar pattern was also observed with regard to positive perception of nursing care, which started at 56%, rose to 87% at midline, then decreased to 80% at end-line (Figure 183). The proportion of patients satisfied with the hospital’s facilities and with hospital services was more than 80% across all three periods and slightly higher than the average of the other eight hospitals (Figure 184 and 185). The proportion of patients who had a positive experience remained under 40%. This was generally lower than the average for the eight other hospitals (Figure 186).

Table 57. Characteristic of patient interview respondents by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals


Sex Male 22.1 29.2 21.9 28.5 27.3 34.7

Female 77.9 70.8 78.1 71.5 72.7 65.3

Education

None and primary school 31.2 25.0 29.7 27.5 22.4 19.0

Junior and high school 54.0 55.8 55.5 57.6 60.8 61.8

Academy and University 14.8 19.2 14.8 14.9 16.8 19.2

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Figure 180. Mean age of patients interviewed by phase, Hospital C vs. 8 other hospitals

Table 58. Method of payment for patients interviewed by phase, Hospital C vs. 8 other hospitals

C 8 Hospitals


Out of pocket 19.7 13.3 9.4 18.6 10.5 13.3


Government insurance 23.8 0.0 0.0 19.1 0.0 0.0

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BPJS for the poor (PBI)/Jamkesmas 41.0 32.5 35.9 42.2 37.6 27.8

BPJS pay for premium 30.8 29.7 31.4 33.5

BPJS paid by the company 6.7 12.5 3.4 9.3BPJS for government employee (Askes, Asabri, etc)

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Figure 181. Length of stay of patients interviewed by phase, Hospital C vs. 8 other hospitals

Figure 182. Patient satisfaction with medical services by phase, Hospital C vs. 8 other hospitals

Figure 183. Patient satisfaction with nursing care by phase, Hospital C vs. 8 other hospitals

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Figure 184. Patient satisfaction with hospital facilities by phase, Hospital C vs. 8 other hospitals

Figure 185. Patient satisfaction with all services at hospital by phase, Hospital C vs. 8 other

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Figure 186. Patient experience at hospital by phase, Hospital C vs. 8 other hospitals

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Accreditation

Hospital C was accredited by KARS in 2014 and JCI in 2016. JCI mock surveys were conducted in 2013 and 2015. Accreditation was not successfully achieved during the first mock survey due to a reported inadequacy of preparation resulting in non-compliance with several standards.

Informant noted that the evaluation standards for KARS and JCI were not substantively different because KARS version 2012 used the JCI Accreditation Standards for Hospitals, Fourth Edition, while the JCI accreditors used the Fifth Edition. Informants reported recognizing that JCI and KARS accreditors had their own strengths and weaknesses. KARS accreditors were more focused in document completeness, while JCI accreditors were more focused on evidence of implementation of the policy document. Additionally, the explanations given by the JCI surveyors were more detailed and standardized compared to KARS surveyors. In preparing for accreditation, Hospital C concentrated more on the JCI process, perceiving it required more effort and investment than KARS accreditation. One example of the effort was translating many hospital policy and procedure documents into English.

Obstacles related to JCI accreditation experienced by Hospital C included a lack of training on the accreditation preparation strategy for staffs. This left the staffs confused about roles and expectations – some did not understand the accreditation process and others were not even aware that the hospital was undergoing the accreditation process.

Hospital management reported difficulties in securing the collaboration of the chief of clinicians in terms of getting medical staff to comply with hospital policy. One Informant underlined that specific challenges identified in achieving JCI accreditation were drug management, documentation and integration of medical records, patient safety, policies and procedures, building maintenance, fire safety, and infectious disease isolation processes.

The JCI surveyors identified 45 non-standardized aspects from Hospital C’s operations, with 38 standards considered partially met and seven unmet. Issues of compliance included cracked walls, hollow ceilings, inadequate storage of hazardous materials, an absence of timekeeping for dialysate water management, and an absence of external benchmarking for medical staff assessment. Due to these 45 deficiencies, Hospital C was required to develop a strategic improvement plan (SIP) to overcome the problems identified in order to meet the quality care and patient safety accreditation standards.

The accreditation process in Hospital C was reported to be running well by the end-line period because the new directors were very familiar with KARS and JCI accreditation and so could provide better guidance in managing the process. One informant stated that a key factor in success was the commitment of hospital leadership. Leaders showed their engagement in the preparation process by performing direct supervision visits to all units.

Hospital C admitted that both KARS and JCI accreditation contributed substantively to improving patient quality and patient safety. The positive impact on the hospital’s financial and remuneration situation was also noted. Hospital service units were reportedly more clearly aware of their responsibilities due to the accreditation process. Activities to evaluate hospital services were initially conducted in pediatric and obstetrics and gynecology departments, and clinical pathways were updated, clarified, and implemented. It was reported that, based on the current hospital data, patient satisfaction had improved since the implementation of the changes due to accreditation. This report was consistent with the findings from our patient interview findings.

Completion of medical records was reported to have increased; a finding consistent with trends in completion of medical records shown by the quantitative data collected during the study. The hospital already has a special working group called the Management of Information (MOI) Team that focused on the medical records standards for accreditation. The MOI regularly performed open and closed medical


record reviews. Key informants reported that it was difficult to get clinicians to complete the medical record fully, but there was an improvement in compliance, especially when compared to previous similar efforts.

JKN implementation

Approximately 90% of Hospital C’s revenue was coming from reimbursements for services provided to JKN patients at the end-line period. As stated by key informants from other hospitals, this was a more secure source of revenue for the hospital than having a high proportion of patients paying for their services OOP. However, the operational costs for Hospital C were generally greater than the payments for services rendered for JKN patients by BPJS. As hospital operational costs increased, it was expected that income would be less able to balance expenses. Since JKN implementation, the demand for hospital services had increased and there was always a waiting list for beds in almost all type of hospital rooms. Waiting time in the ER had also increased.

Since 2015, hospital claims billing for services to JKN patients was around 3 million USD per month. However, there were problems reported with delays in payment, the cause usually being incompleteness of the medical records and delay in submitting supporting document. The hospital service departments reportedly did not seem to appreciate the importance of submitting claim document on time. Consequently, many documents were submitted late to BPJS, and some claims were disallowed. In addition, there were also many documents submitted with errors that required revision before reimbursement by BPJS. Revising and returning the claim documents took up six months. BPJS verifiers were also considered to be slow in verifying the documents, adding to the delay. Of the seven million USD of reportedly outstanding disputed reimbursements, only a partial amount has been paid by BPJS. To add to this amount from previous dysfunctions in billing and payment, BPJS had identified another three million USD in outstanding billing owed to hospital C by the latter part of 2017.

Conclusion

The key strength of Hospital C in achieving JCI accreditation was the enthusiasm and willingness of staff and their leadership to learn and make improvements in their systems of service delivery, which has resulted in significant progress in many areas of care. With regard to the late claim submission for reimbursement by BPJS, the hospital has strong incentive improve the medical record and billing system.


Chapter 4. Hospital D

1. Description

Hospital D is located in a small city on the island of Java and is designated as a type A teaching hospital. It is located in a province with 297 hospitals, of which 73 are public; 130 are private, non-profit; 89 are private, for-profit; and five are owned by national companies. Among them, eight hospitals are type A, funded by the MOH and local government.

The number of beds in Hospital D grew from 912 in 2011 to 967 in 2014 and then 1217 in 2017. It is designated a center of excellence for cardiac services, organ transplantation, radiotherapy, and nuclear medicine.

The hospital had been re-accredited by KARS (2016) and JCI as an academic medical center (2015). The JCI accreditation was fully funded by the hospital rather than by the MOH unlike many of the other JCI-accredited hospitals in this study. The hospital plans to be re-accredited by JCI in 2018 (Figure 187).

Figure 187. Timeline for accreditation of Hospital D

2. Results


Hospital D showed improvement in most of performance indicators, such as bed occupancy rate, waiting time for elective surgery, and waiting time for prescription drugs (Table 59). Indicators met MOH standards except net death rate (NDR), which was higher than the 25 per 1000 case national standard from 2011 to 2015 (Figure 192). The high NDR was possibly associated with the severity of cases referred to the hospital and not necessarily indicative of poor service quality.

Table 59. Hospital-reported basic performance indicators, Hospital D, 2011 to 2015

Variables MoH Standard* Phase (Year)

Baseline Midline End-line (2011) (2013) (2015)

Emergency Response time (minutes) < 5 2.0 0.3 1.6

Waiting time for prescription drug service (minutes)

< 30 minutes 20.0 40.7 30.2

Post-operative death rate 3 0.3 0.9 0.0

KARS 2007 ‐ 16 Service Accred

2008Baseline Data Collection (Dec)

2012

• KARS 2012 Accred (Sept)2013

• JCI Mock Survey (May)

• Midline Data Collection (Jun)

2014

• Final JCI Accred Survey (Feb)

• JCI Accreditation (before June)

2015

• End‐line Data Collection (Feb)

• re‐accreditation of KARS 2012

2016• Future Plan to be re‐accredited by JCI

2018


Figure 188. Bed occupancy rate, Hospital D, by phase

Note: MOH standard is 60-80%

Figure 189. Average length of stay, Hospital D, by phase


Figure 190. Bed turnover interval, Hospital D, by phase


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Figure 191. Bed turnover, Hospital D, by phase

Note: MOH standard is 40-50 times

Figure 192. Net death rate, Hospital D, by phase

Note: MOH standard is 25/1000

Hospital review

Hospital D review results showhospital governance and huma

ed an increase from baseline to end-line in almost all domains except n resources (Figures 193-202). However, the human resources domain

has increased greatly in the end-line period (Figure 195). Hospital D scored similarly to the average of the other eight hospitals across most domains, with only a few components that were lower than average. Patient orientation improved considerably (Figure 194) as did clinical practice, health care associated infection, facilities management, medication safety, and surgical intervention (Figures 196-201).

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Figure 193. Hospital governance by phase, Hospital D vs. 8 other hospitals

Patient orientation

Figure 194. Patient orientation by phase, Hospital D vs. 8 other hospitals

Human resources

Figure 195. Human resource by phase, Hospital D vs. 8 other hospitals

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Figure 196. Clinical practice and patient care by phase, Hospital D vs. 8 other hospitals

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Figure 197. Healthcare-associated infection by phase, Hospital D vs. 8 other hospitals

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Figure 198. Transfusion by phase, Hospital D vs. 8 other hospitals

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Figure 199. Facilities management by phase, Hospital D vs. 8 other hospitals

Medication safety

Figure 200. Medication safety performance by phase, Hospital D vs. 8 other hospitals


Figure 201. Surgery, interventional procedures, and anesthesia by phase, Hospital D vs. 8 other hospitals

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Figure 202. Documentation and records by phase, Hospital D vs. 8 other hospitals

Organizational audit (4 department – average)

Hospital D showed an increase in each phase for the 10 criteria of the organizational audit in the four departments. The surgical department showed a significant increase at the end-line as did pediatrics and internal medicine/cardiology. The obstetric department decreased in the midline, but increased in the end-line period; scoring higher at end-line than during the previous study periods (Figures 203-206).

Total scores for the four departments were generally higher than the average of the eight other hospitals for the organizational audit, especially in pediatric and internal/cardiology department. Hospital D has a specially designated ward for cardiology patients, compared to several of the other eight hospitals that do not, and is classified as a cardiac center of excellence. Orthopedics patients were not placed in a specific ward but were placed in the general surgery ward.

Figure 203. Key organizational audit criteria in Obstetric Department, Hospital D vs. 8 other hospitals

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Figure 204. Key organizational audit criteria in Pediatric Department, Hospital D vs. 8 other hospitals

Figure 205. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital

D vs. 8 other hospitals

Figure 206. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital D vs. 8

other hospitals

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Delivery

At baseline and midline, most delivery patients used out of pocket payment for their hospital costs, but this proportion decreased dramatically with implementation of JKN in 2014. By end-line, most patients were using JKN to pay for their hospital expenses. The proportion using JKN by the end-line was higher than the other eight hospitals in the study (Table 60). The average length of stay did not change significantly over the study period (Figure 207).

Table 60. Method of payment for normal delivery patients by phase, Hospital D vs. 8 other hospitals

D 8 hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 70.0 93.3 10.0 30.4 13.8 20.8Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0Government insurance 0.0 6.7 0.0 15.0 6.3 0.0Insurance for the poor 3.3 0.0 0.0 22.5 32.9 7.1Jampersal 26.7 0.0 0.0 30.0 36.6 0.0BPJS 90.0 64.6Others 0.0 0.0 0.0 0.0 0.0 5.0Do not know 0.0 0.0 0.0 1.7 10.4 2.5

Figure 207. Average length of stay for normal delivery patients by phase, Hospital D vs. 8 other

hospitals

Figure 208. Mean age for normal delivery patients by phase, Hospital D vs. 8 other hospitals

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The patient's condition at discharge was recorded for a high percentage of patients in the baseline and midline. However, there was a slight decrease from midline to end-line. No patients elected for judicial discharge in Hospital D in any of the study periods; whereas there were patients who elected this in all of the other hospitals in the study (Table 61).

There was a significant increase of recording of laceration in normal delivery patients at each phase in Hospital D. At end-line, a greater proportion of patients at Hospital D had laceration recorded at Hospital D than at any of the other hospitals in the study (Figure 209).

The completeness of medical records for normal delivery patients was already high at baseline and remained so throughout the study period. Recording of Apgar scores and birth weight – both indicators reported on birth certificates – remained at 100% from baseline to end-line (Figures 210-211).

Table 61. Percentage of normal delivery patients’ condition at discharge by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 100.0 100.0 83.3 86.7 84.6 85.8Referred to other hospital 0.0 0.0 0.0 0.0 1.3 0.0Death 0.0 0.0 0.0 0.0 0.0 0.0Not cured, judicial discharge 0.0 0.0 0.0 0.4 2.5 4.6Other 0.0 0.0 0.0 4.6 0.4 0.0Control and outpatient 0.0 0.0 0.0 0.0 0.8 0.0Unknown 0.0 0.0 16.7 8.3 10.4 9.6

Figure 209. Laceration recorded of normal delivery patients by phase, Hospital D vs. 8 other

hospitals

Figure 210. Apgar score recorded for normal delivery newborns by phase, Hospital D vs. 8 other

hospitals

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Figure 211. Birth weight score recorded for normal delivery patients by phase, Hospital D vs. 8 other hospitals


Table 62. Age distribution of pneumonia patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals

Age (months) Baseline Midline End-line Baseline Midline End-line

< 1 0.0 10.0 0.0 2.1 19.3 15.8

1 - 11 30.0 60.0 73.4 57.8 47.9 35.4

12 - 23 33.3 20.0 13.3 24.6 17.2 28.3

24 - 35 26.7 6.7 3.3 9.2 10.1 11.7

36 - 47 10.0 3.3 10.0 5.0 3.8 5.8

48 - 59 0.0 0.0 0.0 1.3 1.7 2.9

Table 63.Sex distribution of pneumonia patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals


Male 43.3 56.7 60.0 50.4 54.0 54.6

Female 56.7 43.3 40.0 49.6 46.0 45.4 Figure 212. Mean age in months of pneumonia patients by phase, Hospital D vs. 8 other hospitals

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Most children diagnosed with pneumonia had their hospital costs paid for out of pocket at baseline and midline, but this decreased dramatically once JKN became available in 2014, as observed in the other eight hospitals (Table 64).

The percentage of patients who died decreased slightly after the baseline, while the percentage whose condition was reported to be resolved at discharge increased from baseline (Table 65). Length of stay for pneumonia patients did not change significantly over the whole period; it was slightly higher than the average for the other eight hospitals, but not statistically significantly so (Figure 213).

Table 64. Method of payment for pneumonia patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 86.7 83.3 20.0 55.4 44.8 34.6Commercial insurance 3.3 0.0 0.0 1.3 0.0 0.0Governance insurance 3.3 10.0 0.0 10.4 5.9 0.0Insurance for the poor 6.7 6.7 10.0 29.2 40.2 10.4Other, specified 0.0 0.0 0.0 1.7 1.3 2.5BPJS 70.0 51.3Do not know 0.0 0.0 0.0 2.1 8.0 1.3

Table 65. Condition of pneumonia patients at discharge by phase, Hospital D vs. 8 other hospitals


Figure 213. Length of stay for pneumonia patients by phase, Hospital D vs. 8 other hospitals

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Figure 214. Respiratory symptoms recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals

Figure 215. Immunization recorded for pneumonia patients by phase, Hospital D vs. 8 other

hospitals

Figure 216. Temperature recorded for pneumonia patients by phase, Hospital D vs. 8 other

hospitals

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Figure 217. Respiratory rate recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals

Figure 218. Pulse recorded for pneumonia patients by phase, Hospital D vs. 8 other hospitals

AMI

There was no difference in length of stay for AMI patients from baseline to end-line (Figure 220). With AMI patients, we observed the same pattern of a high proportion of patients initially using OOP for hospital costs, which diminished significantly with implementation of JKN (Table 66).

The proportion of patients with an AMI diagnosis who died in Hospital D as well as the proportion of patients choosing judicial discharge decreased across the three study periods. By way of comparison, on average the other eight hospitals experienced an increase in AMI patient deaths in the end-line period but a decrease in the proportion of patients choosing judicial discharge (Table 67).

The proportion of patients receiving a documented prescription for statins and aspirin increased from baseline (54% for statins; 62% for aspirin) to 97% compliance for both at end-line (Figures 224-225). There was also improvement in oral beta-adrenergic prescription, which started from a very low baseline (42%) to increase to 80% at end-line (Figure 223).

Recording of medical history indicators, such as history of previous AMI, angina pectoris, cerebrovascular accident, and/or heart failure, was low at baseline, but showed some improvement thereafter. The levels in Hospital D were the same or slightly higher than the other eight hospitals, but not statistically significantly so (Figures 226-232). Recording of previous AMI (Figure 226) and angina pectoris (Figure 227) decreased between midline and end-line, but still ended higher than at baseline.

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Figure 219. Mean age of AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 220. Length of stay for AMI patients by phase, Hospital D vs. 8 other hospitals

Table 66. Method of payment recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals


Out of pocket 53.3 73.4 16.7 34.6 27.6 17.1




Other 0.0 3.3 0.0 0.0 0.0 4.6

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Table 67. Recorded condition at discharge for AMI patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals


Cured/improving 66.7 83.3 80.0 61.6 63.0 63.3Referred to other hospital 0.0 0.0 0.0 0.0 0.0 0.4


Other 3.3 0.0 0.0 8.3 1.7 0.0Control and outpatient 0.0 0.0 0.0 0.0 8.6 1.3

Unknown 0.0 0.0 10.0 8.8 8.2 14.6

Figure 221. Cardiac enzymes examination recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 222. ECG examination recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

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Figure 223. Oral beta-adrenergic recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 224. Statins recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 225. Aspirin prescription recorded for AMI patients by phase, Hospital D vs. 8 other

hospitals

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Figure 226. Previous AMI history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 227. Angina pectoris history recorded of AMI patients by phase, Hospital D vs. 8 other

hospitals

Figure 228. Hypertension history recorded for AMI patients by phase, Hospital D vs. 8 other

hospitals

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Figure 229. Hypercholesterolemia history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals

Figure 230. Cerebrovascular accident history recorded for AMI patients by phase, Hospital D vs. 8

other hospitals

Figure 231. Heart failure history recorded for AMI patients by phase, Hospital D vs. 8 other

hospitals

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Figure 232. Diabetic history recorded for AMI patients by phase, Hospital D vs. 8 other hospitals


The average length of stay for hip fracture patients was between 17 and 20 days in Hospital D; slightly longer than the average for the other eight hospitals, but not statistically significantly so (Figure 234). Almost all patients had their medical expenses covered by JKN by the end-line period. The percentage of patients covered by JKN at Hospital D was slightly more than in the other eight hospitals (Table 68).

Figure 237 shows that compliance with mobilization after surgery was consistently high from midline to end-line (100%); this was higher than the average for the other eight hospitals, which showed low compliance at baseline and only some improvement at end-line. The use of thromboembolic showed no change from baseline to end-line (Figure 238).

Figure 233. Mean age for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

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Figure 234. Length of stay for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

Table 68. Method of payment for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 76.7 63.3 3.6 46.0 25.9 12.3Governance insurance 23.3 36.7 0.0 24.4 35.5 0.0Insurance for the poor 0.0 0.0 3.6 23.5 29.8 1.5BPJS 92.8 78.8Other 0.0 0.0 0.0 1.7 0.0 5.4Do not know 0.0 0.0 0.0 4.4 8.8 2.0

Table 69. Condition of hip/femoral neck fracture patients at discharge by phase, Hospital D vs. 8 other hospitals


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Figure 235. Surgery of hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

Figure 236. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital D vs. 8 other hospitals

Figure 237. Mobilization after surgery of hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

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Figure 238. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital D vs. 8 other hospitals

Patient interviews

Most patient respondents were more than 40 years old and had junior to high school education (Table 70). Similar to some other hospitals, at baseline most of patients were using Jamkesmas for financial coverage of their hospital stay, but after JKN implementation the majority were covered by that. Among those covered by BPJS, the majority were patients with independent BPJS (those who paid their own premiums to BPJS compared to those whose premiums were paid by the government); this trend was also observed at the other eight hospitals (Table 71). The average length of stay among the patients interviewed increased in the end-line phase, from 7 days at midline to 8.5 days at end-line (Figure 240).

Patients’ perception of the professional competence of the doctors and nurses was over 80% from baseline to end-line (Figures 241-242), while satisfaction with hospital facilities and a patients’ recommendation of the hospital increased slightly from baseline to end-line and was generally slightly higher than the average of the other eight hospitals (Figures 244-245).

Table 70. Characteristics of patients interviewed by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 26.5 25.8 30.7 27.9 27.7 33.6

Female 73.5 74.2 69.3 72.1 72.3 66.4Education



Academy and University 12.8 15.0 16.9 15.2 17.3 18.9

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Figure 239. Mean age of patient interviewed by phase, Hospital D vs. 8 other hospitals

Table 71. Method of payment of patients interviewed by phase, Hospital D vs. 8 other hospitals

D 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 9.4 5.8 8.9 19.8 11.4 13.3Commercial insurance 0.0 0.0 0.0 1.5 0.4 0.2Government insurance 23.1 0.0 0.0 19.2 0.0 0.0Jampersal 15.4 0.0 0.0 16.4 0.0 0.0BPJS for the poor (PBI)/Jamkesmas 50.4 32.5 26.6 41.0 37.4 29.0BPJS pay for premium 39.2 37.9 30.4 32.5BPJS paid by the company 6.7 12.1 3.4 9.4BPJS for government employee (Askes, Asabri, etc)

15.8 13.7 16.4 14.3

Other 1.7 0.0 0.8 2.0 0.2 1.3Do not know 0.0 0.0 0.0 0.1 0.2 0.0

Figure 240. Length of stay of interviewed patients by phase, Hospital D vs. 8 other hospitals

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Figure 241. Patient satisfaction with medical services by phase, Hospital D vs. 8 other hospitals

Figure 242. Patient satisfaction with nursing care by phase, Hospital D vs. 8 other hospitals

Figure 243. Patient satisfaction with medical decisions and clarity of discharge instruction by phase, Hospital D vs. 8 other hospitals

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Figure 244. Patient satisfaction with hospital facilities by phase, Hospital D vs. 8 other hospitals

Figure 245. Patient satisfaction with all services at hospital by phase, Hospital D vs. 8 other

hospitals


Accreditation

Similar to the other eight hospitals, the accreditation process progressed well in Hospital D in January 2015. Commitment from management to pursue JCI accreditation was very high, as evidenced by the financing of all accreditation activities using their own budget. From the JCI assessment result, Hospital D needed to make improvements in small elements of their operation in 2015. These were successfully made and the hospital passed the final JCI survey.

Key informants reported that work culture was the main problem in fulfilling accreditation standards; however, this reportedly improved after the accreditation. Undertaking the process of JCI accreditation was supported by the management’s commitment to the process as well as engagement in the process by the entire hospital staff, including non-clinical staff. According to one informant, one of methods that the hospital management initiated to improve the work culture of doctors was to engage midwives and nurses, who accompanied the medical staff during their rounds, instructing them to report if the doctors did not work according to JCI standards of care. Hospital directors emphasized that JCI and KARS accreditation were not the only reasons for implementing changes in the hospital, but it was a major factor in inducing commitment from all staff to improve services with the goal of elevating quality overall.

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Accreditation was reported to be a good tool, among others, to stimulate changes toward improvement because it was conducted by external parties.

Rapid changes to improve hospital service were required not only for accreditation but also as part of the Hospital’s Strategic Plan Year 2010. Improvements has been seen since then in indicators such as emergency response times and reducing length of stay. This was neither supported nor refuted by the data collected in this study since 2013. The hospital reportedly looked favorably on the accreditation renewal process, which occurs every 1-2 years, as a means of measuring service quality.

Areas of care in a hospital can be designated as a “center of excellence” by the MOH based the results of a performance review and an assessment of the impact of the unit on overall hospital performance. Hospital D sought the “center of excellence” designation for cardiac and oncology services because these two units were perceived by hospital management to be performing very well.

The hospital conducted open and closed medical reviews and were implementing changes to improve the medical records system. Medical record filing was conducted by staff within the medical record units of each ward, and each record was checked for accuracy and signatures of the doctors responsible for the care of that patient.

JKN implementation

The national health insurance system which came into force in 2014 brought about a major change in entire hospital process. It forced the hospital to implement a tiered referral system that required type A hospitals, such as Hospital D, to provide tertiary referral services for patients with complex diseases. It required substantial increases in human resources and health equipment—and the resultant increases in expenditure. Improvement of the referral system brought a significant decrease in patient volume at the beginning of JKN. Therefore, preparation of the strategic development plan needed careful review to predict future operational challenges. Since Hospital D is administered vertically under the MOH, implementation of existing MOH policies and regulations was mandatory.

About 90% of Hospital D’s patients were covered by JKN at the end-line period. Various attempts were made by the hospital to improve its services, such as evaluating patients with lengths of stay longer than seven days and reviewing prescriptions made for medications not on the national formulary. Implementation of JKN also increased the bed capacity (supply) for its third-class patients. In addition, the hospital also has developed an online system to monitor availability of beds in the ER as part of an integrated emergency medical services system.

Another strategy to improve services and generate higher hospital income was providing private services in separate buildings so that people could choose care from the same doctors but at different facilities. This allowed access, for those who could afford it, to the VIP room with its faster service and administration. It was not reported whether this decreased the time doctors had available to attend to patients in the lower-class wards.

An informant from the medical department noted that BPJS patients were generally admitted in a terminal condition, sometimes because their condition was mishandled at the original provider facility. For continued treatment, there was a risk they would be returned to a type B or C hospital, where adequate quality of care could not be guaranteed.

Implementation of JCI standards for medical record completeness was in line with the JKN policy requirements. Medical records were required to be complete and coherent from beginning to end in order to generate a valid claim for reimbursement from JKN. Informants stated that this encouraged doctors to keep a more thorough and complete medical record; in turn, providing better quality of care.

The hospital encouraged local government to incorporate Jamkesda (a health coverage system provided at the district level for those who are not covered by BPJS) into BPJS. However, after financial


calculations were made, it was seen this would create operating deficits. One reason Jamkesda has not joined with BPJS is because it did not have adequate financial risk protection.

Conclusion

Leadership is the most important factor in facilitating success in the accreditation process. Furthermore, commitment from top-level management and all staff in implementing accreditation standards greatly enhanced the success in the process of accreditation. This can be seen from the improvement of each variable in the hospital review, organizational audit, and clinical review in Hospital D. Completion of KARS and JCI accreditation has improved quality of care in Hospital D and helped them in anticipating the impact of government policy changes in the JKN era. Nevertheless, management already had a strategy prior to accreditation for dealing with changes due to implementation of JKN, including developing a Memorandum of Understanding (MoU) with the BPJS verification teams, to make the necessary adaptations to the remuneration systems of the hospital to maintain a sound financial system.


Chapter 5. Hospital E

1. Description

Hospital E is located in a city with the highest population density in one of province of Sumatera. The province has 48 general hospitals (26 public/government hospitals, 9 non-profit hospitals, 8 private and 5 national company-owned hospitals) and 17 specialty hospitals.

Hospital E is a type A national referral hospital with 969 beds (as of 2016); 51% of which are for class III patients. It serves the nearby provinces: Jambi, Lampung, Bengkulu, and Bangka-Belitung. The hospital has centers of excellence for cardiocerebrovascular care, oncology, minimally invasive surgery, kidney transplantation, and in vitro fertilization services.

This hospital is primarily funded by the MOH and is a main teaching hospital for a major university, mostly for medical residents. The hospital was accredited by KARS in January 2015 and by JCI, as an Academic Medical Centre (AMC), in November 2016 (Figure 246). The accreditation process was originally postponed in 2014 because preparations were incomplete. In 2015, the hospital changed their directors and some of the top management and reinitiated the process.

Figure 246. Timeline for accreditation of Hospital E

KARS 2007 ‐16 Service Accred

2008 Baseline Data Collection (Oct)2012

• Midline Data Collection (Apr)2014

• KARS 2012 Accrediation (Jan)

2015

• Mock Survey JCI accreditation (April ‐May)

• End‐line Data Collection (May)

• Final Survey JCI Accreditation (Oct‐Nov)

2016

2. Results

Hospital secondary data

Overall, Hospital E shows improvement in most performance indicators, even though some did not meet predetermined standards, such as net death rate and waiting times for elective surgery (Table 72, Figures 247-251). Waiting time for patients decreased for both prescription drug service and before surgery. Bed occupancy rate, prescription drug waiting times, average length of stay, and the emergency services death rate showed improvement from the baseline and reached the MOH standard in the end-line.

Table 72. Hospital-reported basic performance indicators, Hospital E, 2011 to 2015

Variables MOH

Standard*

E Baseline

(2011)Midline (2013)

End-line (2015)

Emergency response time (minutes) < 5 5 5 5Waiting time for prescription drug service (minutes)

< 30 > 30 8.1 9.6

Post-operative death rate 3 4 2 NR


Figure 247. Bed occupancy rate, Hospital E, by phase

Note: MOH standard is 60-80%. Source: Source: Hospital Annual Report

Figure 248. Average length of stay, Hospital E, by phase


Figure 249. Emergency room death rate, Hospital E, by phase

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Figure 250. Net death rate, Hospital E, by phase


Figure 251. Pre-operative waiting time, Hospital E, by phase

Note: MOH standard is ≤2 days

Hospital review

Hospital E review results mostly showed low scores at the beginning of the study compared to the mean scores of the other eight hospitals. Most domains increased from baseline to end-line (Figures 252-261), except for human resource, transfusion, and health care associated infection. An exception was facility management, which had higher scores compared with the mean of other eight hospitals at end-line.

The hospital governance domain increased greatly in the midline and remained consistent at end-line (Figure 252). Human resource, transfusion, and health care associated infection scores were more than 3.5 out of a maximum of four; higher than other domains. Clinical practice had the lowest score compared to other domains at baseline and end-line.

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Figure 252. Hospital governance by phase, Hospital E vs. 8 other hospitals

Patient orientation

Figure 253. Patient orientation by phase, Hospital E vs. 8 other hospitals

Human resources

Figure 254. Human resource by phase, Hospital E vs. 8 other hospitals

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Figure 255. Clinical practice and patient care by phase, Hospital E vs. 8 other hospitals


Figure 256. Healthcare-associated infection by phase, Hospital E vs. 8 other hospitals

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Figure 257. Transfusion by phase, Hospital E vs. 8 other hospitals

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Figure 258. Facilities management by phase, Hospital E vs. 8 other hospitals

Medication safety

Figure 259. Medication safety by phase, Hospital E vs. 8 other hospitals


Figure 260. Surgery, interventional procedures, and accompanying anesthesia by phase, Hospital E vs. 8 other hospitals

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Figure 261. Documentation and records by phase, Hospital E vs. 8 other hospitals


Overall, Hospital E showed that on the 10 criteria assessed in the four departments, increases were seen in each successive phase for pneumonia and normal delivery but not for cardiology/internal medicine and orthopedic/surgery departments. At baseline, all department scores were lower than the mean score of eight other hospitals for the respective departments. Both the obstetric and pediatric departments showed improvement between baseline and end-line; by end-line each department’s score was higher than the mean score for other eight hospitals in the study (Figures 262-263). The internal medicine/cardiology showed a slight increase between baseline and midline and then remained stable to end-line (Figure 264) while the orthopedic/surgical department showed slightly decrease scores at end-line (Figure 265); both departments scored below the mean score for other eight hospitals at end-line.

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Figure 262. Key organizational audit criteria in Obstetric Department, Hospital E vs. 8 other hospitals

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Figure 263. Key organizational audit criteria in Pediatric Department, Hospital E vs. 8 other hospitals

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Figure 264. Key organizational audit criteria in internal Medicine/Cardiology Department, Hospital E vs. 8 other hospitals

Orthopedic/surgical

Figure 265. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital E vs. 8 other hospitals

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Chart review (4 diagnoses) Delivery

In Hospital E, the majority of patients changed to JKN when it became available; the same trend observed in the other hospitals. At end-line, the percentage of patients using JKN was the same as all other hospitals in the study (Table 73). The average length of stay and the mean age of delivery patients did not change significantly over the study period (Figures 266 and 267).

Table 73. Method of payment for normal delivery patients by phase, Hospital E vs. 8 other hospitals

E 8 hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 23.3 3.3 6.7 36.3 25.0 21.3Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0Government insurance 3.3 3.3 0.0 14.6 6.7 0.0Insurance for the poor 60.1 3.3 20.0 15.4 32.5 1.6Jampersal 0.0 6.7 0.0 33.3 35.8 0.0BPJS 0.0 0.0 70.0 0.0 0.0 70.0Other 0.0 0.0 0.0 0.0 0.0 5.0Do not know 13.3 83.4 3.3 0.0 0.0 2.1

Figure 266. Length of stay for normal delivery patients by phase, Hospital E vs. 8 other hospitals

Figure 267. Mean age for normal delivery patients by phase, Hospital E vs. 8 other hospitals

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Patients’ condition at discharge was recorded for a high proportion of patients in baseline and end-line. However, there was a marked increase in the percentage of patients whose condition was unknown at discharge during the midline period (Table 74).

Recording of laceration for normal delivery cases were already high at baseline, but this indicator decreased at midline and then remained the same at end-line (Figure 268). Recording of Apgar score and birth weight remained at 100% from baseline to end-line (Figures 269 and 270).

Table 74. Mother’s condition at discharge for normal delivery patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 100.0 53.4 96.7 86.7 90.3 84.1Referred to other hospital 0.0 0.0 0.0 0.0 1.3 0.0Death 0.0 0.0 0.0 0.0 0.0 0.0Judicial discharge 0.0 10.0 3.3 0.4 1.3 4.2Other 0.0 3.3 0.0 4.6 0.0 0.0Control and outpatient 0.0 0.0 0.0 0.0 0.8 0.0Unknown 0.0 33.3 0.0 8.3 6.3 11.7

Figure 268. Laceration recorded for normal delivery patients by phase, Hospital E vs. 8 other hospitals

Figure 269. Apgar score recorded for normal delivery newborns by phase, Hospital E vs. 8 other hospitals

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Figure 270. Birth weight recorded for normal delivery newborns by phase, Hospital E vs. 8 other hospitals


Most children in the sample were less than one year old at baseline, less than one month old at midline, and 12-23 months old at end-line, which was an unexpected degree of variability (Table 75). Length of stay for pneumonia patients under 5 years old at Hospital E was higher than the average for the eight other hospitals at the baseline and midline but decreased at the end-line to be in line with them (Figure 272).

Table 75. Age category for pneumonia patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Age (months) Baseline Midline End-line Baseline Midline End-line

< 1 3.3 48.4 16.7 1.7 14.6 13.8 1 - 11 90.1 24.1 6.7 50.3 52.4 43.7 12 - 23 3.3 6.9 43.3 28.3 18.8 24.5 24 - 35 0.0 10.3 26.6 12.5 9.6 8.8 36 - 47 3.3 0.0 6.7 5.8 4.2 6.3 48 - 59 0.0 10.3 0.0 1.3 0.4 2.9

Table 76. Sex for pneumonia patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-line Male 56.7 43.3 63.3 48.8 55.7 54.2 Female 43.3 56.7 36.7 51.3 44.4 45.8

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Figure 271. Mean age for pneumonia (months) patients by phase, Hospital E vs. 8 other hospitals

Figure 272. Length of stay for pneumonia patients by phase, Hospital E vs. 8 other hospitals

The trend for increasing BPJS coverage as the method of payment was the same as other departments in this hospital and the other hospitals (Table 77).

Table 77. Method of payment for pneumonia patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 30.0 0.0 6.7 62.4 55.3 36.3Commercial insurance 0.0 0.0 0.0 1.7 0 0Governance insurance 13.3 6.7 0.0 9.2 6.3 0Insurance for the poor 50.0 33.3 60.0 23.7 36.8 4.2Other, specified 0.0 3.3 0.0 1.7 0.8 2.5BPJS 33.3 55.7Do not know 6.7 56.7 0.0 1.3 0.8 1.3

The clinical chart review for pneumonia patients showed slightly decreases in midline period for the proportion of patients whose condition at discharge was not recorded (Table 78). Recording of respiratory symptoms was not substantively different, while recording of immunization status substantively decreased

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in midline and then increased at end-line (Figures 273 and 274). Basic physical examination (temperature, respiratory rate, and pulse) did not vary to a significant degree, remaining between 80 to 100% across the three time periods (Figure 275 to 277).

Table 78. Patient condition at discharge for pneumonia patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 90.0 76.6 80.0 64.1 59.7 65.0Referred to other hospital 0 0 0 1.3 1.7 0.0Death 0.0 6.7 10.0 6.6 13.4 12.5Not cured, judicial discharge 6.7 10.0 3.3 15.0 12.6 10.4Other 0.0 0.0 0.0 6.3 0.0 0.0Control and outpatient 0.0 0.0 0.0 0.0 1.7 0.8Unknown 3.3 6.7 6.7 6.7 10.9 11.3

Figure 273. Respiratory symptom recorded for pneumonia patients by phase, Hospital E vs. 8

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Figure 274. Immunization recorded for pneumonia patients by phase, Hospital E vs. 8 other

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Figure 275. Temperature recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals

Figure 276. Respiratory rate recorded for pneumonia patients by phase, Hospital E vs. 8 other

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Figure 277. Pulse recorded for pneumonia patients by phase, Hospital E vs. 8 other hospitals

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AMI

Average age and average length of stay for AMI patients at Hospital E remained mostly unchanged from baseline to end-line and was not significantly different from the average among the eight other hospitals (Figures 278 and 279). Most patients were using insurance for the poor in the baseline, insurance type was not recorded at midline, then there was a major shift to JKN at end-line (Table 79).

The proportion of patients who chose judicial discharge increased in end-line (Table 80). The proportion of patients who did not have their condition recorded at discharge decreased slightly from midline to end-line (Table 80).

The proportion of patients who reportedly received prescriptions of oral beta-adrenergic, statin, and aspirin appeared to improve continuously from baseline to end-line, especially prescription (Figures 282 and 284). While there was good improvement in oral beta-adrenergic prescription reporting, it started from a very low baseline (lower than 20%) and was still lower than 50% at end-line (Figure 282).

Figures 285-291 show that some elements of recording of medical history improved from baseline to end-line. Most indicators were initially very low at baseline, especially recording history of previous AMI, angina pectoris, cerebrovascular, and heart failure. Some indicators, such as heart failure (Figure 290) and cerebrovascular disease (Figure 289) recording were still very low at the end of the study. Recording of other important parts of a patient’s medical history, such as angina pectoris (Figure 286), heart failure (Figure 290), and diabetic history (Figure 291), improved markedly from baseline to end-line, but overall there remained major deficits in the completeness of AMI patient medical chart recordings from this sample.

Figure 278. Average age for AMI patients by phase, Hospital E vs. 8 other hospitals

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Figure 279. Length of stay for AMI patients by phase, Hospital E vs. 8 other hospitals

Table 79. Method of payment recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 10.0 0.0 3.3 40.0 36.6 18.8Commercial insurance 0.0 3.3 3.3 1.3 0.0 0.0Government insurance 66.7 23.4 0.0 35.0 28.8 0.0Insurance for the poor 10.0 20.0 16.7 22.4 34.2 2.9Other 0.0 0.0 0.0 0.0 0.4 4.6BPJS 76.7 72.9Do not know 13.3 53.3 0.0 1.3 0.0 0.8

Table 80. Patient condition at discharge recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 76.7 70.0 63.4 60.4 64.6 65.4Referred to other hospital 0.0 0.0 0.0 0.0 0.0 0.4Death 6.7 0.0 3.3 10.8 13.2 14.6Not cured, judicial discharge 3.3 0.0 10.0 12.9 7.4 5.4Other 0.0 0.0 0.0 8.8 1.7 0.0Control and outpatient 0.0 0.0 0.0 0.0 8.6 1.3Unknown 13.3 30.0 23.3 7.1 4.5 12.9

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Figure 280. Cardiac enzymes examination recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 281. ECG examination recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 282. Oral beta-adrenergic recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

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Figure 283. Statin recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 284. Aspirin recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 285. Previous AMI recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

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Figure 286. Angina pectoris recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 287. Hypertension recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 288. Hypercholesterolemia history recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

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Figure 289. Cerebrovascular disease recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 290. Heart failure recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

Figure 291. Diabetic history recorded for AMI patients by phase, Hospital E vs. 8 other hospitals

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Hip fracture/femoral neck fracture

We were only able to review six clinical charts in the baseline period because there were so few patients admitted with this diagnosis in Hospital E during the 18 months prior. We were able to review 16 charts at midline and 17 at end-line. The inclusion criteria were reviewed in the midline and end-line to ensure that the sample included all upper femoral fractures.

There was an increase in the age of patients admitted for this diagnosis over the study period, from younger than 30 years old to almost 70 years of age (Figure 292). The average length of stay for hip fracture patients slightly increased from baseline to midline, then decreased at end-line (Figure 293). All patients had their medical expenses covered by JKN by the end-line period; this was higher in Hospital E than in the other eight hospitals (Table 81). The proportion of patients who underwent surgical treatment increased about 30% between midline and end-line (Figure 294).

Figure 295 shows compliance of antibiotic prophylactic fluctuated from baseline to end-line. Reports of mobilization after surgery showed continuous improvement from baseline to end-line (Figure 296). The use of thromboembolism prophylaxis also showed an increasing trend (Figure 297).

Figure 292. Age for hip/femoral neck-fracture (mean) patients by phase, Hospital E vs. 8 other hospitals

Figure 293. Length of stay for hip/femoral neck-fracture patients by phase, Hospital E vs. 8 other

hospitals

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Table 81. Method of payment for hip/femoral neck-fracture patients by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 0.0 0.0 0.0 54.7 32.9 12.1Governance insurance 33.3 6.3 0.0 23.7 37.9 0.0Insurance for the poor 16.7 18.8 0.0 18.7 26.5 1.9BPJS 0.0 0.0 100 0.0 0.0 79.0Other 0.0 0.0 0.0 1.4 0.0 5.1Do not know 50.0 75.0 0.0 1.4 2.7 1.9

Table 82. Patient’s condition for hip/femoral neck-fracture patients by phase, Hospital E vs. 8

other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 83.3 62.4 94.1 61.2 64.8 63.7Referred to other hospital 0.0 0.0 0.0 0.0 0.0 0.5Death 0.0 0.0 0.0 3.6 1.8 3.7Not cured, judicial discharge 16.7 6.3 0.0 23.7 19.6 13.0Other 0.0 12.5 0.0 0.0 0.0 2.3Control and outpatient 0.0 0.0 0.0 0.7 10.1 0.5Unknown 0.0 18.8 5.9 10.8 3.7 16.3

Figure 294. Surgery for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals

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Figure 295. Antibiotic prophylactic of hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals

Figure 296. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals

Figure 297. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital E vs. 8 other hospitals

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Patient interviews

Most respondents for the patient interview in all three phases of the study were female, junior and high school graduates, and more than 40 years of age (Table 83 and Figure 298). In the baseline, most of patients were using Jamkesmas for financial coverage of their hospital stay, but after JKN implementation most patients were covered by this system. The proportion of patients using BPJS premium was high and increased from midline to end-line (Table 84). The average length of stay decreased from around 12 days at baseline to seven days at end-line (Figure 299).

Patients’ positive perceptions of the professional competence of doctors remained high from baseline to end-line (Figure 300), while patients’ positive perception of nursing care decreased from 80% at baseline to 70% at end-line (Figure 301).

Patient satisfaction with hospital facilities and overall patient satisfaction showed no significant improvement, but remained high from baseline to end-line with around 90% of patients expressing satisfaction with hospital facilities and 93-95% of patients expressing overall satisfaction (Figures 302-303). However, overall patient experience scores were much lower and fluctuated from baseline to end-line (Figures 304).

Table 83. Characteristics of patients interviewed by phase, Hospital E vs. 8 other hospitals

E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 31.7 23.4 44.4 27.3 28.0 31.9

Female 68.3 76.6 55.6 72.7 72.0 68.1Education



Academy and university 14.2 17.7 22.6 15.0 16.9 18.2

Figure 298. Mean age of patients interviewed by phase, Hospital E vs. 8 other hospitals

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Table 84. Method of payment of patients interviewed by phase, Hospital E vs. 8 other hospitals

Method of Payment E 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 15.0 2.4 0.8 19.2 11.8 14.3Commercial insurance 0.8 0.8 0.0 1.4 0.3 0.2Government insurance 17.5 0.0 0.0 19.9 0.0 0.0Jampersal 4.2 0.0 0.0 17.8 0.0 0.0BPJS for the poor (PBI)/Jamkesmas 60.9 58.1 44.4 39.6 34.4 26.8BPJS pay for premium 15.3 27.4 33.4 33.8BPJS paid by the company 4.0 10.5 3.7 9.6BPJS for government employee (Askes, Asabri, etc.) 19.4 16.9 16.0 13.9Other 0.8 0.0 0.0 2.1 0.2 1.4Do not know 0.8 0.0 0.0 0.0 0.2 0.0

Figure 299. Length of stay of patients interviewed by phase, Hospital E vs. 8 other hospitals

Figure 300. Patient satisfaction with medical services by phase, Hospital E vs. 8 other hospitals

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Figure 301. Patient satisfaction with nursing care by phase, Hospital E vs. 8 other hospitals

Figure 302. Patient satisfaction with hospital facilities by phase, Hospital E vs. 8 other hospitals

Figure 303. Patient satisfaction of patient interviewed by phase, Hospital E vs. 8 other hospitals

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Figure 304. Patient experience at hospital by phase, Hospital E vs. 8 other hospitals


It was reported that Hospital E is considered one of the top referral hospitals on the island of Sumatera and is expected to play a leadership role for other hospitals in this area. There was a concern in the hospital about the high net death rate reported. To reduce this, management secured a commitment from doctors to perform daily visits to the wards to review the condition of existing medical equipment, especially resuscitation trolleys and other intensive/emergency care equipment.

Accreditation

Hospital E delayed the KARS accreditation process twice prior to 2015. However, the national MOH enforced a rule that hospital had to undertake accreditation and the hospital successfully completed KARS accreditation in 2015. This means the hospital went seven years between accreditation times. This is much longer than the three-year interval mandated by the MOH.

Key informants reported that hospital leadership recognized the need for improvement in hospital operations. Hospital leaders provided continuous close monitoring to the entire management team, staff, and hospital services. Despite changes in the organizational structure during the period of the study, especially the replacement of the hospital director, the new management decided to continue participation in JCI accreditation at some later stage, likely in 2018. Hospital E had allocated funds in their operating budget for JCI accreditation. Unlike the other hospitals undergoing JCI accreditation in this study, a key informant said that Hospital E received no financial support from the national MOH to undergo this process.

Significant changes were seen that the key informants directly attributed to JCI accreditation. These were improvements in medical equipment, repairs to the hospital facility, and commitment from the staff. The current hospital standards and policies had been updated and were now in line with accreditation standards. They reported that during the accreditation these changes had a substantive positive impact on the daily working environment by all staff in the service units. However, based on the JCI mock survey result in 2016, there are still many aspects in Hospital E’s operations and facilities that needed to be improved, including infection control, facility management, and patient safety.

An improvement in hospital systems in recent years has improved waiting time in the pharmacy and pre-surgical units. Waiting time for elective surgery reportedly did not meet the standard in the baseline but during the accreditation process it was found to be better.

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Informants also mentioned that lack of equipment in the surgery room is a problem for the quality of services and management noted a need for new equipment, but these problems was reportedly yet to be addressed. One solution suggested was to schedule some of the minor surgical procedures to lower level health facilities.

JKN implementation

Implementation of JKN led to a decrease in the number of patients referred to Hospital E, especially for cases with severity level I and II. Referrals decreased from 86% in 2014 to 41% in 2015. According to informants, the number of beds available for third-class patients, 51% of the total beds in the hospital, was lower than demand. A reallocation of beds of some of the first-class beds to third-class beds is planned. Generally, there were complaints due to insufficient bed availability and inadequate inpatient facilities. Patients complained of long wait times in both outpatient and inpatient units.

The situation has become more complicated since the number of non-BPJS patients in 2016 did not increase. It was expected that if there was an increase in non-BPJS revenue, fees from non-BPJS patients would help cover the costs of BPJS patients, for whom reimbursements were lower than the cost of delivering services.

Key informants reported problems with claims to BPJS for JKN services during 2014, but this was settled by the end-line period in 2016. Additionally, there were some problems with reimbursement claims from the local insurance (Jamkesda). This created revenue problems at the hospital because there were still many patients who were using Jamkesda there.

Since JKN was implemented in 2014, hospitals have needed to adjust their financial operations in response to the JKN payment system. The previous fee-for-service system changed to the INA-CBG package system, and there were many reports that the reimbursement levels for numerous diagnoses were too low. Hospital E also had difficulty when BPJS claims did not meet the verification process because of incomplete documentation and delayed submission. There was also a problem with patients who were transferred to in-patient wards from the outpatient department, since outpatient expenses could not be paid by BPJS and there was a lack of clarity in the claim information submitted. The amounts for claims is changing over time, but there is an overall tendency toward increasing reimbursement, which is a welcome change for the hospital. Alternate understandings about claim policies between the hospital and BPJS staff created disputes, particularly in the beginning of JKN implementation. However, in 2015 and 2016, these issues were resolved and the system was functioning better.

Conclusion

Improvements were found during the accreditation period in Hospital E. However, some areas, including clinical services and medical record completion, still have room for improvement. Compared to the other eight hospitals, Hospital E review results mostly showed low scores at the beginning of the study. However, with support from the top management and staff involvement, many measures of the quality in the medical services increased markedly.


Chapter 6. Hospital F

1. Description

Hospital F is located in Jakarta. The region has 129 general hospitals: 43 public hospitals; 32 private, non-profit hospitals; 50 private, for-profit hospitals; and four hospitals owned by national companies. There are also 61 specialty hospitals for cancer, cardiology, mental illness, and others. There are 15 type A hospitals: referral facilities with the most complete and comprehensive services. Eight of these are funded by the MOH, while the others are funded by the provincial government; police, army, and national corporations; and private companies.

Hospital F is a type A national referral hospital with 600 beds and its respiratory center is a center of excellence and a national referral center. It is primarily funded by the central MOH and is a satellite teaching hospital for an Indonesian university, mostly for medical doctors. The hospital was accredited by KARS in November 2015 (Figure 305). The accreditation process was postponed in 2014 because preparation was not complete at that stage. In 2015, the hospital also changed directors.

Figure 305. Timeline for accreditation of Hospital F

KARS 2007 ‐ 16 Service Accred

(Aug)2011 Baseline Data

Collection (Nov)2012• Midline Data Collection (Mar)2014

• Mock Survey KARS 2012 Accreditation (Oct)

• Final Survey KARS 2012 Accreditation (Nov)

2015

• End‐line Data Collection (May‐June)

• Re‐visitation KARS 2012 (Nov)

2016Future Plan to be accredited

by JCI2018

2. Results

Hospital secondary data

Hospital F showed improvement across most performance indicators, such as emergency response time, waiting times for elective surgery, and waiting time for prescription drug services. Waiting time for prescription drug service and surgery decreased across the study period. Most indicators showed improvement and reached national standards by the end-line period. This hospital did not report all the same indicators as the other eight hospitals (Table 85, Figures 306-309).

Table 85. Hospital-reported basic performance indicators, Hospital F, 2011 to 2015

Variables MOH

Standard*

F

Baseline (2011)

Midline (2013)

End-line

(2015) Emergency response time (minutes)

< 5 5 4 3

Waiting time pre-operative (days)

< 2 3 2 2


Figure 306. Hospital F bed occupancy rate by phase


Figure 307. Percentage of deaths in the emergency room, Hospital F, by phase


Figure 308. Net death rate, Hospital F, by phase

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Figure 309. Waiting time for prescription drug service, Hospital F, by phase

Note: MOH standard ≤ 30 minutes

Hospital review

Hospital F review results mostly showed a general trend of improvement from baseline to end-line. Some domains increased continuously from baseline to end-line, such as clinical practice and patient care, transfusion, and medication safety (Figures 313, 315, and 317). However, some indicators did not change significantly throughout the period, such as hospital governance; surgery, interventional procedures, and accompanying anesthesia; and documentation and records (Figures 310-319).

Hospital governance

Figure 310. Hospital governance by phase, Hospital F vs. 8 other hospitals

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Figure 311. Patient orientation by phase, Hospital F vs. 8 other hospitals

Human resources

Figure 312. Human resource by phase, Hospital F vs. 8 other hospitals


Figure 313. Clinical practice and patient care by phase, Hospital F vs. 8 other hospitals

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Figure 314. Healthcare-associated infection by phase, Hospital F vs. 8 other hospitals

Transfusion

Figure 315. Transfusion by phase, Hospital F vs. 8 other hospitals


Figure 316. Facilities management by phase, Hospital F vs. 8 other hospitals

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Medication safety

Figure 317. Medication safety by phase, Hospital F vs. 8 other hospitals


Figure 318. Surgery, interventional procedures, and accompanying anesthesia by phase, Hospital F vs. 8 other hospitals


Figure 319. Documentation and records by phase, Hospital F vs. 8 other hospitals

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Overall Hospital F showed that, based on 10 criteria assessments in the four departments of interest, there were increases from baseline end-line. In the midline period, all departments scored lower than the mean scores of the other eight hospitals. By the end-line, all departments, except the orthopedic/surgery department, received higher scores than the mean score of respective departments at the other eight hospitals (Figures 320-323). The score for the orthopedic/surgery department at end-line remained slightly below the mean score for the other hospitals, but was higher than its score at baseline and midline.

Obstetric

Figure 320. Key organizational audit criteria in Obstetric Department, Hospital F vs. 8 other hospitals

Pediatric

Figure 321. Key organizational audit criteria in Pediatric Department, Hospital F vs. 8 other hospitals

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Figure 322. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital F vs. 8 other hospitals

Orthopedic/surgical

Figure 323. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital F vs. 8 other hospitals


For normal deliveries, the distribution of method of payment changed in response to implementation of JKN as in the other diagnoses and the other hospitals. By end-line, 65% of patients were covered by JKN (Table 86). The average length of stay did not change significantly over the study period (Figure 324). Length of stay was lower at all stages than the average for the other eight hospitals and was trending downwards throughout the study (Figure 324). Laceration recording was better at this hospital compared to the average of the other eight (Figure 326).

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Table 86. Method of payment for normal delivery patients by phase, Hospital F vs. 8 other hospitals

F 8 hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 63.4 23.3 13.3 31.2 22.5 20.4Commercial insurance 3.3 0.0 0.0 0.0 0.0 0.0Government insurance 13.3 0.0 0.0 13.3 7.1 0.0Insurance for the poor 10.0 33.3 0.0 21.7 28.8 7.1Jampersal 10.0 43.4 0.0 32.1 31.2 0.0BPJS 86.7 65.0Other 0.0 0.0 0.0 0.0 0.0 5.0Do not know 0.0 0.0 0.0 1.7 10.4 2.5

Figure 324. Length of stay for normal delivery patients by phase, Hospital F vs. 8 other hospitals

Figure 325. Age for normal delivery patients by phase, Hospital F vs. 8 other hospitals

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Patients’ condition at discharge was recorded for a high proportion of patients in the baseline and midline periods, but decreased substantively at end-line (Table 87).

Laceration record for normal delivery was already high at baseline and did not change much from baseline to end-line (Figure 326). Recording of Apgar score and birth weight remained at 100% from baseline to end-line (Figures 327 and 328).

Table 87. Mother’s condition for normal delivery patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 100.0 96.7 46.7 86.7 85.0 90.4Referred to other hospital 0.0 0.0 0.0 0.0 1.3 0.0Death 0.0 0.0 0.0 0.0 0.0 0.0Judicial discharge 0.0 0.0 0.0 0.4 2.5 4.6Other 0.0 0.0 0.0 4.6 0.4 0.0Control and outpatient 0.0 0.0 0.0 0.0 0.8 0.0Unknown 0.0 3.3 53.3 8.3 10.0 5.0

Figure 326. Laceration recorded for normal delivery patients by phase, Hospital F vs. 8 other

hospitals

Figure 327. Apgar score recorded for normal delivery newborns by phase, Hospital F vs. 8 other hospitals

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Figure 328. Birth weight recorded for normal delivery newborns by phase, Hospital F vs. 8 other hospitals


The average age of patients from the sample of pneumonia patients did not change markedly from baseline to end-line. From baseline through end-line, the greatest number of pneumonia patients under five years old came from the group of children younger than one year. The age makeup was the same distribution as the eight other hospitals (Table 88). Length of stay decreased consistently from baseline to end-line and was generally lower than the average for the other eight hospitals (Figure 330).

Table 88. Age category for pneumonia patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Age (months) Baseline Midline End-line Baseline Midline End-line < 1 0.0 0.0 0.0 2.1 20.6 15.8 1 - 11 63.3 50.0 63.3 53.8 49.2 36.7 12 - 23 33.3 33.3 23.3 24.6 15.6 27.1 24 - 35 3.3 10.0 0.0 12.1 9.7 12.1 36 - 47 0.0 6.7 13.3 6.3 3.4 5.4 48 - 59 0.0 0.0 0.0 1.3 1.7 2.9

Table 89. Sex of pneumonia patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-line Male 53.3 66.7 40.0 49.2 52.7 57.1 Female 46.7 33.3 60.0 50.8 47.3 42.9

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Figure 329. Mean age for pneumonia (months) patients by phase, Hospital F vs. 8 other hospitals

Figure 330. Length for stay for pneumonia patients by phase, Hospital F vs. 8 other hospitals

The trend for method of payment was the same as for the other hospitals, with the major shift to JKN. The proportion of patients paying OOP was higher than the average of the other eight hospitals at baseline and end-line (Table 90).

Table 90. Method of payment for pneumonia patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 83.4 23.3 36.7 55.8 52.2 32.5Commercial insurance 0.0 0.0 0.0 1.7 0.0 0.0Governance insurance 3.3 3.3 0.0 10.4 6.7 0.0Insurance for the poor 13.3 73.4 0.0 28.3 31.8 11.7Other, specified 0.0 0.0 0.0 1.7 1.3 2.5BPJS 63.3 52.0Do not know 0.0 0.0 0.0 2.1 8.0 1.3

Clinical chart reviews for pneumonia patients showed a major decrease at end-line for the proportion of patients whose condition at discharge was unknown (Table 91). Respiratory rate (Figures 331),

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temperature (Figures 332), and pulse recording (Figures 333) all increased at end-line as well. Respiratory symptom recording was not substantively different, while immunization recording substantively decreased at midline and then increased at end-line (Figures 329-330).

Table 91. Patient condition at discharge for pneumonia patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 83.3 66.7 40.1 65.0 61.0 70.0Referred to other hospital 0.0 0.0 0.0 1.3 1.7 0.0Death 0.0 6.7 13.3 6.7 13.4 12.1Not cured, judicial discharge 16.7 10.0 23.3 13.7 12.6 7.9Other 0.0 0.0 0.0 6.3 0.0 0.0Control and outpatient 0.0 13.3 0.0 0.0 0.0 0.8Unknown 0.0 3.3 23.3 7.0 11.3 9.2

Figure 331. Respiratory symptom recorded for pneumonia patients by phase, Hospital F vs. 8

other hospitals

Figure 332. Immunization recorded for pneumonia in patients by phase, Hospital F vs. 8 other

hospitals

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Figure 333. Respiratory rate recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals

Figure 334. Temperature recorded for pneumonia patients by phase, Hospital F vs. 8 other

hospitals

Figure 335. Pulse recorded for pneumonia patients by phase, Hospital F vs. 8 other hospitals

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AMI

Length of stay for AMI patients decreased from baseline to end-line, ending lower than the average of the other eight hospitals (Figure 337). As with all hospitals, the majority of patients were financially covered by JKN (Table 92).

The proportion of patients in the sample who died during hospitalization increased slightly in end-line by while the proportion who did not have their condition reported upon discharge was high at end-line (Table 93).

The proportion of patients prescribed oral beta-adrenergic, statin, and/or aspirin decreased greatly at end-line (Figures 338 and 340). Oral beta-adrenergic prescription was low, starting from a baseline of less than 60% and decreasing to about 30% at midline and end-line (Figure 340).

Figures 343-349 show fluctuation in medical history-taking completeness. There was a decreased to the end-line in the recording of previous AMI (Figure 343), cerebrovascular disease (Figure 347), and heart failure (Figure 348). However, angina pectoris history recording greatly increased from baseline to end-line (Figure 344).

Figure 336. Mean age for AMI patients by phase, Hospital F vs. 8 other hospitals

Figure 337. Length of stay for AMI patients by phase, Hospital F vs. 8 other hospitals

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Table 92. Method of payment for AMI patients by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 43.4 34.5 13.3 35.8 32.4 17.5Commercial insurance 0.0 0.0 0.0 1.3 0.4 0.4Governance insurance 30.0 34.5 0.0 39.6 27.5 0.0Insurance for the poor 23.3 31.0 3.3 20.8 32.7 4.6Other 0.0 0.0 0.0 0.0 0.4 4.6BPJS 0.0 0.0 83.4 0.0 0.0 72.1Do not know 3.3 0.0 0.0 2.5 6.6 0.8

Table 93. Patient condition at discharge for AMI patients by phase, Hospital F vs. 8 other hospitals


Figure 338. Cardiac enzymes examination for AMI patients by phase, Hospital F vs. 8 other hospitals

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Figure 339. ECG examination for AMI patients by phase, Hospital F vs. 8 other hospitals

Figure 340. Oral beta-adrenergic recorded for AMI patients by phase, Hospital F vs. 8 other

hospitals

Figure 341. Statin recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

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Figure 342. Aspirin recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

Figure 343. Previous AMI history recorded for AMI patients by phase, Hospital F vs. 8 other

hospitals

Figure 344. Angina pectoris recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

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Figure 345. Hypertension recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

Figure 346. Hypercholesterolemia history recorded for AMI patients by phase, Hospital F vs. 8

other hospitals

Figure 347. Cerebrovascular disease recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

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Figure 348. Heart failure recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

Figure 349. Diabetic history recorded for AMI patients by phase, Hospital F vs. 8 other hospitals

Hip fracture/femoral neck fracture

We were only able to review five clinical charts in the baseline period for hip/femoral neck fracture patients in Hospital F. Therefore, some of baseline results have a deceptively high range. The inclusion criteria were reviewed in the midline and end-line periods to ensure they included all upper femoral fractures.

There was an increase in the age of patients admitted for this diagnosis over the period from midline to end-line (Figure 350). The average length of stay for hip fracture patients had decreased slightly at end-line to 13 days (from around 16 days). In Hospital F, a higher proportion of patients were covered by government insurance at baseline and midline than at the other eight hospitals. At Hospital F, almost all patients had their medical expenses covered by JKN by the end-line period, which higher than the average of the other hospitals in the study (Table 94). The percentage of patients who had surgery increased slightly, by about 6%, from midline to end-line (Figure 352).

Figures 353-354 show compliance of antibiotic prophylaxis and mobilization after surgery did not change much between midline and end-line; remaining around 80%. However, the use of thromprophylaxis decreased from midline to end-line (Figure 355).

boembolism

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Figure 350. Mean age for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals

Figure 351. Length of stay for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other

hospitals

Table 94. Method of payment for hip/femoral neck fracture patients by phase, Hospital F vs. 8

other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 40.0 10.0 7.4 52.8 33.7 11.8Governance insurance 40.0 43.3 0.0 23.6 34.6 0.0Insurance for the poor 20.0 46.7 0.0 18.6 22.9 2.0BPJS 92.6 79.0Other 0.0 0.0 0.0 1.4 0.0 5.4Do not know 0.0 0.0 0.0 3.6 8.8 2.0

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Table 95. Patient’s condition at discharge for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals


Figure 352. Surgery for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other

hospitals

Figure 353. Antibiotic prophylactic for hip/femoral neck fracture patients by phase, Hospital F vs.

8 other hospitals

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Figure 354. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital F vs. 8 other hospitals

Figure 355. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital F vs. 8

other hospitals

Patient interviews

Most patients interviewed in all three phases of the study were female, junior and high school graduates, and more than 40 years old (Table 96). At baseline, most patients were using Jamkesmas for financial coverage of their hospital stay, but after JKN implementation most patients had switched to this insurance system (Table 97). The average length of stay for patients decreased from nine days at baseline to six days at end-line (Figure 357).

Patient perceptions of the quality of medical services increased from baseline to end-line (Figure 358), while perceptions of nursing care quality did not change (Figure 359). Overall patient satisfaction increased from baseline to midline, and remained the same in the end-line period. It was more than 90% from baseline to end-line, while the patient satisfaction for hospital facilities increased slightly from baseline to end-line (Figure 360).

Despite medical service perception and satisfaction slightly increasing, overall patient experiences decreased from baseline to end-line (Figure 362).

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Table 96. Characteristics of patients interviewed by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 29.4 24.6 33.6 27.6 27.9 33.2Female 70.6 75.4 66.4 72.4 72.1 66.8

Education None and primary school 23.8 18.0 13.4 28.4 23.3 21.1Junior and high school 62.7 62.3 71.7 56.5 60.0 59.7Academy and University 13.5 19.7 14.9 15.1 16.7 19.2

Figure 356. Mean age of patients interviewed by phase, Hospital F vs. 8 other hospitals

Table 97. Method of payment of patients interviewed by phase, Hospital F vs. 8 other hospitals

F 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 15.9 9.0 10.5 19.1 11.0 13.1Commercial insurance 0.0 0.0 0.0 1.5 0.4 0.2Government insurance 13.5 0.0 0.0 20.4 0.0 0.0Jampersal 23.0 0.0 0.0 15.4 0.0 0.0BPJS for the poor (PBI)/Jamkesmas 46.8 43.5 30.6 41.4 36.2 28.5BPJS pay for premium 26.2 41.0 32.0 32.0BPJS paid by the company 4.1 8.2 3.7 9.9BPJS for government employee (Askes, Asabri, etc.) 15.6 8.2 16.5 15.1Other 0.8 0.0 1.5 2.1 0.2 1.2Do not know 0.0 1.6 0.0 0.1 0.0 0.0

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Figure 357. Length of stay of patients interviewed by phase, Hospital F vs. 8 other hospitals

Figure 358. Patient satisfaction with medical services by phase, Hospital F vs. 8 other hospitals

Figure 359. Patient satisfaction with nursing care by phase, Hospital F vs. 8 other hospitals

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Figure 360. Patient satisfaction with hospital facilities by phase, Hospital F vs. 8 other hospitals

Figure 361. Overall satisfaction of patients interviewed by phase, Hospital F vs. 8 other hospitals

Figure 362. Patient experience at hospital by phase, Hospital F vs. 8 other hospitals

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Accreditation

Key informants reported that there was a turnover of the hospital’s top directors during the study period. Commitment from hospital leaders and management was one of the important factors in accreditation; particularly, financial resourcing for the preparation phase in 2012. The hospital initiated various activities in preparation for accreditation, including establishing accreditation teams, developing a strategic roadmap for accreditation for 2012-2015, preparing new standards, conducting training, and improving awareness of the process among staff. The accreditation process was postponed for three years due to facilities constraints and lack of compliance, particularly in human resources and document completeness. The hospital received full KARS accreditation in 2015.

Since the accreditation, some hospital staff were still maintaining the new work culture that is in accordance with accreditation standards. However, key informants reported that some staff are returning to the old work culture. The changes in the system still needed to be internalized within hospital staff. One problem that the accreditation process underlined was the lack of compliance with medical record filing. There was reported to be significant inconsistency in the forms used within the same medical record. It was reported that integrated sheet notes were rarely written by attending physicians. According to information from the emergency room staff, laboratory results, physical examination notes, and medical history records were often incomplete, and some forms could not be found in the patient’s clinical record. An informant raised the issue that difficulty in reading the doctors’ notes was a problem and this was confirmed by the research assistants in this study during the chart reviews.

Many staff members at Hospital F were also KARS surveyors, and this was considered as an advantage to the hospital. The hospital also conducted its own internal assessment to identify which standards were deficient and therefore needed attention. Furthermore, the hospital conducted an internal accreditation simulation in June 2015 that aimed to simulate the internal KARS accreditation process by involving hospital staffs who were also KARS surveyors in the internal review process. (KARS surveyors cannot survey for KARS accreditation the hospitals in which they work).

Hospital F was scheduled to undergo JCI accreditation early in 2018, though it was taking substantial time for building renovations to be completed because 60% of the hospital facilities were not in a condition appropriate to be assessed for accreditation. Cost for accreditation is independently managed by the hospital without support from the MOH. The hospital argued that applying such a management culture necessary to achieve international standards required substantial financial investment. Hospital F was targeted to be the leading respiratory center in Asia Pacific (self-designation by the hospital to be subsequently approved by the government) and believed passing JCI accreditation was part of that strategy and could be achieved. However, there was apprehension among management that the accreditation would be difficult to maintain on an ongoing basis. Some key informants argued that there was no need for JCI accreditation because KARS is already internationally accredited by ISQua, and the cost of JCI accreditation is considerable.

JKN implementation

Since the implementation of JKN, Hospital F has faced several operational challenges. JKN did not affect budget planning much initially, but there was a significant impact on hospital income, especially from unpaid BPJS claims, which accounted for about 30% of the total billing. Since the number of OOP patients was quite small, there was a major decrease in cash flow. At the end of 2017, the proportion of JKN patients was around 80-85% of admissions from BPJS. The number of OOP patients was continuing to decline, as with all hospitals. Compared to 2015, the number of outpatients had declined because of the tiered referral system, while the number of inpatients had remained relatively stable.


Key informants also reported that Hospital F sometimes encountered difficulty in managing patients from the emergency room for transfer into a certain ward in the current tiered class system. Because of the unavailability of beds, some patients had to wait in the ER for as long as 2-3 days.

Constraints were reported in the medical records system. There were different criteria between the hospital expectations and BPJS expectations in terms of the acceptable level of medical record completeness. For example, for BPJS the standard diagnosis for pneumonia needed to be supported by physical and other supporting examination. However, several physicians used their own judgement without properly documenting their clinical reasoning. Key informants felt that more BPJS verification staff are required, since currents staffing levels appear to be too low, causing delays the verification process.

Conclusion

By the end of 2015, Hospital F had passed KARS accreditation after three years of delays. The long period of preparation allowed several aspects of hospital operations to improve. Most of domains in the hospital review and organizational audit reflected this improvement at end-line. However, there are some aspects of documentation in the medical record that still needed to be improved, especially with regard to AMI medical record systems, to be compliant with BPJS requirements for successful and timely reimbursement.


Chapter 7. Hospital G

1. Description

Hospital G is the only provincial hospital funded by the local government in this study. The province, therefore, is responsible for the hospital and appoints its director. It is a teaching facility located in medium-sized city in East Java. In 2015, it passed KARS 2012 full accreditation (Figure 363).

Hospital G was selected as a pilot study site for ISQua’s evaluation of KARS’s accreditation system. This involved the hospital undergoing KARS accreditation, then ISQua sent their own inspectors to determine if the hospital was scored correctly by the KARS inspectors. This occurred in February 2016.

The hospital has a good laboratory with an integrated online system that can be accessed by mobile phone. The laboratory and ER services are widely recognized as the best in Indonesia, and it is the pioneer for ER specialist development in the country. The pharmaceutical department ranks as the second best in country.

Hospital G has no plan yet for JCI accreditation because it does not have the resources for it. For the KARS accreditation, they organized a specific accreditation team to monitor and supervise the process. Therefore, the hospital was well prepared for its accreditation with well-organized documents and guidelines. The accreditation team had authority over other units during accreditation process.

Figure 363. Timeline for accreditation of Hospital G

KARS 2007 ‐ 16 Service Accred2011 Baseline Data Collection

(Oct)2012• Midline Data Collection (May)2014

• KARS 2012 Accreditation (Feb)

2015

• Re‐visitation KARS 2012 (Feb)

• End‐line Data Collection (March)

2016

2. Results


Overall, Hospital G met performance standards in most indicators at end-line, except bed turn over (Figures 364-367). Waiting times for prescription drugs increased slightly, while pre-operative waiting times improved markedly (Table 98).

Table 98. Hospital-reported basic performance indicators, Hospital G, 2011 to 2014


Phase (Year)

Baseline (2011)

Midline (2013)

End-line (2014)

Emergency response time (minutes) < 5 minutes 1 1 NR

Percentage of deaths in ER (%) < 2% 0 6 NRWaiting time for prescription drug service (minutes)

< 30 minutes

8.8 7.5 12.3

Waiting time pre-operative (days) ≤ 2 days 6.9 6.6 1.7


Figure 364. Bed occupancy rate for Hospital G by phase


Figure 365. Average length of stay for Hospital G by phase


Figure 366. Bed turn over interval for Hospital G by phase


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Figure 367. Bed turn over for Hospital G by phase

Note: MOH standard is 40-50 times

Hospital review

All domains in the hospital review increased in all phases, except documentation and record. Hospital G generally performed close to the average of the eight other hospitals (Figures 368-377).

Improvement was high for patient orientation, human resource, health care associated infection, facilities management, medication safety, surgery, interventional procedures and anesthesia. The increases were from 0.6 to 0.8 points on a four-point scale from baseline to end-line (Figures 369, 370, 372, 373 – 375). No or negligible increases were found from baseline to end-line in clinical practice and patient care domain or hospital governance (Figure 368 and 371). The transfusion domain has the highest consistent value of 4.0 points from the baseline to end-line (Figure 373). Contrary to other domains, the documentation and records domain dropped consecutively across all three phases of the research, even though the change was negligible and the value remained above 3 points (Figure 377).

Hospital governance

Figure 368. Hospital governance by phase, Hospital G vs. 8 other hospitals

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Figure 369. Patient orientation by phase, Hospital G vs. 8 other hospitals

Human resources

Figure 370. Human resource by phase, Hospital G vs. 8 other hospitals


Figure 371. Clinical practice and patient care performance by phase, Hospital G vs. 8 other hospitals

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Figure 372. Healthcare-associated infection performance by phase, Hospital G vs. 8 other hospitals

Transfusion

Figure 373. Transfusion performance by phase, Hospital G vs. 8 other hospitals


Figure 374. Facilities management performance by phase, Hospital G vs. 8 other hospitals

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Figure 375. Medication safety performance by phase, Hospital G vs. 8 other hospitals


Figure 376. Surgery, interventional procedures, and anesthesia performance by phase, Hospital G vs. 8 other hospitals


Figure 377. Documentation and records performance by phase, Hospital G vs. 8 other hospitals

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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 end-line. Hospital G’s obstetric department performed better than the average of the other eight hospitals, while the other three departments performed about on the average (Figures 378-381).

Figure 378. Key organizational audit criteria in Obstetric Department, Hospital G vs. 8 other hospitals

Figure 379. Key organizational audit criteria in Pediatric Department, Hospital G vs. 8 other

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Figure 380. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital G vs. 8 other hospitals

Figure 381. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital G vs. 8

other hospitals


Delivery

The pattern of change in financial coverage was similar to the other eight hospitals in the study. After implementation of JKN, only 50% of patients at Hospital G were covered by it compared to an average of close to 70% coverage for the eight other hospitals (Table 99). The average length of stay for normal delivery patients decreased slightly over time and was slightly lower than the average of the eight other hospitals across all periods of the study (Figure 382).

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Table 99. Method of payment of normal delivery patients by phase, Hospital G vs. 8 other hospitals

G 8 hospitals


Out of pocket 20.0 20.0 40.0 36.7 22.9 17.1




Jampersal 50.0 30.0 0.0 27.0 32.9 0.0

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Other 0.0 0.0 3.3 0.0 0.0 4.6

Do not know 0.0 0.0 0.0 1.7 10.4 2.5

Figure 382. Average length of stay of normal delivery patients by phase, Hospital G vs. 8 other hospitals

Figure 383. Age of normal delivery patients by phase, Hospital G vs. 8 other hospitals

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There was a low percentage of medical records for which the condition at discharge was not recorded and this was slightly lower than the average for the eight other hospitals. No maternal deaths were recorded (Table 100). Recording of lacerations did not vary significantly (Figure 384). Apgar score and birth weight were recorded consistently in the three periods with 100% compliance (Figures 385-386).

Table 100. Condition of normal delivery patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Cured/improving 96.7 86.6 96.7 87.1 86.3 84.1


Death 0.0 0.0 0.0 0.0 0.0 0.0


Other 0.0 0.0 0.0 4.6 0.4 0.0


Unknown 3.3 6.7 3.3 7.9 9.6 11.3

Figure 384. Laceration recorded for normal delivery patients by phase, Hospital G vs. 8 other hospitals

Figure 385. Apgar score recorded for normal delivery newborns by phase, Hospital G vs. 8 other

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Mean


Figure 386. Birth weight recorded for normal delivery newborns by phase, Hospital G vs. 8 other hospitals


Most pneumonia patients were under 12 months of age and the proportion of males and females remained same at about 50% in all three phases (Tables 101-102). At 50%, out of pocket payment for hospital charges was higher at end-line than the average of the eight other hospitals, which was about 30% (Table 103). Average length of stay for pneumonia patients was 7-8 days; there with a slight increase from baseline to end-line (Figure 388). Mortality from pneumonia was twice as high in Hospital G than in the other eight hospitals in the study across all three periods (Table 104).

Table 101. Age distribution of pneumonia patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals

Age (months) Baseline MidlineEnd-line Baseline Midline

End-line

< 1 3.3 50.0 43.3 1.7 14.3 10.4

1 - 11 63.3 43.4 33.3 53.7 50.0 40.4

12 - 23 26.7 3.3 16.7 25.3 19.3 27.9

24 - 35 6.7 3.3 0.0 11.7 10.5 12.1

36 - 47 0.0 0.0 0.0 6.3 4.2 7.1

48 - 59 0.0 0.0 6.7 1.3 1.7 2.1

Table 102. Sex distribution of pneumonia patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


End-line

Male 50.0 46.7 53.3 49.6 55.2 55.4

Female 50.0 53.3 46.7 50.4 44.8 44.6

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Upper 95% CI

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Mean


Figure 387. Mean age in months of pneumonia patients by phase, Hospital G vs. 8 other hospitals

Table 103. Method of payment of pneumonia patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Out of pocket 46.6 66.7 50.0 60.3 46.8 30.8




Other, specified 0.0 0.0 0.0 1.7 1.3 2.5

BPJS 0.0 0.0 43.3 0.0 0.0 54.6

Do not know 0.0 0.0 0.0 2.1 8.0 1.3

Figure 388. Length of stay of pneumonia patients by phase, Hospital G vs. 8 other hospitals

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Table 104. Pneumonia patients’ condition at discharge by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Cured/improving 70.0 33.2 56.6 66.6 65.2 67.9


Death 13.3 26.7 26.7 5.0 10.9 10.4


Other 0.0 0.0 0.0 6.3 0.0 0.0


Unknown 0.0 6.7 6.7 7.1 10.9 11.3

Respiratory symptom recording was very high for all three phases of the study and not substantially different from the other eight hospitals (Figure 389). Immunization recorded decreased drastically from 100% at baseline to 33% at midline, but increased again slightly to 57% at end-line (Figure 390). Figure 391 showed that recording of respiratory rate has decreased sequentially in all three phases (100% to 93%). Completeness of temperature recording was high throughout (Figure 392) and pulse was consistently recorded in 100% of pneumonia patients under five years old throughout all three periods of the study (Figure 393).

Figure 389. Respiratory symptoms recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals

Figure 390. Immunization recorded for pneumonia patients by phase, Hospital G vs. 8 other

hospitals

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Figure 391. Respiratory rate recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals

Figure 392. Temperature recorded for pneumonia patients by phase, Hospital G vs. 8 other

hospitals

Figure 393. Pulse recorded for pneumonia patients by phase, Hospital G vs. 8 other hospitals

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AMI

The average age and average length of stay for AMI patients did not change significantly from baseline to end-line and was not markedly different from the average of the other eight hospitals (Figures 394-395). The proportion covered by BPJS was slightly lower at end-line than the other hospitals and the proportion paying OOP was slightly higher (Table 105). Mortality from AMI remained between 23 and 27 percent across the three periods, which was about twice the average of the other eight hospitals (Table 106).

Recording of cardiac enzymes and ECG examinations was high at baseline and improved to perfect compliance (100%) throughout midline and end-line (Figures 396-397).

Medications prescription recording for oral beta-adrenergic, statin, and aspirin prescriptions for AMI patients showed major variation from baseline to end-line; the recording of this remained particularly low for oral beta-adrenergic (Figures 398-399).

Almost all variables of history recorded for AMI patients in Hospital G started from a very low value (0-40%) except hypertension recording, which was 70% at baseline (Figures 401-407). Previous AMI and cerebrovascular accident history recording increased slightly from baseline to end-line (Figure 401 and 405). Hypertension, hypercholesterolemia, heart failure history recording showed improvements from baseline to end-line (Figures 403-404, 406). Angina pectoris and diabetic history recorded increased from baseline to midline, then slightly decreased from midline to end-line; still ending higher than baseline (Figures 402 and 407).

Figure 394. Average age of AMI patients by phase, Hospital G vs. 8 other hospitals

Figure 395. Length of stay of AMI patients by phase, Hospital G vs. 8 other hospitals

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Table 105. Methods of payment of AMI patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Out of pocket 56.7 63.3 30.0 34.2 28.8 15.4




Other 0.0 0.0 0.0 0.0 0.4 4.6

BPJS 0.0 0.0 66.7 0.0 0.0 74.2

Do not know 3.3 0.0 0.0 2.5 6.6 0.8

Table 106. Patient condition at discharge of AMI patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Cured/improving 56.7 53.3 56.6 62.8 66.7 66.3


Death 23.3 20.0 26.7 8.8 10.7 11.7


Other 0.0 6.7 0.0 8.8 0.8 0.0


Unknown 0.0 6.7 0.0 8.8 7.4 15.8

Figure 396. Cardiac enzymes examination recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

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Figure 397. ECG examination recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

Figure 398. Oral beta-adrenergic recorded for AMI patients by phase, Hospital G vs. 8 other

hospitals

Figure 399. Statins recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

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Figure 400. Aspirin prescription recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

Figure 401. Previous AMI history recorded for AMI patients by phase, Hospital G vs. 8 other

hospitals

Figure 402. Angina pectoris history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

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Figure 403. Hypertension history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

Figure 404. Hypercholesterolemia history recorded for AMI patients by phase, Hospital G vs. 8

other hospitals

Figure 405. Cerebrovascular accident history recorded for AMI patients by phase, Hospital G vs. 8

other hospitals

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Figure 406. Heart failure history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals

Figure 407. Diabetic history recorded for AMI patients by phase, Hospital G vs. 8 other hospitals


The study team reviewed 16 clinical records for hip/femoral neck fracture patients in the baseline, 30 in the midline, and 19 in the end-line. As in other hospitals, there was an increase in average patient age from 38 to 67 years old (Figure 408). Mean length of stay for patients was 16.8 days in baseline, 14.8 days in midline, and 16.9 days in end-line; comparable to the average for the other eight hospitals (Figure 409).

For payment method for hip fracture patients, there was a slightly lower percentage on BPJS and a slightly higher proportion paying out of pocket compared to the average of the eight other hospitals (Table 107). There were no deaths for patients with hip fractures in this sample from Hospital G (Figure 410). Figure 411 shows the proportion of patients given prophylactic antibiotics increased from baseline to end-line (85% to 100%). Mobilization after surgery improved markedly from 0 to 100% (Figure 412). No hip fracture patients (0%) in Hospital G had a thromboembolic event following surgery across all three periods of the study (Figure 413).

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Figure 408. Mean age of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals

Figure 409. Length of stay of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other

hospitals

50

Table 107. Method of payment of hip/femoral neck fracture patients by phase, Hospital G vs. 8

other hospitals

G 8 Hospitals


Out of pocket 68.7 33.3 21.1 50.3 30.2 10.3



BPJS 0.0 0.0 68.3 0.0 0.0 81.7

Other 0.0 0.0 5.3 1.6 0.0 4.7

Do not know 0.0 0.0 5.3 3.9 8.8 1.4

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Table 108. Condition at discharge of hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals


Cured/improving 62.5 66.7 68.4 62.0 64.3 65.6


Death 0.0 0.0 0.0 3.9 2.0 3.8


Other 0.0 0.0 10.5 0.0 1.0 1.4


Unknown 0.0 0.0 0.0 11.6 5.4 16.9

Figure 410. Surgery for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals

Figure 411. Antibiotic prophylaxis given for hip/femoral neck fracture patients by phase, Hospital

G vs. 8 other hospitals

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Figure 412. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital G vs. 8 other hospitals

Figure 413. Thromboembolic for hip/femoral neck fracture patients by phase, Hospital G vs. 8

other hospitals

Patient interviews

Most interview respondents were female, junior and high school graduates, and more than 40 years old (Table 109 and Figure 414). In Hospital G, about the same proportion of patients were covered by BPJS and more paid OOP for their care than the average for the other eight hospitals (Table 110).

Patient confidence in doctors’ and nurses’ professional competence and care decreased from baseline to midline, then increased from midline to end-line (Figures 416-417). Patient satisfaction with medical decisions, discharge instructions, hospital facilities, and their overall satisfaction increased from baseline to end-line, with a decrease at the midline (Figures 418-420). The proportion of patients who would recommend the hospital decreased in all phases (Figure 421).

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Table 109. Characteristics of patient interview respondents by phase, Hospital G vs. 8 other hospitals

G 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 31.4 40.8 26.7 27.3 25.8 34.1Female 68.6 59.2 73.3 72.7 74.2 65.9

Education None and primary school 38.8 34.2 25.0 26.5 21.3 19.6

Junior and high school 51.3 55.0 59.2 58.0 60.9 61.4Academy and university 9.9 10.8 15.8 15.5 17.8 19.0

Figure 414. Mean age of patient interviewed by phase, Hospital G vs. 8 other hospitals

Table 110. Method of payment for patient interviewed by phase, Hospital G vs. 8 other hospitals

Method of Payment G 8 Hospitals


Out of pocket 30.6 18.3 30.8 17.2 9.8 10.7



Jampersal 26.5 0.0 0.0 15.0 0.0 0.0



BPJS paid by the company 3.3 7.5 3.8 10.0

BPJS for government employee (Askes, Asabri, etc.) 5.0 8.3 17.8 14.9

Other 0.0 0.8 1.7 2.2 0.1 1.2

Do not know 0.0 0.0 0.0 0.1 0.2 0.0

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Figure 415. Length of stay of patients interviewed by phase, Hospital G vs. 8 other hospitals

Figure 416. Patient satisfaction with medical services by phase, Hospital G vs. 8 other hospitals

Figure 417. Patient satisfaction was nursing care by phase, Hospital G vs. 8 other hospitals

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Figure 418. Patient satisfaction with hospital facilities by phase, Hospital G vs. 8 other hospitals

Figure 419. Patient satisfaction with all services, Hospital G vs. 8 other hospitals

Figure 420. Patient experience at hospital by phase, Hospital G vs. 8 other hospitals

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Accreditation

Key informants reported that accreditation in Hospital G had generally progressed well. The Accreditation Team assigned by the hospital performed well by establishing working groups. In pursuing KARS accreditation, the hospital conducted comparative studies to other hospitals that had completed accreditation to learn how their efforts had succeeded. One informant stated that Hospital G was selected as a pilot hospital by KARS because they had good existing systems, including for emergency and laboratory services. The highest score of Hospital G was for infection control. During the KARS re-accreditation evaluation, it was found that the intensive care unit (ICU)/ pediatric intensive care unit (PICU) no longer met the standard for facilities and equipment. At the time of the last data collection, the hospital is preparing a new building for ICU/newborn intensive care unit (PICU).

Because the hospital was financed and run by the provincial government, it did not have any MOH financial support and it was for that reason that the hospital decided to forgo JCI accreditation. They also felt that JCI accreditation was not necessary because KARS had already been accredited by ISQua and recognized as being at international standards, so they did not feel the need to have another international accreditation.

JKN implementation

Implementation of JKN has had an impact on the overall functioning of the hospital. The proportion of non-JKN patients has decreased; therefore, most income was coming from BPJS reimbursement. However, the total revenue for 2015 was under target. In order to adapt to these changes, the hospital undertook the following actions in order to increase hospital income: sent staff to participate in training on record coding to improve their capacity to correctly enter cases in accordance with BPJS guidelines and allowed inpatient patients to upgrade their class treatment for an additional fee (e.g., move from second-class bed to first-class/VIP). The first action is expected to help the hospital fully realize reimbursement revenue from BPJS; the second action is expected to generate additional revenue.

Claim constraint. Expected revenue from BPJS was not fully realized – there were delays in payment and some of the claims were rejected. BPJS operators argue that the delays are due to incomplete medical records and invalid data submissions. Delays also occurred because of incomplete documents. Total claims were around 34 billion IDR (2 million USD) per month, and were continuously increasing since 2014. Hospital G was recognized by BPJS to have the highest pending claims among the nine hospitals in this study. A medical committee has been involved in facilitating this issue among medical staff, BPJS, and the hospital management. A regular meeting was instituted to resolve claims and related problems between the hospital and BPJS. One recommendation from hospital was for BPJS to have more verification staff to catch up with the outstanding claims. The hospital was reportedly using a bank loan to cover some of the shortfall in operating expenses. A formal letter had been sent to the MOH regarding this problem. Frequent changes in BPJS policies were also reported to be a problem.

Conclusion

Hospital G was accredited by KARS and noted as a pilot hospital for their accreditation system. The hospital’s accreditation was managed by a designated accreditation team, and the hospital conducted comparative visit to other hospitals that had successfully achieved KARS accreditation in order to better understand the process and changes required. Hospital G was not planning to seek JCI accreditation given that it is not under the MOH. The financial problems of the hospital due to implementation of JKN was noted as a major hindrance to hospital operations.


Chapter 8. Hospital H

1. Description

Hospital H is located in a large city on the island of Sumatera. In this region, there are 74 general hospitals: 26 public hospitals, 11 private non-profit, seven private for-profit and one hospital owned by national company. There are also 29 specialty hospitals. There are two type A comprehensive hospitals; one is a national referral facility funded by the MOH and the other is funded by the provincial government. The hospital has 800 beds and approximately 2,440 employees. It is a center of excellence for cardiology services.

Hospital H is a teaching hospital in collaboration with the medical faculty of the local university. The clinical medical education there includes training for medical specialties. The hospital is also a practice area for nursing, midwifery, nutrition, and medical records education.

Hospital H provides complete specialty and some sub-specialty services and is a referral hospital for West Sumatra, Riau Province, Jambi Province, Bengkulu Province and southern part of North Sumatera.

In 2007 and 2009 there were major earthquakes in Sumatera which caused damage to buildings and other facilities at Hospital H. The hospital was renovated and construction of a new building was completed by the baseline assessment. It was for this reason that KARS accreditation (2007 version) was completed November 2012 – later than mandated. KARS accreditation (2012 version) was conducted from October 2015 until May 2016 (end-line) (Figure 421).

Figure 421. Timeline for accreditation of Hospital H

KARS 2007 ‐16 Service Accred

2007

• KARS 2007 ‐ 16 Service Accred

• Baseline Data Collection (Nov)

2012• Midline Data Collection (Jun)2014

• KARS 2012 Accreditation (Oct)

2015End‐line Data Collection (Apr‐May)


by JCI2018

2. Results


Waiting time for prescription drug services was twice as long in the end-line period compared to the baseline, ending higher than the MOH standard (Figure 422). However, there was reportedly some variation over the duration of the study in the way this was measured and recorded. Other hospital-reported performance data were missing (Table 111).


Table 111. Hospital-reported basic performance indicators, Hospital H, 2011 to 2015


Phase (Year)

Baseline (2011)

Midline (2013)

End-line

(2015) Emergency response time (minutes)

< 5 15 NR NR

Percentage of deaths in the ER (%)

< 2 NR NR NR

Pre-operative time (days)

waiting < 2 1 NR NR

Figure 422. Waiting time for prescription drug service by phase, Hospital H

Note: MOH standard is ≤ 30 minutes

Hospital review

Hospital H review results showed low scores at the beginning of the study compared to the other eight hospitals, and generally they remained below the average of those eight (Figures 423-432).

Hospital governance

Figure 423. Hospital governance by phase, Hospital H vs. 8 other hospitals

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Figure 424. Patient orientation by phase, Hospital H vs. 8 other hospitals

Human resources

Figure 425. Human resources by phase, Hospital H vs. 8 other hospitals


Figure 426. Clinical practice and patient care performance by phase, Hospital H vs. 8 other hospitals

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Figure 427. Healthcare-associated infection performance by phase, Hospital H vs. 8 other hospitals

Transfusion

Figure 428. Transfusion by performance phase, Hospital H vs. 8 other hospitals


Figure 429. Facilities management by performance phase, Hospital H vs. 8 other hospitals

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Figure 430. Medication safety performance by phase, Hospital H vs. 8 other hospitals


Figure 431. Surgery, interventional procedures, and anesthesia performance by phase, Hospital H vs. 8 other hospitals


Figure 432. Documentation and records performance by phase, Hospital H vs. 8 other hospitals

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Similar to the hospital review criteria, scores for the 10 organizational audit criteria in the other eight hospitals were higher than in Hospital H in all departments (Figures 433-436).

There was some fluctuation of results for the 10 criteria in all four departments. The Obstetric Department showed similar results between baseline (60%), midline (60%), and end-line (55%) (Figure 433). The pediatric (Figure 434) and internal medicine/cardiology units (Figure 435) had similar patterns. The Orthopedics Department increased sequentially in all phases (Figure 436).

Figure 433. Key organizational audit criteria in Obstetric Department, Hospital H vs. 8 other hospitals

Figure 434. Key organizational audit criteria in Pediatric Department, Hospital H vs. 8 other

hospitals

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Figure 435. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital H vs. 8 other hospitals

Figure 436. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital H vs. 8

other hospitals


Delivery

The proportion of patients whose method of payment was not known was higher than the other eight hospitals and the proportion paying out of pocket was lower. There was a slightly higher proportion using BPJS (Table 112). Average length of stay and the average age of patients was the same as the other eight hospitals and did not change significantly across the three study periods (Figures 437-438).

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Percentage

Hospital by Phase

Percentage

Min

Max


Table 112. Method of payment of normal delivery patients by phase, Hospital H vs. 8 other hospitals

H 8 hospitals


Out of pocket 23.3 3.3 3.3 36.3 25.0 21.7



Insurance for the poor/Jamkesmas 6.7 86.7 6.7 22.1 22.1 6.3

Jampersal 3.3 0.0 0.0 32.9 36.7 0.0

BPJS 0.0 0.0 73.3 0.0 0.0 66.7

Other 0.0 0.0 0.0 0.0 0.0 5.0

Do not know 0.0 0.0 16.7 1.7 10.4 0.4

Figure 437. Average length of stay of normal delivery patients by phase, Hospital H vs. 8 other hospitals

Figure 438. Mean age of normal delivery patients by phase, Hospital H vs. 8 other hospitals

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As in the other eight hospitals, there were no maternal deaths reported and the proportion of delivery patients for whom their condition at discharge was not recorded was close to the average of the other eight hospitals (Table 113).

The recording of laceration status for normal delivery patients in Hospital H was very low (3%) in the baseline period, then had a major increase (83%) in the midline period, but decreased at end-line (47%) (Figure 439). Apgar score and birth weight were consistently well recorded throughout the three study periods (Figures 440 and 441).

Table 113. Condition of normal delivery patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Cured/improving 76.7 73.4 80.0 89.6 87.9 86.2


Death 0.0 0.0 0.0 0.0 0.0 0.0


Other 0.0 0.0 0.0 4.6 0.4 0.0


Unknown 23.3 23.3 13.3 5.4 7.5 10.0

Figure 439. Laceration recorded for normal delivery patients by phase, Hospital H vs. 8 other hospitals

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Figure 440. Apgar score recorded for normal delivery newborns by phase, Hospital H vs. 8 other hospitals

Figure 441. Birth weight recorded for normal delivery newborns by phase, Hospital H vs. 8 other hospitals


There was slightly more variability in the age of patients diagnosed with pneumonia, but they were not substantively different from the other eight hospitals and the sex balance was close to that expected (Tables 114-115). At baseline, there was a higher proportion of patients whose hospital expenses were paid out of pocket and a lower proportion using JKN than the other eight hospitals (Table 116). Average length of stay increased slightly from baseline to midline, then dropped back at end-line (Figure 443). A higher proportion of pneumonia patients' condition at discharge was not recorded compared to the other eight hospitals, but the case fatality ratio from the sample was close to the same (Table 117).

Recording of medical history and physical examination results remained high throughout the three study periods and generally did not vary significantly from the findings in the eight other hospitals (Figures 444 to 448).

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Table 114. Age distribution of pneumonia patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals

Age (months) Baseline Midline End-line Baseline Midline End-line

< 1 0.0 36.7 30.0 2.1 16.0 12.1

1 - 11 50.0 43.3 36.7 55.3 50.0 40.0

12 - 23 20.0 10.0 16.7 26.3 18.4 27.9

24 - 35 20.0 3.3 13.3 10.0 10.5 10.4

36 - 47 10.0 6.7 0.0 5.0 3.4 7.1

48 - 59 0.0 0.0 3.3 1.3 1.7 2.5

Table 115. Sex of pneumonia patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Male 53.3 53.3 56.7 49.2 54.4 55.0

Female 46.7 46.7 43.3 50.8 45.6 45.0

Figure 442. Mean age in months of pneumonia patients by phase, Hospital H vs. 8 other hospitals

Table 116. Method of payment of pneumonia patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Out of pocket 70 46.7 50.0 57.5 49.4 30.8




Other, specified 0.0 0.0 0.0 1.7 1.3 2.5

BPJS 0.0 0.0 40.0 0.0 0.0 55.0

Do not know 6.7 3.3 10.0 1.3 7.5 0.0

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Figure 443. Length of stay of pneumonia patients by phase, Hospital H vs. 8 other hospitals

Table 117. Pneumonia patients’ condition at discharge by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Cured/improving 23.3 20.0 43.4 72.4 67.0 69.6


Death 3.3 16.7 13.3 6.3 12.0 12.1


Others 6.7 0.0 0.0 5.4 0.0 0.0


Unknown 40.0 20.0 20.0 2.1 9.2 9.6

Figure 444. Respiratory symptoms recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals

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Figure 445. Immunization recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals

Figure 446. Respiratory rate recorded for pneumonia patients by phase, Hospital H vs. 8 other

hospitals

Figure 447. Temperature recorded for pneumonia patients by phase, Hospital H vs. 8 other

hospitals

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Figure 448. Pulse recorded for pneumonia patients by phase, Hospital H vs. 8 other hospitals

AMI

Average age of AMI patients in Hospital H was about the same as for the other eight hospitals and did not vary significantly across the study period (Figure 449). Length of stay of AMI patients was slightly lower than the average from the other eight hospitals and decreased slightly from baseline (6 days) to end-line (4 days) (Figure 450). There was a slightly higher proportion than the average who subscribed to JKN at end-line and a lower proportion than the average who paid for their hospital stay out of pocket (Table 118).

For patients’ condition at discharge, in Hospital H there were no deaths reported in the baseline sample, but there were 17% at midline and 33% at end-line. It was reported that this was more likely a result of changes in the case mix than a change in the quality of care. The trend in the other eight hospitals was more consistent across time periods and was lower at midline and end-line (Table 119).

Recording of cardiac enzymes examination and ECG examination was high at the beginning of the study, but decreased from baseline to end-line (Figures 451-452). The proportion of patients who had prescriptions of oral beta-adrenergic, statin, and/or aspirin recorded in their medical records appeared to improve slightly from baseline to end-line. More than 80% of AMI patients had a recorded prescription for statins and aspirin at end-line (Figure 453-455).

Recording of history of AMI, angina pectoris, and heart failure improved from baseline to end-line (Figures 456-457, 461). Recording of history of hypertension, cholesterol levels, cerebrovascular accidents, and diabetes increased from baseline to midline, then decreased again at end-line (Figures 458-459, 462).

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Figure 449. Average age of AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 450. Length of stay for AMI patients by phase, Hospital H vs. 8 other hospitals

Table 118. Methods of payment for AMI patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Out of pocket 46.7 50.0 6.7 35.4 30.5 18.3




Others 0.0 0.0 0.0 0.0 0.4 4.6

BPJS 0.0 0.0 83.3 0.0 0.0 72.1

Do Not Know 0.0 0.0 6.7 2.9 6.6 0.0

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Table 119. Patient condition at discharge for AMI patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Cured/improving 56.7 63.3 43.3 62.9 65.4 67.9


Death 0.0 16.7 33.3 11.7 11.1 10.8


Other 10.0 0.0 0.0 7.5 1.7 0.0


Unknown 30.0 3.3 16.7 5.0 7.8 13.8

Figure 451. Cardiac enzymes examination recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 452. ECG examination recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

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Figure 453. Oral beta-adrenergic recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 454. Statins recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 455. Aspirin prescription recorded for AMI patients by phase, Hospital H vs. 8 other

hospitals

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Figure 456. Previous AMI history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 457. Angina pectoris history recorded for AMI patients by phase, Hospital H vs. 8 other

hospitals

Figure 458. Hypertension history recorded for AMI patients by phase, Hospital H vs. 8 other

hospitals

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Figure 459. Hypercholesterolemia history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 460.

Cerebrovascular accident history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals

Figure 461. Heart failure history recorded for AMI patients by phase, Hospital H vs. 8 other

hospitals

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Figure 462. Diabetic history recorded for AMI patients by phase, Hospital H vs. 8 other hospitals


There were 23 clinical records for hip/femoral neck fracture patients reviewed at baseline, 29 at midline, and 30 at end-line, with the samples are taken in 18-month periods. As with other hospitals in the study, there was an increase in the age of patients admitted for this diagnosis over the period from less than 50 to almost 68 years of age (Figure 463). Average length of stay of hip fracture patients increased slightly from baseline to end-line, but remained close to the average of the other eight hospitals (Figure 464). Most patients had their medical expenses covered by JKN by the end-line period (Table 120). The percentage of patients who had surgery decreased from 74% at baseline to 60% at end-line (Figure 465). Figures 466-467 shows antibiotic prophylactic use and compliance of post-operative mobilization decreased from midline to end-line. The use of thromboembolism increased from baseline to end-line (0% to 11%), but remained the same from midline to end-line (Figure 468).

Figure 463. Mean age of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

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Figure 464. Length of stay of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

Table 120. Method of payment of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Out of pocket 52.2 44.8 16.7 52.4 28.5 10.4



BPJS 0.0 0.0 73.3 0.0 0.0 81.6

Others 0.0 0.0 0.0 1.6 0.0 5.5

Do not know 8.7 3.5 10.0 2.5 8.3 0.5

Table 121. Condition of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Cured/improving 34.8 58.7 26.7 67.2 65.5 71.7


Death 8.7 0.0 3.3 2.5 1.9 3.5


Other 0.0 0.0 0.0 0.0 1.0 2.5


Unknown 17.4 10.3 40.0 9.0 3.9 11.9

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Figure 465. Surgery of hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

Figure 466. Antibiotic prophylaxis given to hip/femoral neck fracture by phase, Hospital H vs. 8

other hospitals

Figure 467. Mobilization after surgery for hip/femoral neck fracture patients by phase, Hospital H

vs. 8 other hospitals

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Figure 468. Use of thromboembolism in hip/femoral neck fracture patients by phase, Hospital H vs. 8 other hospitals

Patient interviews

Most patient respondents were female, junior and high school graduates, and more than 40 years of age (Table 122). The proportion paying out of pocket was higher and the proportion covered by JKN was lower than the average for the other eight hospitals in the study (Table 123).

Figure 470 shows the average length of stay at baseline and midline was six days and increased to 10 days by the end-line. Patients’ positive perception of medical services, nursing care, hospital facilities, and overall satisfaction started at a high percentage in the baseline period (more than 72%), then decreased in the midline, and increased to more than 83% at end-line (Figures 471-474). Patient positive experience was 51% in baseline, decreased to 18% at midline, then increased to 52% at end-line (Figure 475).

Table 122. Characteristics of patients interviewed by phase, Hospital H vs. 8 other hospitals

H 8 Hospitals


Sex

Male 35.1 34.2 37.6 26.9 26.7 32.7

Female 64.9 65.8 62.4 73.1 73.3 67.3

Education

None and primary school 19.3 15.0 17.6 28.9 23.7 20.5Junior and high school 54.4 64.2 58.4 57.6 59.7 61.5

Academy and university 26.3 20.8 24.0 13.6 16.6 18.0

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Figure 469. Mean age of patients interviewed by phase, Hospital H vs. 8 other hospitals

Table 123. Method of payment of patients interviewed by phase, Hospital H vs. 8 other hospitals

Method of Payment H 8 Hospitals


Out of pocket 16.7 4.2 29.6 18.9 11.6 10.7



Jampersal 16.7 0.0 0.0 16.3 0.0 0.0



BPJS paid by the company 3.3 5.6 3.8 10.2

BPJS for government employee (Askes, Asabri, etc.) 22.5 18.4 15.6 13.7

Other 1.8 0.0 4.8 2.0 0.2 0.8

Do not know 0.0 0.0 0.0 0.1 0.2 0.0

Figure 470. Length of stay of patients interviewed by phase, Hospital H vs. 8 other hospitals

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Figure 471. Patient satisfaction with medical services by phase, Hospital H vs. 8 other hospitals

Figure 472. Patient satisfaction with nursing care by phase, Hospital H vs. 8 other hospitals

Figure 473. Patient satisfaction with hospital facilities by phase, Hospital H vs. 8 other hospitals

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Figure 474. Patient satisfaction with all services by phase, Hospital H vs. 8 other hospitals

Figure 475. Patient experience at hospital by phase, Hospital H vs. 8 other hospitals


Accreditation

Key informants reported that the hospital needed to remediate some deficiencies before they were likely to achieve accreditation. It was stated they need to improve the staff’s working culture and some specific aspects, including completion of medical record, doctor visitation schedules, hand-washing behavior, and obtaining informed consent. Hospital H allocated part of its budget for facilities construction, but more capital was required to complete needed upgrades. Building damage caused by the earthquake highlighted the need to redevelop specific facilities, including some outpatient and inpatient buildings and the pharmacy department, and there had been some investment toward this. Limits on available capital was reported as the main obstacle to reaching and maintaining accreditation status. Commitment from hospital leadership was also raised by one informant as a problem that still needed to be addressed.

Some hospital processes were not compliant with accreditation standards due to a lack of supporting elements, such as availability of drugs and safety boxes. Personnel standards and hospital-reported response time guidelines were not consistently met and evidence-based clinical pathways were not

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applied to all diagnoses. Also, medical records were not consistently completed and this resulted in delays in claim payment by BPJS and other payers. There was a change in the hospital director in 2016, and this improved communication and coordination among staff and between clinicians and patients. Hospital H was upgraded to a type A hospital in 2014 and the change in status came with consequences, including an increase in cases referred from other hospitals. They were also forced by the MOH to fully pass KARS accreditation in 2015 in order to keep their type A status.

It was reported that the pharmacy unit suffered from medication shortages due to budget shortfalls. This led to the hospital purchasing medications from alternate suppliers or instructing patients to purchase the medications independently. This resulted in higher costs for patients and the hospital. An informant also reported that some services were not delivered optimally due to a lack of facilities and equipment.

JKN implementation

Implementation of JKN had changed the financing of the hospital such that, as of the end of 2017, 90% of revenue came from reimbursements from BPJS; an amount that varied from 15 to 20 billion IDR (9-12 million USD) per month. However, total claims had declined due to a tiered referral system. Previously, there were around 800 patient visits per day, but this had decreased to 400 to 500 per day.

One constraint reported in submitting claims to BPJS was incomplete administration files for many patients, and there were many unverified claims found in submissions to the payer. Coding and documentation were deficient, leading to delayed or non-payment of claims. Also, it was reported that the sudden and frequent change in BPJS rules had adversely impacted the billing calculation at the end of the month. Furthermore, lengthy negotiations over claims between BPJS and Hospital H has created delay in billing payment.

Conclusion

Key informants reported that the commitment of hospital leadership played a crucial role in KARS accreditation, and it was reported that this still needed to be strengthened. Elements of hospital operations needed to improve, including human resources; communication with patients and among staff; facilities; availability of essential medications; consumables, such as sharps disposal boxes; and medical records management.

The earthquake that destroyed some facilities was clearly a major setback for the hospital. Budget limitations meant that rebuilding was delayed and incomplete, causing a shortage of facilities and equipment. With such a large proportion of patients covered under JKN by the end-line period, together with the difficulties the hospital was having with delayed payment from BPJS because of incomplete billing claims, a further financial burden was placed on hospital operations.


Chapter 9. Hospital I

1. Description

Hospital I is a public, type A, referral hospital in a province in eastern Indonesia at the periphery of a large city. The province has 26 public hospitals; 14 non-profit, private hospitals; four for-profit, private hospitals; and five specialty facilities, including one for the mentally ill and a dental hospital.

Hospital I was a type B facility before being upgraded to type A in 2013. It has 795 inpatient beds, of which 744 are for adults and 51 are for children. Specialty medical services available at the hospital include open-heart surgery, endovascular abdominal aortic aneurysm repair surgery, catheter installation in the abdomen without general anesthesia, hemodialysis, endoscopy, and cerebrovascular accident services. It is a center of excellence for open-heart surgery, kidney transplantation, and ultrasound endoscopic surgery.

The hospital is primarily funded by the central MOH and is the main teaching hospital for the city’s university, mostly for medical residents. It was accredited by KARS in April 2015 (Figure 476). It had to undergo accreditation inspections twice prior to data collection in the baseline.

Figure 476. Timeline for accreditation of Hospital I

KARS 2007 ‐ 5 Service Accred (Aug)

2007

• KARS 2007 ‐ 16 Service Accred (Mar)

• Baseline Data Collection (Oct)

2011

• Midline Data Collection (Apr)

• Mock survey of KARS 2012 Accred (Dec)

2014KARS 2012 Accreditation (Nov)

2015End‐line Data

Collection (April)


by KARS International

2018

2. Results


Several performance indicators were missing for Hospital I; therefore, it was difficult to compare performance across the phases (Table 124). Emergency response times and prescription drug waiting times showed continuous improvement from baseline to end-line. Average length of stay and bed occupancy rates were within or close to MOH standards (Figures 477-478).

Table 124. Hospital-reported basic performance indicators, Hospital I, 2011 to 2015

Variables MOH

Standard*

I

Baseline (2011)

Midline (2013)

End-line (2015)

TOI (days) 1 – 3 1.6 NR 3

BTO (times) 40 – 50 44.1 NR 37

Emergency response time (minutes) < 5 15 5 4

Percentage of deaths in the ER (%) <2 NR 0.3 1

Net death rate (%) < 25 NR NR 57

Prescription drug service waiting time (minutes) < 30 minutes 15 15-30 15

Post-operative death rate 3 NR 0.7 0

Pre-operative waiting time (days) < 2 NR 5 2


Figure 477. Bed occupancy rate for Hospital I by phase


Figure 478. Average length of stay for Hospital I by phase


Hospital review

Hospital I showed almost all hospital review variables increased from baseline to end-line. However, human resources, transfusion, and documentation records showed slight declines (Figures 481, 484 and 488). Measures of hospital governance, patient orientation, clinical practice, health care associated infection, facilities management, medication safety, and surgery increased slightly but were still below the average of other eight hospitals (Figures 479, 480, 482, 483, and 485- 487).

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Hospital governance

Figure 479. Hospital governance by phase, Hospital I vs. 8 other hospitals

Patient orientation

Figure 480. Patient orientation by phase, Hospital I vs. 8 other hospitals

Human resources

Figure 481. Human resources by phase, Hospital I vs. 8 other hospitals

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Figure 482. Clinical practice and patient care performance by phase, Hospital I vs. 8 other hospitals


Figure 483. Healthcare-associated infection by performance phase, Hospital I vs. 8 other hospitals

Transfusion

Figure 484. Transfusion by performance phase, Hospital I vs. 8 other hospitals

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Figure 485. Facilities management by performance phase, Hospital I vs. 8 other hospitals

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Figure 486. Medication safety performance by phase, Hospital I vs. 8 other hospitals


Figure 487. Surgery, interventional procedures, and anesthesia performance by phase, Hospital I vs. 8 other hospitals

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Figure 488. Documentation and records performance by phase, Hospital I vs. 8 other hospitals


Based on the 10 criteria assessed, Hospital I improved in all four departments from baseline to end-line. Significant improvements were seen in the Obstetric and Surgical Departments (Figures 489 and 492), whereas only a slight increase was observed in Pediatrics and Cardiology/Internal Medicine Departments (Figures 490 and 491). Even after these increases in all departments, the hospital was generally still below the average of the other hospitals in the study.

Figure 489. Key organizational audit criteria in Obstetric Department, Hospital I vs. 8 other hospitals

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Figure 490. Key organizational audit criteria in Pediatric Department, Hospital I vs. 8 other hospitals

Figure 491. Key organizational audit criteria in Internal Medicine/Cardiology Department, Hospital I


Figure 492. Key organizational audit criteria in Orthopedic/Surgical Department, Hospital I vs. 8

other hospitals

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Chart review

Delivery

At end-line, there was a slightly higher proportion of patients’ hospital costs covered under JKN than the average for the other eight hospitals and a slightly lower proportion of patients paying hospital costs out of pocket (Table 125). Average length of stay for normal delivery patients did not change significantly across the study periods and was not different from the other hospitals in the study (Figure 493). The age distribution of patients was also unchanged and not significantly different (Figure 494). There were no maternal deaths reported in any of the three study periods, and the proportion of patients who did not have their discharge status noted in the medical record decreased from 40% at baseline to 0% at end-line (Table 126). Recording of laceration status, Apgar score, and birth weight were generally high at baseline and remained high or increased throughout the study (Figure 495-497).

Table 125. Method of payment of normal delivery patients by phase, Hospital I vs. 8 other hospitals

I 8 hospitals

Baseline MidlineEnd-line Baseline Midline End-line

Out of pocket 6.7 0.0 13.3 38.3 25.4 20.4Commercial insurance 0.0 0.0 0.0 0.4 0.0 0.0Government insurance 0.0 3.3 0.0 15.0 6.7 0.0Insurance for the poor 16.7 0.0 6.7 20.8 32.9 6.3Jampersal 76.6 96.7 0.0 23.8 24.6 0.0BPJS 80.0 65.8Other 0.0 0.0 0.0 0.0 0.0 5.0Do not know 0.0 0.0 0.0 1.7 10.4 2.5

Figure 493. Average length of stay of normal delivery patients by phase, Hospital I vs. 8 other hospitals

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Figure 494. Mean age of normal delivery patients by phase, Hospital I vs. 8 other hospitals

Table 126. Condition of normal delivery patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 60.0 76.6 86.7 91.7 87.5 85.4Referred to other hospital 0.0 0.0 0.0 0.0 1.3 0.0Death 0.0 0.0 0.0 0.0 0.0 0.0Judicial discharge 0.0 0.0 13.3 0.4 2.5 2.9Other 0.0 0.0 0.0 4.6 0.4 0.0Control and outpatient 0.0 6.7 0.0 0.0 0.0 0.0Unknown 40.0 16.7 0.0 3.3 8.3 11.7

Figure 495.Laceration recorded for normal delivery patients by phase, Hospital I vs. 8 other hospitals

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Figure 496. Apgar score recorded for normal delivery newborn by phase, Hospital I vs. 8 other hospitals

Figure 497. Birth weight recorded for normal delivery newborns by phase, Hospital I vs. 8 other

hospitals


More than half of the sample of pneumonia patients at baseline were between one and 11 months of age, but this decreased to only 7% at end-line, when more than half were 12-23 months of age (Table 127). Length of stay decreased from seven days to about five days at end-line, which was higher than the average of the other eight hospitals (Figure 499). At midline and end-line there were slightly higher proportions of patients who paid out of pocket for their medical care compared to the eight other hospitals, while at end-line about the same proportions were covered by JKN as in the other hospitals (Table 129).

The mortality ratio was lower was slightly lower in Hospital I compared to the average of the eight other hospitals, and there was a higher proportion whose discharge status was not recorded, especially in the midline (Table 130). Recording of clinical signs and symptoms and medical history remained high throughout the period of the study; similar to the results observed in the other study hospitals (Figures 500-504).

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Table 127. Age distribution of pneumonia patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals

Age (months) Baseline MidlineEnd-line Baseline Midline

End-line

< 1 3.3 3.5 0.0 1.7 20.1 15.8 1 - 11 56.7 51.6 6.7 54.5 49.0 43.8 12 - 23 20.0 27.6 56.6 26.3 16.3 22.9 24 - 35 16.7 3.5 20.0 10.4 10.5 9.6 36 - 47 0.0 10.3 10.0 6.3 2.8 5.8 48 - 59 3.3 3.5 6.7 0.8 1.3 2.1

Table 128. Sex of pneumonia patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals End- End-

Baseline Midline line Baseline Midline line Male 53.3 55.2 46.7 49.2 54.2 56.2 Female 46.7 44.8 53.3 50.8 45.8 43.8

Figure 498. Mean age in months of pneumonia patients by phase, Hospital I vs. 8 other hospitals

Table 129. Method of payment of pneumonia patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 33.3 69.0 40.0 62.0 46.7 32.1Commercial insurance 0.0 0.0 0.0 1.7 0.0 0.0Governance insurance 6.7 6.9 0.0 10.0 6.3 0.0Insurance for the poor 53.4 20.6 0.0 23.3 38.3 11.7Other, specified 3.3 3.5 3.3 1.3 0.8 2.1BPJS 56.7 52.8Do not know 3.3 0.0 0.0 1.7 7.9 1.3

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Figure 499. Length of stay of pneumonia patients by phase, Hospital I vs. 8 other hospitals

Table 130. Condition at discharge of pneumonia patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 50.0 37.9 70.0 69.1 64.5 66.2Referred to other hospital 0.0 0.0 0.0 1.3 1.7 0.0Death 3.3 0.0 10.0 6.3 14.2 12.5Not cured, judicial discharge 30.0 6.9 13.3 12.0 12.9 9.2Others 10.0 0.0 0.0 5.0 0.0 0.0Control and outpatient 0.0 0.0 0.0 0.0 1.7 0.8Unknown 6.7 55.2 6.7 6.3 5.0 11.3

Figure 500. Respiratory symptom recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals

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Figure 501. Immunization recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals

Figure 502. Respiratory rate recorded for pneumonia patients by phase, Hospital I vs. 8 other

hospitals

Figure 503. Temperature recorded for pneumonia patients by phase, Hospital I vs. 8 other

hospitals

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Figure 504. Pulse recorded for pneumonia patients by phase, Hospital I vs. 8 other hospitals

AMI

Average length of stay and average age of AMI patients remained consistent across the three time periods and were the same as the averages observed for the eight other hospitals (Figures 505-506). At Hospital I, there were fewer patients who paid out of pocket for their hospital care and slightly more who subscribed to BPJS by the end-line period compared to the average of the other hospitals (Table 131).

There were no deaths among the sampled AMI patients at baseline and midline and two patients out of a sample of 30 who died at end-line, lower throughout compared to the other eight hospitals (Table 132). Cardiac enzyme examination recordings in medical records was slightly lower compared to the other eight hospitals, but not statistically significantly so (Figure 507). ECG examination recordings showed a major improvement after the baseline, rising to full compliance (100%) like the other hospitals in the study (Figure 508). Recording of evidence-based medications for AMI cases was slightly better, though not statistically significantly different, than the average and improved slightly over time (Figure 509-511). Recording of medical history was mixed with cerebrovascular accident history lower than average, diabetes and heart failure average but increasing over time, hypertension average except for being very low at baseline, and previous AMI and angina history lower than average (Figure 512-518).

Figure 505. Average age of AMI patients by phase, Hospital I vs. 8 other hospitals

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Figure 506. Length of stay of AMI patients by phase, Hospital I vs. 8 other hospitals

Table 131. Method of payment of AMI patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 20.0 35.3 6.7 38.8 32.2 18.3Commercial insurance 0.0 0.0 0.0 1.3 0.4 0.4Governance insurance 20.0 26.5 0.0 40.7 28.5 0.0Insurance for the poor 60.0 38.2 3.3 16.3 31.8 4.6Other 0.0 0.0 3.3 0.0 0.4 4.2BPJS 86.7 71.7Do not know 0.0 0.0 0.0 2.9 6.7 0.8

Table 132. Condition at discharge of AMI patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 50.0 55.9 83.3 63.7 66.6 62.9Referred to other hospital 0.0 0.0 0.0 0.0 0.0 0.4Death 0.0 0.0 6.7 11.6 13.4 14.2Not cured, judicial discharge 16.7 2.9 10.0 11.3 7.1 5.4Other 20.0 5.9 0.0 6.3 0.8 0.0Control and outpatient 0.0 14.7 0.0 0.0 6.7 1.3Unknown 13.3 20.6 0.0 7.1 5.4 15.8

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Figure 507. Cardiac enzymes examination recorded for AMI patients by phase, Hospital I vs. 8 other hospitals

Figure 508. ECG examination recorded for AMI patients by phase, Hospital I vs. 8 other hospitals

Figure 509. Oral beta-adrenergic recorded for AMI patients by phase, Hospital I vs. 8 other

hospitals

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Figure 510. Statin recorded for AMI patients by phase, Hospital I vs. 8 other hospitals

Figure 511. Aspirin prescription recorded for AMI patients by phase, Hospital I vs. 8 other

hospitals

Figure 512. Previous AMI history recorded for AMI patients by phase, Hospital I vs. 8 other

hospitals

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Figure 513. Angina pectoris history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals

Figure 514. Hypertension history recorded for AMI patients by phase, Hospital I vs. 8 other

hospitals

Figure 515. Hypercholesterolemia history recorded for AMI patients by phase, Hospital I vs. 8

other hospitals

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Figure 516. Cerebrovascular accident history recorded for AMI patients by phase, Hospital I vs. 8 other hospitals

Figure 517. Heart failure history recorded for AMI patients by phase, Hospital I vs. 8 other

hospitals

Figure 518. Diabetic history for AMI patients by phase, Hospital I vs. 8 other hospitals

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The number of hip/femoral neck fracture cases in Hospital I was lower than the target sample size; there were seven cases at baseline, 10 cases at midline, and 19 cases at end-line, even when we extended the period of eligibility to 1.5 years for each phase. These patients were slightly older with lengths of stay about the same as at the other eight hospitals (Figures 519 and 520).

Among the sample, there were slightly fewer patients paying hospital expenses out of pocket and slightly more enrolled in JKN than the average of the eight other hospitals (Table 133). There were fewer surgeries at midline and end-line compared to the other hospitals in the study (Figure 521). The small sample size gave no statistically significant findings for the quality measures for surgery. However, there were fewer patients whose medical record indicated they received antibiotic prophylaxis or post-operative mobilization than the average of the other eight hospitals (Figures 522–424).

In this province, key informants reported that the hospital patients generally preferred alternative treatment for hip fractures to surgical repair, which is generally indicated by strong and consistent medical evidence, even if they subscribed to JKN – a method of payment that would cover surgical repair.

Figure 519. Mean age of hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals

Figure 520. Length of stay for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other

hospitals

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Table 133. Method of payment of hip/femoral neck fracture patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-line

Out of pocket 42.8 30.0 5.3 52.9 30.6 11.7Governance insurance 14.3 40.0 0.0 24.6 35.6 0.0Insurance for the poor 28.6 30.0 5.3 18.2 25.8 1.4BPJS 89.4 79.8Other 14.3 0.0 0.0 0.7 0.0 5.2Do not know 0.0 0.0 0.0 3.6 8.0 1.9

Table 134. Patients’ condition for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineCured/improving 57.1 10.0 63.1 62.3 67.2 66.1Referred to other hospital 0.0 0.0 0.0 0.0 0.0 0.5Death 0.0 0.0 5.3 3.6 1.8 3.3Not cured, judicial discharge 28.6 50.0 31.6 23.2 17.3 10.3Other 0.0 0.0 0.0 0.0 0.9 2.4Control and outpatient 14.3 30.0 0.0 0.0 8.4 0.5Unknown 0.0 10.0 0.0 10.9 4.4 16.9

Figure 521. Surgery for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals

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Figure 522. Antibiotic prophylaxis given for hip/femoral neck fracture by phase, Hospital I vs. 8 other hospitals

Figure 523. Mobilization after surgery for hip/femoral neck-fracture patients by phase, Hospital I


Figure 524. Thromboembolic for hip/femoral neck-fracture patients by phase, Hospital I vs. 8 other hospitals

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Patient interviews

Most patient interview respondents were junior and high school graduates of more than 40 years of age (Table 135). As in the other eight hospitals, the proportion covered by JKN was high at end-line (Table 136). The average length of stay for patients interviewed decreased between baseline and midline and remained unchanged between midline and end-line (Figure 526).

The proportion of patients with positive perceptions of nursing and medical staff and overall services was lower than average at end-line. Overall satisfaction with services was about the same throughout as the average for the eight other hospitals and the proportion of patients who would recommend the hospital to others was lower than the average for the other hospitals (Figures 527-531).

Table 135. Characteristics of patient interview respondents by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineSex

Male 23.3 23.1 38.8 28.3 28.0 32.6Female 76.7 76.9 61.2 71.7 72.0 67.4

Education None and primary school 23.3 19.0 16.5 28.4 23.2 20.6Junior and high school 62.5 68.6 71.1 56.6 59.2 59.9Academy and university 14.2 12.4 12.4 15.0 17.6 19.5

Figure 525. Mean age of patients interviewed by phase, Hospital I vs. 8 other hospitals

Table 136. Method of payment of patients interviewed by phase, Hospital I vs. 8 other hospitals

I 8 Hospitals Baseline Midline End-line Baseline Midline End-lineOut of pocket 35.0 25.6 14.1 16.7 8.9 12.7Commercial insurance 0.0 1.7 0.8 1.5 0.2 0.1Government insurance 15.8 0.0 0.0 20.1 0.0 0.0Jampersal 20.8 0.0 0.0 15.7 0.0 0.0BPJS for the poor (PBI) 20.8 33.8 33.0 44.6 37.4 28.2BPJS pay for premium 0.0 20.7 30.6 0.0 32.7 33.3BPJS paid by the company 0.0 0.8 1.7 0.0 4.1 10.7BPJS for government employee (Askes, Asabri, etc.) 0.0 17.4 19.8 0.0 16.3 13.6Other 7.6 0.0 0.0 1.3 0.2 1.4Do not know 0.0 0.0 0.0 0.1 0.2 0.0

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Figure 526. Length of stay of interviewed patients by phase, Hospital I vs. 8 other hospitals

Figure 527. Patient satisfaction with medical services by phase, Hospital I vs. 8 other hospitals

Figure 528. Patient satisfaction with nursing care by phase, Hospital I vs. 8 other hospitals

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Figure 529. Patient satisfaction with hospital facilities by phase, Hospital I vs. 8 other hospitals

Figure 530. Patient satisfaction with all services at hospital by phase, Hospital I vs. 8 other

hospitals

Figure 531. Patient experience at hospital by phase, Hospital I vs. 8 other hospitals

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Accreditation

Key informants reported that Hospital I considered the accreditation process a high priority. The hospital failed to pass KARS (2007 version) before this study began. The process of changing systems to fulfill the standards required a large capital expenditure for facilities and infrastructure improvement, and the budget provided by the hospital was inadequate to meet all of the standards set. Total budget planning is 500 billion IDR, meanwhile budget allocation for building facilities is relatively small.

During the accreditation process, the hospital undertook benchmarking activities with several hospitals, partly under the guidance of KARS. Unfortunately, preparation in the accreditation process was mostly conducted by a working group without broader inclusion of the general staff. Therefore, there was limited understanding among the rest of the staff about accreditation standards. For example, compliance with standards of usage and disposal of safety boxes and storage of oxygen cylinders was not well known among the relevant staff. Key informants reported that the process of accreditation did not stimulate any significant change in the working culture. Medical record completion was one the most difficult elements to improve, especially because of the change in behavior required of the medical and nursing staff. It was reported that the overall improvement in human resources also requires high costs.

Change in the classification of Hospital I, from type B to type A, also indirectly affected the volume of patients and case mix handled by the hospital, and therefore impacted the services provided and the use of the facilities. The process of hospital accreditation with KARS (2012 version) was started in December 2014. However, at that time the hospital was not prepared for the types of cases usually handled by type A hospitals. Facilities were incomplete to perform percutaneous coronary intervention for AMI cases. The hospital was equipped to do those by the end of 2015.

Key informants reported that the impact of accreditation was rapid development of facilities and improvement in quality of human resources. One impact of accreditation included an increase in patient volume, reportedly due to improvement in service quality. Factors driving this included shorter waiting times for services, improved facilities, and an increase in specialist equipment availability. Improving service quality was still the major challenge, especially changing the work culture of the medical staff, who reportedly were still not working as effectively and efficiently as needed to improve. Key informants said that there were still too many medical staff members who relied on their students to provide services.

JKN implementation

During initial implementation of JKN from January 2014, the hospital had to implement the new policies with their limited facilities, degraded infrastructure, and inadequate number health workers. The proportion of BPJS patients was reported to be about 80-85% at end-line. Because of the tiered referral system, the number of outpatient visits dropped dramatically, while the number of inpatient cases did not change substantively. There has been a decline in out-patient visits from 2014 to August 2015 of about 7000 cases per month. Key informants reported that care was not always provided efficiently and optimally because the hospital is a teaching center and sometimes examinations and other academic activities interfered with the running of the hospital.

Generally, hospital revenues reportedly increased since the implementation of JKN. Most revenue came from BPJS (at about 90%) and the rest from general patients. Since Hospital I is tertiary referral facility, the tariff paid by BPJS through the INA-CBG is automatically increased. Total hospital claims per month were around 25-30 billion IDR for services, or 30 billion IDR, including pharmaceutical sales. However, as the hospital had financial difficulties due to the change in billing, some pharmaceutical distributors stopped deliveries to the hospital due to unpaid bills. Lengths of stay in the hospital are now better matched to the bed capacity of the hospital. However, during the BPJS verification process, it was noted that lengths of stay for some diagnoses were higher than the targets of BPJS.


Hospital I developed an innovative financial plan called E-Budgeting and implemented it in 2016. It is a computer-designed annual plan that organizes programs, activities, performance indicators, and costs in five-year cycles.

Conclusion

Not all staff were exposed to or involved in the process of accreditation. This lack of familiarity with and decreased involvement in and engagement with the accreditation process led to many staff not understanding the purpose and importance of the standards set by KARS. Facilities and infrastructure are generally the largest cost of hospitals in the accreditation process, but in this case there was inadequate funding to make all necessary changes. Also, the current working culture and coordination among hospital personnel was not well organized, with poor communication between staff and managers.

Changes in classification from type B to type A led to an increase in the claims payment for JKN patients, but the overall number of patients decreased because of implementation of the referral system established by BPJS. Given that the case mix for the hospital changed to more severe cases in greater medical need, there was an increase in the average length of stay.


III. POLICY IMPLICATIONS AND RECOMMENDATIONS

KARS accreditation has been a fixture of the hospital health system in Indonesia for more than three decades. With the 2012 reforms that better aligned KARS accreditation standards with international standards, and KARS’ recent increase in the training and the quantity of accreditation inspection staff, there has been an improvement in their performance. It also led to their accreditation as an accreditation authority by ISQua. The fact that deficits in indicators of quality and safety were still observed in the nine hospitals in this study after they all underwent KARS accreditation indicates there is room for further improvement in the system.

One suggestion from findings in this study is for KARS leadership to continue to implement changes to improve their accreditation system. Judging by comments from key informants, the most likely route for this would be to improve the quality of training provided to the inspectors and to deploy a significantly higher number of them so that they can complete inspections every three years in each of Indonesia’s 2,822 hospitals (35). As of January 2018, KARS had only accredited 1,603 hospitals (36). It is thought the reason is both a lack of adequate capacity of surveyors to conduct accreditation at KARS and a lower than mandated demand for accreditation surveys by hospitals While it is generally recognized in the health policy literature that accreditation alone is not sufficient to ensure that a hospital is providing health care to acceptable quality standards, regular accreditation surveys should facilitate optimal and sustained performance by the hospital to as great a degree as possible (37, 38). They are also required for participation in JKN, though this was not enforced during the period of the study.

Given that KARS accreditation costs a considerable sum of money and takes staff labor resources away from patient care activities, the hospitals and their patients should expect an improvement in service quality at least commensurate in value with the opportunity cost associated with the process.

Our findings generally show that hospitals undergoing additional JCI accreditation improved more in measures of quality of their systems of care. They also generally started at a higher level in quality and performance indicators. It is difficult to interpret the additional improvement seen in the JCI-KARS hospitals to JCI-only accreditation because there was selection bias whereby higher-performing hospitals were selected by the MOH to undergo additional international accreditation. While improvements were seen in these five hospitals, deficits remained in their quality performance scores. JCI accreditation costs a substantial amount more than KARS, and it is unclear from results of this study that these expenditures are commensurate with the increase in performance above KARS accreditation alone. From key informant interviews, it seemed that the JCI accreditation process did have a positive effect on management and staff behavior. Whether these positive changes are sustainable and create significant enough improvement in hospital functioning to warrant the outlay of resources to get them is an open question. It would be prudent to explore other methods of improving hospital quality outside JCI accreditation because it is impossible for all but the financially strongest hospitals to be involved with such a resource-intensive activity.

The MOH has formed a new unit, the Directorate for Accreditation and Quality. Part of its purpose is to monitor and improve the quality of hospital services. It is uncertain the degree to which this new directorate’s function will coordinate with KARS. While its stated purpose is to improve the quality of service delivery, the actions it will take to fulfill this purpose are still being developed (39). It is recommended that the directorate provide their expertise in quality to consult with BPJS to ensure that the reimbursement system in JKN provides incentives for hospitals to provide high quality of care (40). It is also recommended that the directorate provide guidance and feedback to KARS to ensure that the accreditation organization understands that their role in facilitating hospitals to provide quality care is acknowledged and tracked.

This research was not designed to study the roll-out of the JKN single-payer national health system. However, it happened during the study, and its effects were so profound on hospital care that we included


it in the analysis. Implementation of JKN during the study period was seen to change the behavior of the hospital system in predictable ways. Hospitals reallocated human resources to meet new demands for reimbursement documentation and noticeably changed their admission criteria to act more in line with their status as top referral hospitals. Financial concerns were clearly a powerful driver of changes in the hospitals. With JKN in the early stages of implementation, there was uncertainty over rules and procedures for reimbursement. As expected, BPJS was primarily concerned with establishing a basic functioning health insurance system, with millions of new subscribers, to ensure adequate coverage and appropriate reimbursement. With the continued maturation of the JKN system, it is hoped there will be organizational scope for BPJS to begin considering how JKN can incentivize high quality care and base payments at least partially on health outcomes rather than service volume alone.

BPJS has established a Quality and Cost Control Team (Tim Kendali Mutu dan Kendali Biaya) that was operating in 2017 (41). It consists of coordinators, academics, professional organizations, and clinician experts from hospital medical committees that collaborate with BPJS. It is hoped that this new team can facilitate a system to stimulate interventions to improve service quality and work in concert with the MOH’s Directorate for Quality and Accreditation as noted above.

BPJS should recognize that the benefits of their monopsony power in this new system does not continue in perpetuity and must be used judiciously. Low reimbursement rates, set by the MOH tariff team, for relatively expensive diagnoses and procedures will decrease quality of care in the short and medium term and may lead hospitals to game the system. Over the long term, promising the population comprehensive coverage while paying too little for the services offered will have the perverse effects of decreasing investment in health care, stifling innovation, and making the health care professions less attractive options for highly-motivated, high-performing workers. These factors must be considered against the power BPJS has to set prices for health care. The payment system must create incentives for optimal efficiency while achieving high quality care to produce the greatest benefits to patients and society. Technically, this is very challenging and will require BPJS itself to be nimble and innovative as it searches for the optimal formula for the system.

It was apparent from the findings of the study that the performance of KARS has improved over time. Adoption of the 2012 accreditation standards was followed with another review and update of the standards that came into effect in January 2018 (42). It is an encouraging sign that the standards and their application are evolving over time. KARS should continue to increase the number of surveyors it employs to perform accreditations, and the training these surveyors receive should continue to be improved in order to achieve the goal of consistency and validity in their survey results.

The Government of Indonesia has been working to develop an accreditation system for primary health services, including Puskesmas (community health clinics), private primary health centers, private doctors’ clinics, and dental offices (43). By the end of December 2016, it was reported that the number of sub-districts with a minimum of one accredited Puskesmas increased from 93 in 2015 to 1,308 in 2016. Furthermore, a total of 1,479 Puskesmas have been accredited, which are located in 1,308 sub-districts, 320 district/municipalities, and 34 provinces (4).

Implementation of JKN has been a profound change to the Indonesian health system. While the system is still young and relatively flexible, experimentation with methods of reimbursement and incentives for quality services should be explored in a rigorous and systematic manner. The evidence from such experimentation can help develop the system to maximize its benefit to society while providing broad and equitable coverage. In this way, Indonesia has the opportunity to build the world’s premiere universal health system for a middle-income country that provides high quality, comprehensive health care.

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