AHS Implementation in Universitas Gadjah Mada

Rukmono Siswishanto Dr. Sardjito Hospital/ Fac. of Medicine

Outline ① Introduction ② Why do we need AHS ③ The risk of not being integrated ④ The underlying concept ⑤ Implementation of AHS ⑥ Challenges ahead

Yogyakarta Special Region • Located in the central part of Java Island • Population: more than 3.5 million • Four districts and 1 city: – Yogyakarta city – Sleman – Bantul – Kulonprogo – Gunungkidul

Universitas Gadjah Mada (UGM) established on December 19, 1949

Faculty of Medicine UGM established on March 5, 1946

FACULTY OF MEDICINE UNIVERSITAS GADJAH MADA

General Profile Faculty of Medicine UGM • • • • • • • • •

3 undergraduate programs 6 master programs 1 doctoral program 20 clinical specialization programs 32 Departments 14 Research centers-WGs >1,000 staff (teaching and administrative) >500 new undergraduate students >600 new graduate students and residents

Human Resources Lecturers: 673* • 303 (45%), full time – 209 (government civil servant) and 94 (university-based) • 156 (23%) clinical teachers from Sardjito • 214 (32%) clinical teachers from other teaching hospitals *Excluding part-time lecturers from non-teaching hospitals and 77 retired lecturers

Quality Assurance Systems Internal • Quality assurance office (University level) • Quality assurance unit (Faculty level) • Academic standard committee (Study program level)

External • National accreditation – Public health graduate program accreditation: A

• International accreditation – IMIA (HMIS, provisionally accredited) – PAASCU (Medicine, in process) – FERCAP (IRB) – JCI for AMC (Sardjito hospital) – ISO certification 9001:2008 (Faculty administration)

5 Hospital 1927 beds++

Sardjito General Hospital • Ministry of Health owned hospital in Yogyakarta • 750 beds capacity • Top referral hospital for Yogyakarta Special Province and southern part of mid Java Province (23 million population) • Cardiac and Cancer excellence services • JCI accreditation for AMC

Soeradji Tirtonegoro Hospital • Ministry of Health owned hospital in Klaten (30 kms east of Yogyakarta) • 400 beds capacity • Located in rural/ suburban area • Geriatric excellence services

Universitas Gadjah Mada Hospital • University owned hospital • 200 beds capacity, secondary services • Official opened in 2012 • Disabled child growth excellence services

Hardjolukito Hospital • Air-force military owned hospital • 400 beds capacity, tertiary services • Located at eastern part of Yogyakarta city • Special in Flight Medicine

Banyumas Hospital • District government owned hospital • Located in rural area, 200 kms west of Yogyakarta • 300 beds capacity, secondary services • Comprehensive Mental Health excellence services

② WHY DO WE NEED AHS

Legislation related to AHS • • • • • • • •

UU no 12 tahun 2012 tentang pendidikan tinggi UU no 12 tahun 2013 tentang pendidikan kedokteran UU no 44 tahun 2009 tentang rumah sakit UU no 29 tahun 2004 tentang praktek kedokteran UU no 36 tahun 2014 tentang tenaga kesehatan UU no 5 tahun 2014 tentang ASN PP no 93 tahun 2015 tentang RS Pendidikan Permenristekdikti no 26 tahun 2015 tentang pendidikan • Permenristekdikti no 2 tahun 2016 tentang perubahan permenristekdikti no 26 tahun 2015 1/13/2017

Mission

Disruption?

• Changing in societal needs and values • Disease patterns • Economics • Globalization • Politics • Population demographics • Market consolidation • Consumer empowerment • Policy changes • Enterpreneurism Wartman: The Transformation of Academic Health Centers (2015)

16

① ② ③ ④ ⑤ ⑥ ⑦

Free trade of AEC (31 December 2016) Legislation Medical & information technology Customer orientation JKN (BPJS & referral system) Remuneration system AHS/ AMC/ AHC 17

Current Situation Faculty of Medicine • Clinical educator • Cost of medical education • Unmet need of clinical educator (focus on health care, quota) • Clinical & translational research , not optimal • Low contribution on medical/ health science • Community services less comprehensive

Hospital • Less priority on educational activity (not included in remuneration system) • Quota of HR based on case load • Research is not priority • Un-strategic choice of featured services (inefficient) • Less responsibility to foster the others

Other problems - Limited facilities: patients booming long waiting list - Limited budget: Hospital priority - Different Regulations between Institutions/ hospitals - Administration system - Remuneration

Education

Research

Healthcare

Community

③ THE RISK OF NOT BEING INTEGRATED

① Less adaptive in dynamic world ② Failure to thrive

④ THE UNDERLYING CONCEPT

Large-scale social change requires broad cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organizations (Kania & Kramer, Collective impact, 2011)

Level of perspective

Generative Vision

Reflective i

Mental Models

Leverage increases

Creative Systemic structure

Adaptive Patterns

Reactive Events

Action mode Carter R.: A need for systems thinking in public health, 2016)

Collective Success ① Common agenda ② Shared measurement systems ③ Mutually reinforcing activities ④ Continuous communication ⑤ Backbone support organization (Kania & Kramer, Collective impact, 2011)

Scope of AHS International

National

Regional zone

AHS

Stakeholders

Capacity building

Aligning patient care, teaching, & research

Perceived benefit

Leadership

Sharing experiences Standard setting

Agenda Integrated information system

Primary

Secondary

1

3

Tertiary Public Health & Health Promotion 3

2

Counseling, Support, & Care continuum

2 2

3

1

1

Clinical care

Treatment

Wellness,Pr omotion/ Prevention

Early Detection

Management: • Initial diagnosis • Determinat ion of treatment • Treatment

Follow up care

Plan & treat recurrence

End of life care

Optimal Patient journey: facilitated by information, coordination, supportive care, service linkage

Involving primary, secondary, tertiary care

Modified from Healthcare Management Advisors (HMA) for the Northern Territory Government Department of Health and Families, Australia

Integration: Functional PP 93/2015 (ps 21)

Perjanjian kerjasama tertulis RS Integrasi Fungsional Koordinasi & kolaborasi dalam perencanaan, pelaksanaan, & evaluasi: pendidikan, pelayanan, penelitian, & abdimas Integrasi Struktural Penyatuan institusi menjadi satu kesatuan kerja

FK

Harmonization: Health care System & Health Professional Education

Tertiary Puskesmas

RS lainnya

Secondary

Primary

FKTP lainnya

Kemenkes Dinkes

Selfcare

AHS Concept of UGM Teaching Hospital

Teaching Hospital Teaching Hospital

Main Teaching Hospital

Pharmacyst

District Hosp

AHS UNIVERSITAS Dentistry

PRACTICE PLAN Health office

Faculty of Medicine

Nutrition Nursing

MD MD specialist

PHC Lab Res.Unit

Partnership & vehicles Synergy of program Organization

⑤ IMPLEMENTATION OF AHS

Partnership & Vehicles • 10 Hospitals – Combine for MD& Specialist training • 32 Hospitals – For Specialist training • Sister hospitals – Bajawa, Balikpapan, Jayapura, etc. • Health Office • Public Health Center

Synergy of Program Education -Share education facilities, IT -Standardized curricula for undergraduate, profession and residents for teaching and partner hospitals -Capacity building for staffs in teaching hospitals : TOT

-Quality control in education

Sample AHS Agenda for Spesialist Training • Involving related stakeholders: – GCU, Vaccination – Insurance – Insentive • Working hours (referring to ACGME) • Professional behaviour

Teleconference: AHS Management

Case Teleconference (Dept. of Skin & Venerology)

Library Sharing • Library facility sharing: Connection between UGM & Dr. Sardjito Hospital

Synergy of Program Research - Coordinated Ethical Committee in Faculty of Med and University Hospital

-Sharing research budget, scholarships -Sharing Laboratory Facilities

-Capacity building for researchers: GCP, GCLP -Organize clinical trial

2014-Project Highlights Oral Rv3 rotavirus vaccine research in Indonesia (Bill&Melinda Gates Foundation)

Malaria Transmission Consortium (Bill&Melinda Gates Foundation)

Monitoring progress Family Planning 2020 (Future Institute and Bill&Melinda Gates Foundation)

USAID-TBCTA Regional Training Centre for TB control & Neglected Infectious Disease Diagnostic Consortium (EU)

Primary Care Accelerator Program and InterUniversity Consortium on Global Health (New Proposal)

Knowledge Sector Initiative, HIV-AIDS, Sister hospital (Ausaid), Health policy network (Ausaid, IDRC)

Eliminate Dengue Project-Tahija Foundation and Dengue Waening Signs (WHO-TDR)

Fever Study-INA Respond (NIH USA R&D in collaboration with MOH & Teaching Hospitals)

Translational research on Nasopharyngeal Cancer and other types of Cancer (IRAC, AvL and partners)

Our Partners

• 62 international partners • 51 new national partners • Leading national consortiums

Synergy of Program Health/ Patient Care • Center of Excellence • Improvement quality (JCI Accreditation) • Sharing Facilities: CT Scan, MRI, Gamma Camera, ICU – not only 3 hospitals • Sharing health professionals: send specialist to referral hospitals • Send senior residents for health services and training • Referral system

Organization of UGM Academic Health System Advisory Board

Functional coordination system

Board of Directors Education Coordinating Board

Research Coordinating Board

Patient Care According to each hospital

(Department & Group of Medical Staff)*

Education Coordinator

Research Coordinator

Health care Coordinator

Community Service Coord.

⑤ CHALLENGES AHEAD

1. Share vision on common agenda

2. Forming the leadership team & shaping its accountability 3. Include all stakeholders in the process of integration

Synergy of operational governance: patient care, education, research (including recruitment, capacity building, career path, accountability, & insentive)

Synergy of organizational structure and financing

Summary • Academic Health System, with one established faculty of medicine, university hospitals, referral hospitals, and primary care in surrounding areas seems promising because lack of facilities, workforces, and funding could be shared together to improve community health care • All effort should be made to share the idea to all stakeholders: government, universities, all ministry involved to fasten the program

• Key success factors of AHS: Optimal Leadership, Strategic Organization, & Good Governance

Acknowledment • • • • • • • • •

Prof. dr. Ali Ghufron Mukti, MSc., PhD. Prof. DR. dr. Teguh Aryandono, SpBK (Onk) Prof. dr. Ova Emilia, PhD. dr. M. Syafak Hanung, MSc., SpA Prof. dr. Arif Faisal, SpRad Prof. dr. Budi Mulyono, SpPK, PhD. Prof. dr. Laksono Trisnantoro, PhD. dr. Alida Lienawati, Mkes. et all.