HEALTH SECTOR REVIEW

QUALITY AND SAFETY OF HEALTH CARE

JULY 2014 1

AUTHORS: CHARLES D. SHAW DEWI INDRIANI

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Acknowledgements This report was prepared by World Health Organization Country Office for Indonesia for the Health Sector Review. The report benefited from various comments and input from Muhammad Shahjahan (WHO), Rachel Cintron (USAID Jakarta), Edhi Rahmat (USAID Jakarta), John Langenbrunner (AIPHSS), Anhari Achadi (University of Indonesia), Edward Broughton (URC), Budihardja Singgih and Pusat Manajemen Pelayanan Kesehatan (PMPK) Universitay Gadjah Mada. The team coordinated with, and benefited from, the valuable inputs, reviews, and consultations with Nina Sardjunani (Deputy for Human Resources and Culture, Bappenas) and Arum Atmawikarta (Coordinator, Health Sector Review Secretariat). The comments and inputs from all stakeholders; Kementrian Kesehatan, Bappenas, DFATAIPHSS, IDI, Konsil Kedokteran have been great contribution to the report.

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Table of Contents Acknowledgements.................................................................................................................. 3 Table of Contents ..................................................................................................................... 4 List of Tables ............................................................................................................................ 5 List of Figures .......................................................................................................................... 6 Abbreviations and Acronyms .................................................................................................. 7 Executive Summary ................................................................................................................. 9 1.

Global Context of Quality and Safety in Healthcare ..................................................... 11

2.

Situation Analysis, Achievements and Trends ............................................................. 13

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4

5.

6.

2.1

Policy ..........................................................................................................................13

2.2

Organization ................................................................................................................13

2.3

Methods ......................................................................................................................14

2.4

Resources ...................................................................................................................16

Challenges Remaining .................................................................................................... 18 3.1

Policy ..........................................................................................................................18

3.2

Organisation ................................................................................................................18

3.3

Methods ......................................................................................................................18

3.4

Resources ...................................................................................................................21

Strategic Issues ............................................................................................................... 24 4.1

General Considerations...............................................................................................24

4.2

Values of a Comprehensive Quality Approach ............................................................24

2.1

Linking Quality to Other Health Sector Review Themes ..............................................25

Policy Direction and Strategies ...................................................................................... 26 5.1

Introduction .................................................................................................................26

5.2

What Do We Want Values and Principles....................................................................27

5.3

Where Should We Be Expectations and Standards .....................................................28

5.4

Where Are We now – Measurement, Monitoring .........................................................30

5.5

How Do We Get There – Implementing Change..........................................................33

Indicators of Achievement.............................................................................................. 43

Appendix 1. Assessment tool for national quality systems ................................................ 46 Appendix 2. International quality indicators, OECD text links ............................................ 53

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List of Tables Table 1. Examples of indications of policy on quality and safety ............................................... 13

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List of Figures Figure 1. Differentiating between licensing and accreditation ....................................................19 Figure 2. Range of performance scores in 10 domains, 9 class A hospitals RI ..........................19 Figure 3. Patient Satisfaction, Normal Delivery, Nine Hospitals, RI............................................20 Figure 4 heart attack patients receiving recommended discharge medication ...........................21 Figure 5. Undocumented critical times for heart attack patients .................................................22 Figure 6. Intregating Quality Systems ........................................................................................26 Figure 7. Overlap of need demand and supply ..........................................................................30

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Abbreviations and Acronyms AGREE

Appraisal of Guidelines for Research and Evaluation

AMI

Acute Myocardial Infarction

Askes

Asuransi Kesehatan (Health Insurance)

BPJS

Badan Penyelenggara Jaminan Sosial (Social Security Administrative Body)

BPOM

Badan Pengawas Obat dan Makan (National Drug Regulatory Authority)

BPRS

Badan Pengawas Rumah Sakit (Hospital Supervisory Board)

BUKD

Bina Upaya Kesehatan Dasar (Directorate of Primary Health Care)

CME

Continuing Medical Education

CPD

Continuing Professional Development

CPDMS

Clinical Performance Development and Management System

CPG

Clinical Practice Guideline

CVD

Cardio Vascular Disease

DHO

District Health Office

DJ BUK

Direktorat Jendral Bina Upaya Kesehatan (Directorate General of Health Service)

DRG

Diagnosis Related Group

DTCs

Drugs and Therapeutic Committee

EFQM

European Foundation for Quality Management

HAPIE

Hospital Accreditation Project Impact Evaluation

HSR

Health Sector Review

HTA

Health Technology Assessment

ICD

International Classification of Diseases

IMCI

Integrated Management Childhood Illnesses

ISO

International Standard Organisation

ISQua

International Society for Quality of Healthcare

JCI

Joint Commission International

JKN

Jaminan Kesehatan Nasional (National Health Insurance)

KARS

Komite Akreditasi Rumah Sakit (Indonesian Commission on Accreditation of Hospital)

KCl

Potassium Chloride

KKI

Konsil Kedokteran Indonesia (Indonesian Medical Council)

MCH

Maternal and Child Health

MKDKI

Majelis Kehormatan Disiplin Kedokteran Indonesia (Medical Disciplinary Board)

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MoE

Ministry of Education

MoH

Ministry of Health

MoHA

Ministry of Home Affairs

MSS

Minimum Service Standard

MTKI

Majelis Tenaga Kesehatan Indonesia (Indonesian Health Worker Council)

NCDs

Non Communicable Diseases

NDRA

National Drug Regulatory Authority

NGO

Non-Governmental Organisation

OECD

Organisation for Economic Cooperation and Development

PAMALI

Perkumpulan Pasien dan Masyarakat Peduli TB (TB patient’s organisation)

PATH

Performance Assessment Tool for Quality Improvement in Hospitals

PHBS

Pola Hidup Bersih dan Sehat (Clean and Healthy Lifestyle)

PHC

Primary Health Care

PMK

Peraturan Menteri Kesehatan (Health Ministry Decree)

Pusdatin

Pusat Data dan Informasi (Centre for Data and Information)

QIP

Quality Innovation Progremme

SARA

Service Availability and Readiness Assessment

TB

Tuberculosis

UHC

Universal Health Coverage

UU

Undang – undang (Law)

WHO

World Health Organisation

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Executive Summary This summary is based on analysis of the national picture, mostly at central level and in hospitals. This used an assessment framework, developed for WHO, comprising four key elements of a national quality system: policy, organization, methods and resources. The multiplicity of stakeholders, the elusive concept of quality, and a general lack of information in the public domain have been a challenge to this cross-cutting issue which is new to the national five-year plan. Further attention is needed to identify existing structures and mechanisms, especially in primary care and at sub-national level. Suggestions and comments in the chapter should be regarded as topics for discussion and consultation, rather than as prescription for action. The intentions of government to increase access to healthcare are indicated by commitment to universal health coverage, and to add resources (human and financial) to the system. Legislation underpins professional regulation and institutional accreditation at national level. Decrees from the MoH, especially in the past three years, have laid the foundations for improving quality and safety through structures and methods which are widely used around the world. These include institutional regulation (hospital supervision and puskesmas accreditation), clinical governance, technology assessment, medical practice guidelines and patient safety. The impact of these initiatives has not been evaluated but appears to vary widely at provider level, and between hospital and primary care. Responsibilities for many elements of quality management are distributed throughout the MoH, and some appointed commissions such as for technology assessment and for patient safety. Responsibilities for undergraduate, postgraduate and continuing education of the healthcare workforce are shared with the Ministry of Higher Education. Practical application of national policy is widely effected by the Ministry of Home Affairs. Registration of health professions is overseen by national councils but licenses are issued at regional or district level. NGOs representing patients, professions and managers are potential contributors to quality improvement at national level. Methods of improvement divide broadly into external assessment (institutional accreditation, licensing and ISO certification; professional registration and licensing) and internal quality systems (e.g. risk management, clinical governance, individual credentialing). BPJS adds a further dimension by defining preferred providers (“credentialing”) and by monitoring quality of service delivery in terms of compliance with contract specifications. Methods for developing standards (both organizational and clinical), and for measuring compliance, varies between these mechanisms and between institutions. Information systems (for clinicians, managers and financing) exist, in varying degrees, within institutions. There is little publication or exchange of information between agencies, and little feedback for learning and performance improvement within the health system. In short, the fundaments of a national quality system already exist in Indonesia but these could be made more effective by clearer definition and alignment of standards, measurements and incentives for improvement. Steps towards integration could include:

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•

Defining the national vision of performance: identifying stakeholders, values and dimensions of quality to ensure that the system is responsive, effective and safe at both population and at individual level; involving stakeholders through consultation, communication and public information; confirming the rights of patients not just to access to care but also to social rights such as choice, privacy, safety and information

•

Defining responsibilities for quality and safety: mapping the aims, authority, accountability and infrastructure of government agencies, and the relationships and coordination between them; encouraging and developing the capacity of NGOs, academics and private sector

•

Adopting proven methods for improvement: alignment with international practice eg ISQua standards for accreditation, AGREE principles for clinical practice guidelines. OECD and WHO for performance indicators; ensuring consistency between curriculum, training, CPD, and standards for accreditation, licensing and clinical practice

•

Aligning incentives: linking personal and organizational assessment and development to social, professional and financial reward – and public recognition of achievement; removal of practical barriers (eg lack of time, data, skills, tools, information)

•

Promoting learning: feedback of aggregated data, performance benchmarking; recognizing peer review and team-based learning as a contribution to CPD credits; systematic reporting and analysis of adverse events and “near-misses” to improve safety for patients and staff

•

Sharing information: developing integrated data systems for clinicians, managers and financing; standardizing data definitions, clinical coding and performance indicators; making practical tools and technical advice available at all levels

The table of qualitative indicators for quality and safety in the health sector review offers examples of understandable, measurable and achievable actions 2014-19. By the end of this period, Indonesia could have a more integrated and effective quality management system within an explicit national policy framework, supported by a national resource centre and agreed among stakeholders. Initial steps should be led by the MoH, leading to progressive engagement of executive and advisory organizations and establishment of an autonomous national agency for quality and safety.

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1. Global Context of Quality and Safety in Healthcare Since the 1980s, many countries have identified quality as a central concern for policy and planning in health systems1; development at national level has been tracked around the world in successive publications of Health in Transition. Definitions of “quality” vary between countries, but they consistently include a combination of dimensions: access, equity, appropriateness, effectiveness, efficiency and safety. The world’s attention was drawn to patient safety by publication of a study in the USA2 which indicated that, even in the best hospitals, a significant proportion of in-patients are harmed during their stay. Similar studies around the world have reached the same conclusions in widely differing economies and health systems: one patient in ten is damaged by adverse events in hospital3. Expert analysis by the Institute of Medicine45traced the origins of systematic failures to a variety of causes, including staff attitudes, communication skills, team working, management transparency and public information; lack of resources was rarely the underlying problem. Apart from the cost to patients (suffering, disability, loss of earnings or death) the costs to institutions and insurers (extended stay, repeated interventions, litigation, compensation) added significantly to the overall cost of healthcare. Recognizing that concerns for patient safety were not confined to developed countries, WHO launched the Global Challenge6in 2004, providing a range of checklists, toolkits and teaching materials. These focus on high risk activities such as medications (storage, prescribing , administration), surgical intervention (consent, identification, communication) and continuity of care (between shifts, departments, other hospitals and primary care). In Indonesia, “Quality and safety” becomes a separate topics of the Health Sector Review for the RPJMN 2015-2019. It previously was implicit in other topics, but largely overlooked in 1 Quality and accreditation in health services: a global review. Geneva WHO/ISQua, 2003 http://whqlibdoc.who.int/hq/2003/WHO_EIP_OSD_2003.1.pdf 2Brennan T, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study. New England Journal of Medicine 324, 370-376. 1991 3Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in medicine. BMJ 316, 1154-1157. 1998. 4

Institute of Medicine. To Err is Human. Washington: National Academy Press, 2001

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Institute of Medicine.Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press, 2001 http://books.nap.edu/openbook.php?record_id=10027&page=R1 6

WHO Global Patient Safety Challenge http://www.who.int/patientsafety/challenge/en/

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strategic planning. The launch of universal health coverage program (SJSN) gives urgency to questions of equitable, patient-centered, safe, effective, integrated and efficient health service for all the population.

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2. Situation Analysis, Achievements and Trends 2.1 Policy Healthcare Policy on Quality and Safety National strategy on quality and safety is not stipulated in a single policy but is implicit in a wide range of legislation and directives (examples in Error! Reference source not found.). Some regional policies are explicit e.g. Special Region of Jogjakarta (DIY) Mayor Regulation No. 52/2008; Tarakan City Regional Regulation No. 7/ 2010. Table 1. Examplesof indications of policy on quality and safety

Medical practice

Law 29/2004

Accreditation medical laboratory

HM 298 /2008

Compulsory hospital accreditation

Law 44/2009

Accreditation linked to licensing

HM 147/2010

Hospital medical committee functions

HM 755/2011

Safety of patients in hospital

HM 1691/2011

Medical Practice guidelines PHC

HM 5/2014

2.2 Organization Various institutions, boards, committees, and networks concerned with healthcare quality include MoH, non-governmental,educational and research institutions, and professional organizations. The principal focus in the Ministry is in DG Health Services (BUK) and a sub-directorate of hospital accreditation. The Hospital Supervisory Board (BPRS),was established in 2012. Although this organization is not yet fully functioning, it was designed to oversee hospitals across the country.The national accreditation agency (Komisi Akreditasi Rumah Sakit KARS) was set up within the MoH by ministerial decree 23/1992 in 1995 as the main vehicle for improving hospital care; it is nowre-launched as an independent legal entity. Puskesmas accreditation began development within the primary care directorate (BUKD) in 2012. Commissions designated by the MoH which are relevant to healthcare quality include patient safety (2012) and health technology assessment (2014). As a cross-cutting issue, quality of healthcare is relevant to many other DGs (including human resources, maternal and child health) within the MoH, and within other ministries, especially the Ministry of Education. Professional regulation of doctors was formalised in 2004 with the establishment of the Indonesian Medical Council (KKI) and its Medical Disciplinary Board (MKDKI). KKI is governed

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by a board of 17 members, three of whom represent the lay public. The Council is certified under ISO 9001. Principal functions are to oversee educational standards, individual registration and professional development. Recertification is issued by the Council every five years based on CPD credits or examination. The Indonesian Health workers council (MTKI) was introduced for midwifery, pharmacy, physiotherapy and nutrition in 2011. Other national entities related to quality include the healthcare branch of the National Agency on Consumer Protection (by Government Regulation No. 57/2011) and the National Blood Committee (by MoH regulation 2310/2011). Non-governmental organizations at national level include professional associations such as the Indonesian Medical Association which is designated by the MoH as a partner in the formulation of national clinical guidelines. The Indonesia Healthcare Quality Network is a voluntary association of health professionals, private facilities owners, managers, researchers and patients established in 2005. Provincial health authorities also operate inspectorates, and District Health Offices issue professional licenses and are responsible for licensing the facilities which they own and operate as well as private providers. Clinical care in hospital is defined in MoH Regulation No 755/2011 as the responsibility of medical committees. 2.3 Methods Regulation of Professions Licensing and re-licensing of doctors and dentists are regulated by the 2004 directive on medical practice which established the Konsil Kedokteran Indonesia/KKI (Indonesian Medical Council). The Council has responsibility to register medical doctors and dentists; standardize medical and dental education (develop curriculum); and supervise medical practice. Within the organization, there is Majelis Kehormatan Disiplin Kedokteran Indonesia/ MKDKI (Indonesian Medical Disciplinary Board) which judges and decides sanctions for malpractice and other actions which violate the medical code of ethics. KKI has no representative offices at provincial or district level.The medical committee in each hospital is responsible for annual credentialing of all medical staff. Other healthcare professions are regulated by the Majelis Tenaga Kesehatan Indonesia/MTKI whichtook over the registration of 17 professions from the DHO in 2011. The MTKI has offices at provincial and district level. Regulation of Pharmaceuticals, BloodProducts and Devices Pharmaceuticals are monitored by BPOM/NDRA. There is a national formulary which is often adapted at local level. The directorate of Basic Medical Care has developed standards for blood products, based on WHO guidance, which are monitored by the National Blood Committee. The

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MoH is currently developing a compendium of medical equipment (and safe usage) based on WHO guidelines. External Assessment of Healthcare Providers NationalMethods ExternalAssessmentof Hospitals Until BPRS, the supervisory body established in 2012, becomes fully operational the principal regulator of hospitals is effectively the KomiteAkreditasiRumahSakit(KARS), a mandatory programme technically separate from the MoH.External assessment on quality of healthcare through accreditation began with the establishment of the KARS in 1995. The Hospital Law of 2009 made accreditation compulsory for all hospitals every three years. In 2010 a ministerial decree reinforced this by making accreditation a condition of hospital licensing. Despite this, there are still many hospitals which are licensed to operate without being accredited. Some medical laboratories are accredited (HMD No. 298/2008 Accreditation Guideline for Health Care Laboratory) or certified under ISO 15189. In six of the nine HAPIE hospitals, the medical laboratory was certified under ISO 15189; seven participated in a formal external quality assurance programme for validation of test results. Many hospital emergency departments (and some puskesmas) have been certified under ISO 9004 (a generic standard for quality management systems). External Assessment of Puskesmas Puskesmas accreditation is a new programme of external assessment of quality management and service delivery systems being developed by the Commission on Accreditation and its provincial representatives. The Directorate of Primary Health Care (BUKD), Ministry of Health, through a group of national consultants, commissioned the development of accreditation standards and instruments, released in draft in October 2012. The standards were derived from QIP in Australia and first tested in Central Java (resulting in nine amended versions) before extending to three provinces. Local Methods Assessment of Patient Experience The rights of patients in terms of eligibility for health coverage are defined by health insurers, especially BPJS. Rights to Informed consent are regulated (law 29/2004 and Ministerial Decree 290/2008) and HMR No. 1691/2011 refers to the safety of patients in hospital but there is no national charter to describe, in simple language, the rights of patients to choice, privacy or information.An exception is the “Patient Charter for TB Care” issued by the patients’ association “PAMALI” in 2009. Some patient satisfaction surveys are conducted by individual providers particularly in the private sector. Individual institutional complaint and compliment mechanisms do exist,

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particularly in private providers, and some districts maintain registers of complaints about public services. Clinical Governance Accountability of medical committees for clinical care in hospital is defined in Health Ministerial Regulation No 755/2011. The national Medical Council has responsibility to supervise individual medical practitioners(including evidence of continuing education) and hospital medical committees are expected to review the credentials of medical staff annually. The KARS accreditation standards (adapted from the Joint Commission International) require documented evidence of effective structures and activities for clinical governance, such as committees and indicators for infection control, clinical records, pharmacy and therapeutics, and patient safety. Clinical Practice In principle, hospital medical committees are responsible for receiving and approving clinical practice guidelines (CPGs), and for auditing compliance and impact. Some national guidelines have been developed for hospitals through a documented procedure (of literature review, stakeholder consultation, pilot testing and evaluation) compatible with international practice defined in the AGREE principles. Permenkes 5/2014, issued by the MoH in February, introduced 144 clinical practice guidelines for primary care, both public and private. Hospitals commonly adapt the national formulary to a local drug list; some incorporate guidelines on usage, especially concerning antibiotics eg combination therapy, surgical prophylaxis. Staff at department level are not involved in systematic peer review but occasional case-presentations are used for teaching, mostly in teaching hospitals. Risk Management Systems to protect the safety of patients, staff and visitors are a requirement of hospital accreditation standards and practical advice and tools are freely available on the internet from WHO and national patient safety agencies. Responsibility for patient safety is assigned to the hospital medical committees. 2.4 Resources Skills for Quality Improvement Some health personnel education institutions include quality management and the evaluation of individual and organizational performance in the curriculum, but there is no national template to standardize the content of the curriculum, the teaching program or learning outcomes. Patient-based data The primary source of patient-based data is the clinical record. Minimum patient data is regulated by HMR No. 269/2008 (Medical Records) and requirements of the hospital records function is described in KARS JCI standards.

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InformationResources for Quality Improvement Almost all health care facilities provide access to the internet, and thus to national and international sources, but there is no virtual or actual centre for exchange of information or learning.

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3

Challenges Remaining

3.1 Policy Regulations and directives relate to many dimensions of healthcare quality, but they focus primarily on hospitals rather than primary care and are not integrated within a comprehensive framework. In general, government remains the main agent; civil society, private sector and professional institutions are given little part in consultation or responsibility. Dissemination, implementation, monitoring and evaluation of the impact of directives is weak. This may be improved by putting more information on the websites of public institutions, by clarifying the responsibilities of monitoring agencies, by providing technical assistance to provider institutions to comply with requirement, and by rewarding their compliance and performance through the financing system. 3.2 Organisation Mapping Responsibilities for Quality and Safety The legislative instruments do not clearly define roles and inter-relationships between units, agencies and committees, or between national, provincial, district and facility level. Many key elements of a national program for improvement already exist – at least on paper – but their accountability, reporting structures and coordination could be clarified by mapping their quality functions into an organizational chart. This could start with the MoH in order to identify opportunities for coordination between directorates on quality and safety, and to identify the resources and infrastructure available or required to support those functions, such as for patient safety, technology assessment and the health inspectorate. Assessments of healthcare provision, such as of MCH in districts and HAPIE in class A hospitals, have identified common failings in the management and delivery of patient care but responsibility for coordinated resolution of systematic weaknesses (such as in documentation, prescribing and risk management) in public facilities is unclear. 3.3 Methods NationalMonitoring Compliance with many laws and regulations related to quality and safety is not consistently monitored in provider institutions. District Health Offices are responsible for licensing and supervision of the facilities which they own and operate as well as private providers but there is little national coordination or mutual agreement either with KARS or BPRS which is not yet fully functional. In many countries licensing is used to verify a static minimum standard of safety below which institutions are not permitted to operate; accreditation requires higher standards and usually discriminates between the excellent and the merely acceptable institutions. The discrimination may be used by health insurers to apply a differential payment tariff and thus encourage and reward improvement.

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Figure 1. Differentiating between licensing and accreditation

Even in class A hospitals, not all medical laboratories are accredited or certified under ISO 15189, or participate in external quality assurance of results by comparison with reference laboratories. In other countries many health insurance funds adjust tariffs accordingly. Devolution of the regulation of institutions and professionals could be assisted by a clearer definition of the aims and methods of the various systems, the resource implications and inspectorate skills required and the information which needs to be shared between regulators, development agencies and the public. Figure 2. Range of performance scores in 10 domains, 9 class A hospitals RI

(Note wide gap between highest and lowest scores, especially in governance)

Source: HAPIE baseline study

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Local Monitoring The Patients’ Experience Figure 3. Patient Satisfaction, Normal Delivery, Nine Hospitals, RI

(Hospital average scores ranged from 34 to 43%)

Source: HAPIE baseline study Compliance with statutory patients’ rights is not systematically monitored and evaluation of patients’ experience is inconsistent. National guidance to institutions from the MoH or from the national consumer council may help to promote awareness and help institutions to be more responsive to the public. This could include published leaflets, patient survey tools and advice to management on providing information and protecting dignity and privacy. Clinical Practice Despite various regulations, mechanisms and supervisory organisations, clinical practice is not well controlled at local level. For example, the excessive use of antibiotics is unethical, encourages resistance in the community and is a financial burden to the public and to the health system; in some hospitals patients are routinely prescribed antibiotics in the absence of evidence of infection. This is a problem in many countries, especially with more expensive cephalosporin given intravenously, and requires active intervention at national and local level, and monitoring by healthcare insurers. Clinical practice guidelines, on rational drug use or on any other clinical practice, are known to have little impact unless they are actively distributed, taught, and monitored – and compliance is recognized by colleagues, patients and funding agencies. Without this support many guidelines reach – at best - the medical library. Criteria for formal adoption of guidelines (from any source) should be defined at national level, such the international AGREE II principles. A national register of relevant health technology

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assessment and evidence-based guidelines should be maintained and monitored by a fullyresourced central agency in order to provide reliable advice to clinicians, insurers and patients. Figure 4 heart attack patients receiving recommended discharge medication

(Current guidance recommends the use of all four drugs)

Source: HAPIE baseline study The science behind evidence-based guidelines is not for local negotiation but implementation should be managed according to identified variations in clinical epidemiology, access to services and skills, and social culture. Dissemination may be supported by making guidelines freely available to clinicians (eg on websites, reference manuals) and, in appropriate language, to patients as information leaflets or posters. Compliance and education may be promoted by issuing simple audit tools and numerical indicators for peer review and learning. Risk Management Awareness of safety - for patients, public and staff – is generally low. Monitoring, reporting and analysis of clinical complications, adverse events and near-misses are weak at local level and absent at national level. There is minimal learning from failures in the health system, and few mechanisms to correct them. Hazards observed in hospitals include non-functioning resuscitation equipment, concentrated electrolyte solutions stored with general medication, insecure gas cylinders and locked fire exits. These should not be blamed on the individual institutions but may be interpreted as a reflection on the general level of information and management guidance available about safety, and on the effectiveness of external regulation and monitoring. 3.4 Resources Information A regulation of 2010 defines performance accountability for government institutions, including a requirement to publish an annual report. But this and other information which is commonly in the public domain, are hard to find or understand. Information on quality standards, measures,

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results and research is not widely disseminated or centrally collected as a national learning resource Clinical Documentation The primary source of patient-based data is the clinical record but patient records are commonly incomplete. The HAPIE baseline study identified significant failure in class A hospitals to document the clinical process: examination, investigations, interventions, rehabilitation, discharge status and diagnoses. This severely limits the value of the clinical record for continuity of care (especially between departments, or transfer to another institution), for evaluation of care, for clinical coding and case-mix measurement – and for reimbursement.Internationally recognized measures of clinical performance require complete and accurate patient records, such as the delay between onset of an acute event and initiation of treatment; most hospitals in the HAPIE study did not document critical times for heart attack patients. Figure 5. Undocumented critical times for heart attack patients

(“door-to-needle time” is a common indicator of effective management)

Source: HAPIE baseline study Clinical data Partly due to the lack of information written in hospital records, clinical abstracting and coding fails to capture co-morbidity, complications and adverse events – which are key measures of clinical performance. In most institutions, there is no regular, systematic feedback of data on important process and outcome measures to individuals, departments or organizations. The lack of reliable data undermines institutional capacity for planning, control, clinical audit and service evaluation. The lack of standard definitions, data capture methods, and systematic analysis and reporting is a major barrier to the development of comparable performance indicators for benchmarking and improvement.

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Clinical Audit There is little practical guidance on how internal audit could best promote compliance with clinical guidelines or how systematic peer review could contribute to continuing education at local level. Review tends towards examination of case records, case presentation and anecdotal reflection; patient-level data are not readily available to support systematic audit Management Data Likewise, poor quality of data on health structures (eg personnel, medication, equipment and building), and activities (eg attendance, immunization, admission and operation) and outcomes (complications, readmission and life discharge) limits the value of performance measures at local, regional and national level.

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4

Strategic Issues

4.1 General Considerations The national medium term development plan of 2009-2014 focused primarily on allocation and investment of resources. In that context there was mention of performance based budgeting, performance indicators and the need for accurate technical data; the focus was more about providing resources and financing than on how the resources were used to the benefit of patients and populations. The impact of many proven quality interventions – such as performance indicators, clinical guidelines and accreditation – depends more on organisational culture and incentives than on technical competence. Each element contributes to a cycle of defined objectives, monitoring and measurement, and change management. Each program should have an identified role in the national strategy and contribute to overall improvement of the health system. Changing culture takes many years, but the process can be accelerated by strategic cooperation and consultation with a wide range of stakeholders. A first step is to recognise that lack of resources is less of a barrier to improvement than the underuse, overuse or misuse of existing resources, and that adverse events are caused more by system failures than by human failure. A common feature of many well-intentioned initiatives which have yet to achieve their goals (such as patients’ rights, complaints management, health inspectorate, ethics committee, clinical guidelines) is the lack of effective strategies and practical tools for implementing, monitoring and rewarding change in organisations and in the health system. Compliance with many laws and regulations related to quality and safety is not actively monitored in provider institutions; their impact on the health system is not evaluated or published. 4.2 Values of aComprehensive Quality Approach An effective quality improvement programme should change the way everyone works, at every level of the health system. This demands widespread acceptance of underlying values and principles to provide: •

Transparency: consultation with stakeholders would be included in developing policies, standards and guidelines that impact on the provision of health care. Results of institutional assessments would be available to the relevant public.

•

Professionalism: the provision of care would be guided by the code of ethics of respective professions, clinical governance and increased self-regulation.

•

Evidence-based healthcare: current scientific knowledge would guide health policy, the management of healthcare institutions and the care rendered to patients.

•

Top-down, bottom-up approach: supervision and inspection would be reduced by staff participation in self-assessment, self-regulation and quality improvement and feedback from patients and relatives.

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•

Accountability: all health care providers, direct and indirect, would be held accountable for their actions or inactions.

•

Training: the principles and practice of quality improvement would be included in undergraduate, postgraduate training and in continuing professional development

4.3 Linking Quality to Other Health Sector Review Themes Relative to the other HSR themes, quality and safety in healthcare has almost no existing policy, organisation or infrastructure in Indonesia. However, all the themes need a dynamic combination of realistic targets or standards, reliable measurement (data and monitoring) and effective mechanisms for change (incentives, sanctions, feedback, training, learning…). In this, the quality improvement cycle is similar to budget control, management by objectives and healthcare planning. A high level of correspondence is evident in between several chapters of HSR including accountability, institutional development, measuring performance, data, and managing change. However, there is little reference to some major quality issues such as evidence-based medicine, clinical practice, professional development, and no mention of safe care, integrated care and continuity. Standards and indicators may vary between the themes, but they should all share the same patient level data capture in order to avoid duplication and conflicting systems. They should also share approaches to change management.

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5. Policy Direction and Strategies trategies 5.1 Introduction The issues and focus points identified during the development of the HSR represent a mixture of values, priorities, topics and solutions. solutions. The situation analysis of quality and safety is structured around a conceptual framework and system-wide system wide assessment tool developed for WHO in 2000. This section of the chapter attempts to relate the content of other HSR chapters to the quality cycle – essentially, standards, measurement and change management. The summary picture is of historic and systematic failure to define, measure and improve standards of health services; this leads to a recommendation that the mid mid-term term plan should aim to integrate integrat new and existing mechanisms and focus on performance and implementation to “close the planning loop” in all strategies. This requires support in terms of practical guidance and directions, coordination, monitoring, feedback and incentives for improvement at all levels. Quality and safety are relevant to all components and personnel in the health system, but their relationships are not well-defined, defined, especially with respect to change management – which is the weakest element of many health systems. The figurebelow urebelow aims to identify the principal connections between existing organizations and functions, and assumes the establishment of a national centre for resources and learning. Quality and safety are cross cross-cutting issues which cannot be introduced solely through hrough existing vertical management structures. Figure 6. Intregating Quality Systems

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5.2 What Do We WantValues and Principles “Quality” is mentioned frequently in planning documents, but is rarely defined in terms of underlying values and dimensions. Internationally, the most quoted dimensions of health service quality are access, equity, efficiency, effectiveness, continuity and acceptability to the public. OECD has reduced these to three dimensions: effectiveness, efficiency and patientcenteredness Access In HSR, the introduction of UHC is the principal vehicle for improving access to health care by facilitating payment for eligible services, and resource allocation (financial, manpower) increases the availability of services. Physical access to services, such as for disabled or infirm patients, is not included. Equity Equity implies fairness in the allocation of resources and the definition of how services are funded; in principle, services should be compatible across the country, consistent with variations in demography and geography and without ethnic or gender discrimination. Efficiency Efficiency implies getting optimum benefit from available resources; it is an implicit criterion in defining the scope and pricing of insured services. In many countries, health service planning focuses more on resource inputs (to build system capacity) than on how well they are used (to improve system performance). Overuse, misuse and underuse of expensive medical technology waste resources; nosocomial infection, complications and medical incidents create additional burden to patients and costs to the health system. Health system planning in Indonesia should make financing conditional on effective systems to manage risk, utilisation and performance. Effectiveness Effectiveness of healthcare is commonly measured by patient outcome (eg mobilisation, return to work), population impact (eg control of communicable diseases, survival rates) or patient experience (eg feedback survey). Clinical outcome is relatively easily and quickly measured in acute medicine, surgery and obstetrics – but is more difficult in mental health, primary care and chronic diseases. The quality of clinical care is most effectively evaluated by comparing the clinical process against guidelines which are based on evidence from biomedical research; active purchasing and reimbursement schemes should be designed to reward appropriate procedures and behaviours. Another approach is to document adverse reactions, clinical complications and unexpected outcomes. Indonesia has no reliable measures of clinical process or outcome, but the basic data could be drawn from contract monitoring and reimbursement claims if these can be validated.

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Continuity Continuity is expressed in HSR as “the alignment of primary health care and referral health care” and “strengthening the referral system”. The weaknesses of many health systems lie in the potential gaps between provision not only between primary and referral care, but also between funding, departments, clinical teams and day/night shifts. Continuity requires alignment not only of funding but also of clinical guidelines and pathways, monitoring systems, numerical indicators,documentation and handover procedures. Patients’ Rights Health insurance schemes often present the rights of patients in terms of access to services or essential drugs. HSR refers to community empowerment as a strategy to promote awareness (health literacy) rather than respect for the rights of patients (and their families) to information, consent, privacy and security. Changing Attitudes and Behaviours Technical interventions such as performance measurement, risk management, clinical guidelines and accreditation have little impact unless they are accompanied and reinforced by leadership, engagement, learning and incentives for improvement. A major challenge to increasing quality and safety – in any society – lies in developing a culture of improvement within individuals and organisations, especially: •

Improving documentation of patient care

•

Communicating with patients and their families

•

Providing information to the public, developing “health literacy”

•

Sharing work and learning in peer groups and multidisciplinary teams

•

Accepting responsibility and self-governance

•

Developing confidence to report, analyse and learn from adverse events

This culture is not yet widely accepted or evident in Indonesia. Suggestions By 2016, Indonesia should publicly identify the values and dimensions of quality in health services, and how these expectations will be fulfilled and evaluated by 2019. Governments at all levels should put more information in the public domain 5.3 Where Should We Be Expectations and Standards Systems for planning, management, control and quality improvement must include the capacity to define a direction, to know current position and to make appropriate change. Given an agreed definition of a “good health system”, directions can be described in terms of laws, decrees, and guidelines; there is an abundance of “standards” in Indonesian healthcare, and they are widely

28

neglected because there are insufficient systems to coordinate, disseminate implement and monitor their implementation. Clarity of Guidance This is illustrated by the example of rational drug use: there are three versions of the national drug list, using different levels of evidence for technology assessment and giving conflicting advice on appropriate prescribing; pharmacy and therapeutics committees are expected to develop and monitor local formularies but rarely do so; antibiotic overprescribing is a common source of out-of-pocket income generation in Indonesia. Assessment of provider side readiness, using WHO’s Service Availability and Readiness (SARA) framework, showed that clinical guidelines were unavailable for basic obstetric care in 30% of puskesmas and for advanced care in 50% of hospitals; guidelines for the “Integrated Management of Childhood Illness” (a strategy adopted nationally in 1995 to reduce infant morbidity and mortality) were unavailable in 28% of puskesmas by 2011. Evidence-Based Guidance Clinical practice standards should be developed nationally, based where possible on existing literature, research and validated guidance from other countries. Indonesia should adopt a protocol for filtering and adapting foreign guidance according to national culture, epidemiology, biomedical research and economics. The resulting clinical practice guidelines, together with criteria for audit of compliance, should be publicly accessible and become the basis for defining and monitoring service contracts with BPJS. Systematic variation from national clinical standards by provincial or district offices should be based on documented local evidence of population need, demography or clinical epidemiology , or on identified priorities for resource allocation. Consistency of Guidance Standards for the competence, capacity and delivery of clinical services should be compatible between agencies responsible for licensing, accreditation and funding, and between primary and hospital care. Organisational standards should cite their sources of evidence and reference national and local guidance where available; they should be accessible on public websites. Minimum Service Standards The MSS was developed to prevent inequality of health services as a result of decentralisation. In that it describes the basic services to be provided by local (district) government– rather than to their performance – MMS is a specification more than a standard. Even so, the application of MSS to local populations should be based on quantified population health needs assessment. Standards for delivery of services included in MMS should be consistent with – and explicitly linked to -organisational standards which are applied to licensing or accreditation, and to clinical practice standards which are based on health technology assessment. For instance the minimum standard for early detection of diabetes in puskesmas and its networks requires early

29

detection for all patients above 15 years old who attend each year, according to unspecified clinical guidelines. MSS does not define what systems are required to assure the quality of services provided; eg cervical smears require consistent procedure, equipment calibration, cytology screening, and laboratory accreditation. Suggestions Responsibility for identifying, archiving and developing standards for health service and system performance should be made clear first at national level, then at provincial and district level. Technical procedures for developing, adopting and adapting standards for clinical services should be developed consistent with international principles and practices (eg ISQua for accreditation standards, AGREE II for clinical guidelines) Clinical practice guidelines and pathways should be based on evidence and technology assessment independent of political or commercial interest. 5.4 Where Are We now – Measurement, Monitoring Population-Based Data “A 2007 survey “Riskesdas” by the government shows that the actual number of misdiagnoses per year in the population is very large and the level of misallocation of scarce resources within the health sector is very high. This error rate would not be tolerated in any other sector of the economy.” (This and subsequent quotations come from drafts of various other chapters of the HSR.) “To prioritize public goods interventions, the MoH need to rely more on population based measures of morbidity and mortality”. The funding, application and monitoring of minimum service standards should be based on epidemiological and qualitative evidence to determine priorities, including clinical and cost effectiveness, and patients' perspectives. This population “health needs assessment” is a way of identifying unmet health and healthcare needs of a population - as opposed to demands. Figure 7. Overlap of need demand and supply

30

Clinical Records Documentation of patient care is weak; records are inadequate for maintaining continuity of care, for clinical audit, for clinical coding and case-mix measurement, and for reimbursement. A recent study of basic midwifery care indicated that results of examinations were not recorded in 80% of hospital cases and in 57% of puskesmas. The HAPIE baseline study showed that significant interventions for stroke and acute myocardial infarction were not recorded at all. Patient-Based Data “In 2007, the degree of inaccuracy was most prevalent among cardio-vascular disease, which comprises one of the most prevalent NCDs in the Indonesian population and is a leading cause of mortality in the country. CVD was symptomatically diagnosed accurately less than 10% of the time, and, even among the most affluent in the population only 16% of the time. “ Clinical Coding “A concern is the quality of coding at the clinical level..It is reported that the coding is inconsistent across the country, and that the training of coding clerks is often poorly conducted.” Failure to capture co-morbidity and complications underestimates case-based reimbursement, fails to explain extended length of stay and costs to the hospital), and under-records adverse events which are a key measure of clinical performance. One simple measure of the depth of coding is the average number of ICD codes per discharged case. Given the significance of their contribution of coding clerks to quality management and hospital income, relatively little investment is apparent in training and development, in data quality and in the overall management of the records function. Suggestions Develop training program for coders, with a standardized program and manual for coding consistently across all facilities in Indonesia. Management Information Systems “At present, the management information systems which enable effective planning, effective performance management, and regulation, accurate budgeting and reporting are weak. “ “While under PT ASKES, hospitals were required to submit claims using electronic systems, it is estimated that currently only 20% of hospitals have IT systems and they are all different.” “Currently, most Puskesmas have no patient-level data systems, meaning that reporting becomes essential.” Apparently only 26% of hospitals sent their data to MoH regularly.

31

Suggestions Management information systems should adapt standard approaches to capturing clinical and cost information to improve contracting and service performance. There is an urgent need to unify and align health information systems across the sector. Data Aggregation and Sharing “Although large amounts of staff time appear to be spent on collecting and reporting information upwards, data is seldom used for programme improvement at the district or sub-district level; Only two-third of districts report their data upwards and parallel reporting channels for nutrition data persist.” “At present there are (at least) three data-handling units in the MoH; Pusdatin (Centre for Data and Information); Pusat Informasi BUK (Information Centre of Health Services Directorate) and Litbangkes. “The BPJS (gathers data) at an individual level to manage operational transactions (registration, membership card issue etc.). The data are then deployed in various levels of aggregation for monitoring, contract compliance and statistical purposes.” Suggestions Across all areas of the landscape is the pressing issue of creating an effective performance management process Performance Indicators “A simple performance indicator-based system to monitor the quality and outcomes of PHC services (eg NCDs such as hypertension and diabetes, and TB control and other infectious diseases) is often used together with capitation.” “The full set of indicators endorsed by WHO’s member states through WHA Resolution 65/6 to monitor progress towards improving maternal and child nutrition should be considered. “ Suggestions Develop quality assurance monitoring indicators, by MOH or BPJS, related to preventing unnecessary admissions, related to needed care services during admission, and related to preventing early discharge and re-admissions within 90 days. Use internationally validated measures, such as OECD and WHO for comparison across borders (see appendix 2) Information strategy The MoH website refers to “Improving Surveillance System, Monitoring and Health Information” as one of four main strategies, and “Establishment of national information system policy in the field of health” as one of six functions.

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Suggestions The MoH should identify key partners in developing a comprehensive national strategy and standards for data definitions, capture, coding and information management. A national information strategy should identify the needs of various users (eg BPJS, MoH, clinicians and managers) and describe how they may be met by aligning existing and new data systems. For the purpose of quality improvement, this may include: •

Consistency with CPDMS (Clinical Performance Development and Management System)

•

Compatibility of clinical coding in hospitals and primary care

•

Data quality standards and measures; validation of case-mix grouping

•

Data protection

•

Definition of indicators of clinical, managerial and financial performance at institutional and national level consistent with international principles (eg OECD, WHO PATH)

•

Aggregation, presentation, benchmarking and feedback to local hospitals, clinics or Puskesmas.

Suggestions Performance assessment tools and indicators should be defined and published by national agencies to accompany clinical guidelines and pathways Standardised measures of performance (clinical, institutional, financial, system) should be pooled to identify benchmarks, monitor progress and stimulate improvement at all levels 5.5 How Do We Get There – Implementing Change “The focus of the “Clean and Healthy Lifestyle” programme (PHBS) is on data collection, and insufficient focus is given to the implementation of community-level activities to improve health and nutrition behaviours. “ Implementing change is the greatest challenge in any system. Single influences such as statutory inspection, payment for performance or consumer pressure can be powerful motivators for change (for better or for worse) but the greatest impact comes when a coherent demand for improvement comes from multiple sources. These can include professional associations, journals, training institutions, regulators, supervisory bodies, as well as social media and the lay press. This alignment will not happen by mere chance; it must be managed through shared visions and plans. Suggestions There is abundant evidence internationally that directives, standards and guidelines have little impact on healthcare providers, especially clinicians, unless they are accompanied by coherent systems of support and incentives. These systems will not converge by chance; they must be

33

actively integrated through a common national framework, shared by the key stakeholders and functions of the ministries of health, home affairs and education. Financing “Jamkesmas has a great ability to enforce standards—as they can apply controls over the release of funds in the form of reimbursements—than is possible by either the MoH or professional associations” ( http://uhcforward.org/content/indonesia ) “There is often the situation of soft, relational contracts where there is an expectation from both sides (purchaser and provider) to automatically extend contracts for ensuing years. This is the case to date with the BPJS.” “In the face of limited capacity for health technology assessment processes, it is not surprising that opinion based selection drives the choice of medicines for the benefits package. But it is critical to take control of this aspect of insurance as soon as possible to reduce the risk of catastrophic total financial expenditure.” “In terms of health care practice, there is evidence of inefficient operating practices, including, for example, a very high dependency on in-patient care, a very low level of use of 24 hour – surgery, high drug costs and a reimbursement regime which is likely to aggravate this.” BPJS and Quality of Healthcare “At the primary care level, where the predominant provider payment method for health facilities is capitation, this payment should be linked directly or indirectly to the attainment of minimum standards analogous to the accreditation of private facilities… At the secondary level, DRGrelated payments could be made conditional on the adequacy of services provided in order to encourage investments in improving service readiness.” The linkage of funding to organisational competence, as defined by independent accreditation, and to clinical practice, as defined by compliance with evidence-based guidelines, is the principal strategy for improving quality, safety and clinical effectiveness in the public sector. BPJS should explicitly agree how payments will be related to quality assessment of organisational and clinical performance; without links this to reimbursement, there are no incentives for compliance with approved clinical practice guidelines, either for individuals or for institutions. Third party assessment In order to be self-financing, KARS accreditation needs demand driven primarily by health insurance; and BPJS needs reliable affirmation of competent providers. There is no formal arrangement to define how preferred providers would be identified or how accreditation awards (there are four grades) would be reflected in contracts and reimbursement, or whether KARS would be acceptable as a third party assessor. Similarly demonstration of capacity and competence of medical laboratories, by accreditation, certification or external calibration, should be reflected by BPJS in payment tariffs.

34

The desired results of introducing UHC are not guaranteed, and the system was not piloted to identify potential problems; close observation of the system should include: •

Monitor clinical coding: -

accuracy, timeliness and completeness

-

inclusion of co-morbidity and complications

-

average count ICD codes per hospital discharge

•

Correlate pricing with real costs of compliance with evidence-based guidelines

•

Monitor changes in referral, on clinical indications, to specialist services

•

Monitor perverse responses eg misuse of interventions, especially medications, intended to generate income or out-of-pocket payments.

•

Monitor performance of services and institutions, giving feedback and comparative benchmarks

•

Monitor quality, as well as cost and volume of services

Education, Training HSR has put much emphasis on increasing the health workforce, but little on matching knowledge, attitudes and skills to the needs of the service. Several comments made in the context of individual specialties could be applicable across many, if not all specialties. Pre-service Training “The structure of medical education (mixed public and private), and the mixed responsibility across Ministries, means that it is impossible to design a balanced demand – acquisition – supply framework, and to ensure that skills are dispersed appropriately through the decentralised structures in the health care economy.” “Ensure the clinical competence of doctors, specialists and other health providers through clear mechanism and regulation.” “The quality of pre-service nutrition training for nutritionists is not consistent in all academies and training curriculums need to be updated to reflect the double burden of malnutrition” Continuing Professional Development “Systems to assure continuing clinical skills are weak, and are based on exposure to learning opportunities (often linked to promotional activities by drug and equipment suppliers). There are no effective systems to ensure continuing and developing clinical competence, and to sanction practice for incompetence.” “While IMCI training has been introduced in pre-service education across many nursing, medical and paramedical schools, implementation has varied widely and faced numerous challenges, including: shortages of IMCI-trained teachers and learning materials, which is partly attributed to

35

disproval of IMCI among paediatric teachers; insufficient political commitment from the majority of deans and paediatric department heads; and deficient clinical sites for IMCI clinical practice.” “Incorporate the National Medicines Policy, National Essential Medicines List, National Medicines Formulary, Therapeutic Guidelines and Antibiotics Guidelines in continuing medical education.” Training for Quality Improvement Several of the chapters and the emerging policy priorities require knowledge and skills which need development in the workforce, such as: •

Interpretation of HTA, implementation of clinical practice guidelines, rational use of drugs

•

Performance assessment, clinical audit, use of statistical indicators

•

Clinical documentation, integrated records systems, clinical coding and case-mix

•

Working in multi-disciplinary clinical teams

Suggestions The mid-term plan should include steps to ensure that these "new" skills and knowledge are explicit in the teaching curriculum and are evident in (academic and in-service) training and in CME/CPD for clinicians and managers. This would provide practical support to most elements of the HSR. See WHO Patient Safety Curriculum Guide For Medical Schools http://www.who.int/patient safety/activities/technical/medicalcurriculum/en/index.html MoH, MoE and MoHA should develop a strategy to harmonise medical and technical education to deliver a curriculum which is consistent with health system needs. Management “Regular assessment for drugs use in health facilities needs to be undertaken and remedial action undertaken based on the assessment. Such assessment can be done by MOH in collaboration with other institutions like universities and non government organizations.” But it may be more economical and effective to leave this to self-governance, pharmacy committees, cost-containment and BPJS – if they are developed as effective regulators. Management Authority “Countries that have experience of new payment systems have recognized that all the achievable efficiency gains do not happen automatically. They require some formal delegation of management responsibility to primary care clinics and to hospitals. In turn, this relies on hospitals having sufficient management capacity to realize the potential of the new payment system.” “Decentralization of management capacity and of responsibility is an important prerequisite for obtaining micro-efficiency.”

36

Suggestions Delegate management responsibility to primary care clinics and to hospitals; give managers flexibility to buy equipment, open beds and close beds as needed. Develop management skills and capacity; require formal training as a condition of senior appointments. This should be embedded in accreditation standards and a criterion for discriminating accreditation grading Control Systems “There are concerns about the quality of prescribing, the absence of agreed treatment guidelines, the lack of control over prescribing in hospitals and inappropriate prescribing of antibiotics in particular.” “A comprehensive package for improving the use of medicines needs to be developed, both for prescribers, dispensers and consumers, including approaches to good governance of medicines uses in health facilities.” Clinical Governance Accountability of medical committees for clinical care in hospital is defined in Health Ministerial Regulation No 755/2011; also, the Medical Council has responsibility to supervise medical practice. The JCI and KARS accreditation standards require documented evidence of effective structures and activities for clinical governance, such as committees and indicators for infection control, clinical records, pharmacy and therapeutics, and patient safety. The decree (755/2011) refers to the role and responsibility of medical committee, and to others such as for credentialing, medical audit and peer review. However the implementation of this regulation is poorly monitored. “Effective management of pharmaceuticals and devices spending in hospitals in systems using DRGS requires, amongst other strategies, effective Drugs and Therapeutic Committees (DTCs) to quality assure prescribing – DTCs in Indonesia are generally not very effective.” Risk Management Despite the requirements of accreditation standards, risk management systems in hospitals are weak, for example: •

Resuscitation: staff have regular training but equipment is not consistently checked to be complete and fully functional.

•

Medications: Some high risk medicines (eg concentrated KCl) are held among nonemergency ward stock in many hospitals (described as a “never event” in the WHO patient safety guidance).

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•

Environment: the baseline HAPIE assessment showed inattention to facilities management and environmental safety; eg emergency generators not tested regularly on full load; fire exits and escape routes unclear or obstructed

Suggestions Standards for the organisation and management of provider institutions should be defined, assessed and enforced consistently across the country. MoH and MoHA should provide technical assistance for development of institutional systems and facilitate their implementation. Public Involvement, Consumer Voice “Individual institutional complaint and compliment mechanisms do exist, particularly in private providers. Local registering of complaints about public services - including health - do exist in several districts, but the mechanisms are weak and ineffective. There is no national program to receive and analyze complaints about health care.” Significantly the Road Map targets (for UHC) make explicit reference to enriching community, patient and staff experience of the system…”At least 75 percent of the members shall satisfy with the services provided at the NHIC and by health care providers contracted by the NHIC.” By 2014 (85% by 2019) Suggestions The MoH should promote “health literacy” by raising public awareness and providing public information including •

on the rights of patients to information, participation and security, including provisions of relevant regulations eg Law no 29/2004 and the Jakarta convention

•

on healthcare standards, assessment procedures and results

•

on access to healthcare and preventive services

Professionalism The provision of care would be guided by the code of ethics of respective professions, clinical governance and increased self-regulation. The Medical Council has responsibility to supervise medical practice, and non-governmental associations, such as the Indonesian Medical Association, are designated as partners in the formulation of national clinical guidelines. The Indonesian Healthcare Quality Network is a voluntary association of health professionals, private facilities owners, managers, researchers and patients established in 2005. Suggestions Professional associations and regulatory bodies should be actively recruited into an effective network to influence and complement government’s policy on quality improvement.

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Regulation Healthcare providers are subject to supervision and inspection by a variety of regulatory bodies. Their requirements (standards), assessments (indicators, interviews, observations), reporting and feedback are not shared as an opportunity for learning - or to reduce costs and the burden of inspection. Suggestions Supervision and regulation at district, provincial and national level should share common principles, methods and information. Standards, procedures, results and sanctions should be in the public domain. Accreditation Programmes In principle, the assessment of healthcare institutions should be independent of the organisation which owns and/or manages them (ie third-party assessment); healthcare accreditation should be provided by an independent agency, preferably one. Both accreditation systems should be consistent with international (ISQua) recommendations regarding the organisation, standards and surveyor training, and should be independent of the MoH. Suggestions Both accreditation agencies should by publicly accountable: •

Maintain a public register of accredited institutions, indicating grading and expiry date

•

Make their standards, assessment and adjudication procedures available to the public

•

Publish an annual report on programme activity and trends in institutional compliance with the published standards

•

Make this information easily available on a public website

Hospital Accreditation If the hospital law requires KARS to accredit (rather than assess) all hospitals every three years regardless of compliance with standards, it is not surprising that few are denied accreditation. Fixing the term of accreditation at three years further disables KARS as an independent and credible assessor. KARS thus appears to be a more sophisticated duplicate of the licensing system operated by each district. Moreover, KARS is the only national accrediting body which is recognized by the government as stated in Ministerial decree (Permenkes) No 428 in 2012. Given the number of hospital across the country (2103 hospitals are registered in MoH), this decree will give a heavy workload to KARS if all providers to be contracted by BPJS have to be KARS accredited. The obligation of hospitals to be accredited every three years is written in the hospital law and is not subject to amendment by ministerial decree. However, a legal opinion would be valuable to

39

clarify the nature of that obligation (incentives or sanctions on whom), and whether every hospital has to be accredited, or merely assessed (at least) every three years. KARS has adapted assessment standards from Joint Commission International which had previously been accredited by ISQua. These do not explicitly refer to national requirements such as in the Indonesian Hospitals Act 44/2009 (for general and teaching hospitals), HMR No. 1691/2011 (safety of patients in hospital) and various advisories issued by the MoH. Puskesmas Accreditation Whereas KARS has already submitted to external assessment by ISQua (February 2014), the puskesmas program has so far been developed without support either from KARS or ISQua. KARS is established as a legal entity and is now separated from the MoH and governed by an independent body. The puskesmas program is under the Directorate of Primary Health Care (BUKD), Ministry of Health; there is no legal basis for a separate accrediting body. Government “Neither government officials nor professional associations have really addressed how to ensure more rigorous clinical standards of treatment” HSR has focused on decentralisation among tiers of government rather than allocation of responsibilities within MoH and between government, NGOs and semi-autonomous bodies. They would be more effective and efficient if their functions and authority were aligned to a common national plan for improvement. Developing and implementing such a plan will demand new relationships and communications between multiple stakeholders; quality and safety are cross-cutting issues which cannot be introduced solely through existing vertical management structures. Responsibility Within the MoH “It is the responsibility of the MoH to provide guidance, supervision and technical facilitation to local government especially the District Health Office. In practice, this guidance is rarely exercised by the MoH since their priorities are their own programmes.” The MoH “suffers from the absence of professional leadership across the professions, countrywide. It would be a step forward to appoint a Chief Medical Officer, a Chief Nursing Officer, a Chief Pharmaceutical Officer and a Chief Scientific Officer whose roles would be around the development of their professions rather than as Ministry functionaries.” Suggestions An identified unit should define coordination, accountability and responsibility for quality within MoH and within public sector facilities. This unit should make information on facilities, standards and performance readily available for public access, and be responsible for publishing an annual report on progress in implementing relevant legislation, directives and policy.

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Policy Integration National policy “One cross-cutting policy is recommended to build on the work of the HPK Movement and encourage stronger linkages between sectors and stakeholders to Improve effective leadership, multi-sector coordination, and division of responsibilities to support the …movement at national and subnational levels.” Suggestions A stakeholder group should be established to steer the development of national vision and strategies for quality improvement. A national framework for quality in healthcare should be defined, consulted, published and accepted as a basis for operational planning and development of quality systems. The framework should be comprehensive, consistent and based on evidence and consultation. This should identify the roles of organisations and individuals, the contributions and interactions of improvement mechanisms, and the required educational and technical resources (especially performance data). After an overall national framework has been generally agreed, the national steering group should draft and consult stakeholders on a plan for implementation. National Resource Centre Suggestions The national steering committee should issue a consultation document on the potential scope of responsibilities of a national resource centre, and its relationship to similar organisations. This should be formally established with terms of reference as a public body A separate independent agency is needed to develop consistent guidance, information, practical tools and comparative data for learning, improvement. Functions could include: Clinical guidelines and pathways •

Technology assessment in collaboration with responsibilities for regulation of medical devices, equipment, pharmaceuticals and blood products

•

Importing and developing clinical practice guidelines including the evidence-based use of pharmaceuticals and consistent with the national formulary

•

Evidence to support appropriateness, pricing and reimbursement by BPJS for patient care

•

Service-specific standards for BPJS

•

Systems for dissemination, local adoption and related audit tools

41

•

Evaluation of uptake and impact of guidelines on patients and costs

•

Identifying priorities for epidemiological research

Performance indicators •

Clinical process and outcome

•

Institutional performance

•

Comparative information on health system performance

Adverse events and clinical incidents •

Design Incident reporting system for healthcare institutions

•

Collate and analyse causes and trends in reported incidents

•

Identify and disseminate tools, systems and solutions to reduce risks

•

Feedback findings to reporting institutions

Reference sources •

National and international guides, methods, tools and findings

Training •

Quality and risk management systems

•

Clinical audit

•

Clinical coding

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6. Indicators of Achievement Quality and Safety in the HSR and Planning Framework There is no baseline to describe achievements in quality and safety over the last RPJMN, responsibilities for appropriate actions are not defined between organizations, there has been little discussion among stakeholders to define what steps are appropriate, and any target dates for achievements are very likely to be unrealistic. The principal recommended policy direction should be to start consultation in Indonesia towards a coherent plan, rather than to prescribe solutions based solely on international experience. If patient-based data are reliable, timely and consistently coded as a routine by-product of clinical systems, then it is possible to monitor and benchmark quality and safety, and make comparisons of outcome (clinical and population) over time and between provider institutions. Some such measures are available in RI, but data definitions are weak, aggregation methods are variable and coordination and data sharing are limited. In chronic diseases, and in data-poor settings, measurements of process, rather than outcome, are more practical and indicative of the causes of unacceptable variation. Some processes may be measured quantitatively (eg delay analysis, age-specific intervention rates) but the achievement of strategic goals is more reliably measured qualitatively. The development of nationally-agreed, evidence-based, internationally comparable statistical measures of quality must be driven by national commitment and collaboration. This is an important step for any country which cannot be by-passed with technical short-cuts. Below are a several measures which have been used to evaluate progress on national quality systems; target dates for these achievements, and responsibility for them would depend on a variety of organisational and behavioural variables which have yet to be clarified during consultations and the progress of the health sector review. Policy

2015 2016 2017 2018 2019

National framework consultation

Q&S

issued

for

x

National framework Q&S approved

x

National quality policy issued for consultation

x

National quality policy approved National implementation consultation

plan

x issued

for

x

National implementation plan approved National

information

strategy

issued

x for

x

43

consultation National information strategy approved

x

National clinical indicator set defined

x

BPJS/KARS agree formula to link payment to organisational performance

x

BPJS/centre agree formula to link payment to clinical performance

x

Graded accreditation payment tariffs by BPJS

x

awards

determine

Organisation Define authority, responsibility, structure and budget for national commissions (HTA, PS)

x

National resource centre established in MoH x Resource centre becomes separate national agency Unit established to coordinate MoH quality activities

x

x x

MoH unit publishes first annual report on Q&S Organisational chart identifies responsibilities within MoH

x

Organisational chart identifies responsibilities outside MoH

x

HTA, clinical guidelines commission fully resourced

x

Patient safety commission fully resourced

x

Methods Model patients’ charter in plain language

x

44

published by MoH Charter visible in every health facility

x

Management guidance issued to providers on patient survey methods

x

Management guidance issued to providers on complaints management

x

Management guidance issued on institutional Q&S systems

x

Accreditation standards require compliance with referenced national guidance Standards, methods and results accreditation assessments accessible public

of to

x

x

Accreditation programmes publish first annual report

x

KARS compliant with ISQua standards

x

KARS fully accredited by ISQua Puskesmas accreditation ISQua standards

compliant

x with

x

Resources Clinicians have access to standardised data on clinical process and outcome

x

Managers have access to standardised data on institutional performance

x

Quality of clinical coding monitored and fed back to hospitals Quality improvement methods specified in national curriculum for healthcare workers

x

x

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Appendix 1.Assessment tool for national quality systems 1. Policy: The government’s values, vision and strategies for quality improvement are comprehensive, consistent and based on evidence and consultation. They are explicitly stated and disseminated to purchasers, providers and the public. Yes

No

The policy is explicit and accessible •

is formally published

•

is systematically disseminated to providers, purchasers, public

•

is accessible free of charge

The policy is consistent •

with existing and proposed legislation and regulations which it identifies

•

with public health policy and priorities

•

with WHO Health for All policy

The policy is comprehensive •

defines the scope of quality (eg technical, social, economic) and factors which affect it

•

identifies and reflects the differing viewpoints of stakeholders

•

actively involves consumers in defining and assessing quality

•

relates to independent, voluntary and social care, as well as the public sector

The policy identifies key roles in quality improvement •

commits Government to lead quality improvement by example and to ensure that quality remains visible on every management agenda

•

identifies the responsibilities and accountabilities of public, private and professional bodies (eg for training, monitoring)

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The policy identifies incentives for quality •

requires evidence of quality improvement systems as a condition for funding contracts with practitioners, hospitals and health care organisations

•

identifies incentives to motivate staff to participate in quality improvement

2. Organisation: There are effective mechanisms to integrate and implement the national policy within national and local government, and between all stakeholdersand sectors of health care provision. Yes No 2.1 Coordination of quality improvement is clearly defined within the ministry of health •

there is an identified quality unit and a named accountable officer

•

an organisational chart identifies sections within the ministry which contribute to quality improvement, and shows relationships between them

•

a published annual report identifies quality activities and quantified improvements in performance of the health care system

2.2 Accountability and mechanisms for implementing quality improvement are defined throughout the health care system •

quality improvement is explicitly incorporated into national health programmes

•

implementation of national guidance (eg reports, enquiries and ministry/health department advice) is systematically followed up through performance management or independent review in primary, secondary and tertiary services

•

there is designated leadership, accountability, supervision, monitoring and communication of quality at sub district, district, regional and national levels

•

quality management structures and mechanisms are integrated within each provider and commissioning organisation (eg clinical governance, clinical , patient and public satisfaction, audit, performance measurement, risk management)

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•

accountability for the quality of clinical practice is clearly defined within each provider organisation

2.3 Support structures, such as agencies, boards, committees and networks (including non-governmental organisations, teaching and research institutions and professional groups) are established, publicised and accessible nationally •

there is a national quality policy group representing consumers, providers, insurers, and professions

•

there is a national resource centre for technology assessment

•

there is a resource centre for collecting and developing clinical practice guidelines

•

the dissemination of clinical standards is co-ordinated nationally to avoid duplication and to ensure they are coherent, affordable and cost-effective

•

there is a resource centre for the collation and dissemination of comprehensive comparative information on health system performance

•

there is a national information and resource centre for quality improvement

•

there are active quality improvement structures identified within self-regulating clinical profession and specialty

•

there is a national society for quality in health care

each

3. Methodology: Effective methods for quality improvement are systematically promoted at national and local level, consistent with experience and scientific evidence. Adoption of demonstrated quality methods is recognised and rewarded in organisations and individuals

Yes No 3.1 Statutory mechanisms to ensure the safety of public, patients and staff are established and evaluated. Their regulations, standards, assessment processes and results are accessible to the public. •

licensing of public health care facilities

•

licensing of private health care facilities

•

licensing of doctors, dentists, nurses and allied practitioners

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•

periodic re-licensing of facilities

•

periodic re-licensing of practitioners

•

certification of radiation safety

•

certification of fire safety

•

certification of environmental and occupational safety

•

licensing of medical equipment and drugs

3.2 Voluntary external quality assessment and improvement programmes are recognised by and consistent with statutory investigation and inspection. Their standards, assessment processes and operations comply with international criteria. •

there is a formal mechanism by which voluntary and statutory programmes collaborate towards convergence of standards, assessment, quality improvement and public accountability

•

the uptake of ISO certification and EFQM assessment in health care, regulated by their formal national bodies, is actively monitored and supported

•

accreditation programmes are supported in primary, secondary and tertiary care

•

accreditation programmes meet international ALPHA standards

•

there is a national external quality assurance system for clinical laboratories

•

there are systematic, confidential national enquiries into the occurrence of adverse events and outcomes in health care

3.3 There are formal mechanisms to define and protect the rights of patients and their families to health services •

patients’ rights to high quality health care are explicitly stated, widely disseminated, and in the language of ethnic minorities

•

the results of national sample surveys of patient experience and with health care have been made public

•

there is a well-publicised national programme for receiving and analysing complaints about health services

satisfaction

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3.4 Local quality programmes are systematically planned and co-ordinated to meet national priorities and the needs of local stakeholders. They use standards, measures and improvement techniques which are explicit and known to be effective in that setting. •

Population access and system responsiveness to community needs

•

Consumers’, users’ and clients’ views and experience

•

Staff welfare, morale, development

•

Staff competence, knowledge, attitudes, skills, accountability

•

Clinical practice, guidelines, care pathways

•

Service delivery, co-ordination, continuity, management

•

Risk, health and safety

•

Resource management, efficiency, cost-benefit, rationing

•

Communications, records, information

4. Resources: The national programme identifies responsibility for funding and providing the basic knowledge, skills and information required for quality improvement

Yes No 4.1 Personnel are trained to evaluate and improve the performance of their own work and of their health care organisation •

relevant techniques of quality improvement are incorporated in the curriculum, teaching and examination of all clinical undergraduates

•

performance analysis and improvement are included in the continuing professional development programme provided by all health facilities

•

professional colleges, academic centres and research institutions have an agreed and specified role in supporting the skills and knowledge of personnel in hospitals, clinics and health centres

•

a national curriculum is defined for staff who specialise in the co-ordination of quality programmes

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•

responsibility is identified for national integration and provision of training in quality management in all health disciplines

4.2 Personnel have protected time to participate in formal, systematic quality improvement programmes •

time for quality improvement activity is specified in contracts with employees and with health care purchasers

•

participation in clinical and organisational peer review is a condition of employment or staff privileges in all health facilities

4.3 Health facilities provide staff with accurate, complete and timely data by which clinical and organisational performance can be measured •

there is a nationally agreed minimum patient data set

•

this includes in-patient, ambulatory, primary and preventive care

•

national standards for data quality are defined and monitored

•

patient administration systems in all facilities are designed to generate indicators, indices and data for clinical and administrative review

•

data systems are accessible to clinicians and managers for routine or ad hoc analysis

4.4 Information on the theory and practice of standards, measurements and improvement is accessible to all health personnel •

staff have access to a database of quality experience in their own organisation

•

staff have access through publications, library services or Internet to national and international resource centres

•

national quality resources, reference centres and publications are actively catalogued, signposted and accessible to intended users across all borders of the nation

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4.5 The direct financial costs of the quality programme are realistically identified in advance and allocated to agreed budgets, especially for training, research and information •

direct costs of agreed quality programmes are identified in purchaser-provider contracts

•

service level agreements identify agreed quality targets as well as price and volume of clinical activity

•

local resource allocation mechanisms respond to deficits demonstrated by quality management programmes

•

central funding of quality initiatives is based on an agreed programme which is publicly accountable

•

priority is given to research and development to identify and implement incentives and mechanisms which are shown to effect behavioural change

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Appendix 2. International quality indicators, OECD text links The OECD Health Care Quality Framework Strengthening Health Information Infrastructure Cardiovascular Disease and Diabetes Primary Care Avoidable admissions: Asthma hospital admission COPD hospital admission Uncontrolled diabetes hospital admission Acute Care In-hospital mortality In-hospital case fatality within 30 days after admission for AMI In-hospital case fatality within 30 days after admission for ischemic stroke In-hospital case fatality within 30 days after admission for hemorrhagic stroke Mental Health Care Excess mortality from schizophrenia Excess mortality from bipolar disorder Cancer Care Cervical cancer screening in women aged 20-69 Cervical cancer five-year relative survival Cervical cancer mortality in women Mammography screening in women aged 50-69 Breast cancer five-year relative survival Breast cancer mortality in women Colorectal cancer, five-year relative survival Colorectal cancer mortality Patient Safety Obstetric trauma, vaginal delivery with instrument Obstetric trauma, vaginal delivery without instrument Foreign body left in during procedure Postoperative pulmonary embolism or deep vein thrombosis Postoperative sepsis Responsiveness/Patient Experiences Regular doctor spending enough time with patients during the consultation Regular doctor giving opportunity to ask questions or raise concerns to their doctor Regular doctor providing easy-to-understand explanations by their doctor Regular doctor involving patients in decisions about care or treatment

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