Hospital Assesment for Quality of Care Country experience : INDONESIA

1. Hospital Assesmentfor Quality of CareCountry experience : INDONESIA 1

2. OUTLINE BACK GROUND HOSPITAL ASSESMENT RESULT FOLLOW UP AFTER ASSESMENT 2

3. HEALTH INFRASTRUCTURE • Number of:* • Hospitals (*2011) : 1686 • Community Health Centers : 9133 • -Integrated service posts : 266.827 • - Maternity Huts : 28.558 • Village Health Posts : 51.996 • (*2011) • Number of Health Personnel* • General Practitioners : 25.333 • Medical Specialists : 8.403 • Obstetricians : 1104 • Pediatricians : 1800 • Nurses : 160.074 • Midwives : 96.551 3

4. Background The sickest children require hospital care IMCI assumes referral for the sickest children ~10 (-20%) of children require referral Child survival interventions depend on good referral system & good care at referral level To known situation about quality hospital care as a based data

5. Hospital Improvement Process 1. Country Orientation 2. Hospital Assessment 3. Agreement on standards 4. Definition of interventions & area PLAN 5. Improvement in hospitals • 7. Sharing of • Information DO ACT CHECK 6. Monitoring and Evaluation 5

6. IMCI Minimal Standard of care IDAI Standards/guideline, case management, hospital accreditation instrument (MOH) ADAPTATION process 2006-2008 GENERIC ASSESSMENT TOOL Indonesian assessment tool 6

7. Methodology: stratified 2 stage random sampling to be geographically representative . 1.RSDr Doris Sylvanus (B) 2.RS Buntok (C) 3.RS MuaraTeweh (C) 4.PKM Kandui 1.RS Ternate (C ) 2.RS Tidore (C) 3.RS Sanana ( D ) 4.PKM Galala 1.RSDr Doris Sylvanus (B) 2.RS Buntok (C) 3.RS MuaraTeweh (C) 4.PKM Kandui 1.RS Ternate (C ) 2.RS Tidore (C) 3.RS Sanana ( D ) 4.PKM Galala 1.RS ProvSultra (B) 2.RS Kota Bau-Bau (C) 3.RS Kab. Konawe (C ) 4.PKM Batauga 1.RS ProvSultra (B) 2.RS Kota Bau-Bau (C) 3.RS Kab. Konawe (C ) 4.PKM Batauga RSU RadenMattaher (B) RSU MuaraBungo (C) RSU Bangko(C) PKM. Pemenang RSU RadenMattaher (B) RSU MuaraBungo (C) RSU Bangko(C) PKM. Pemenang RSU Dr R Sosidoro (B) RSU Dr Soegiri (C) RSU Dr Soedomo (C) PkmBaureno RS. Yohannes(B) RS. KalabahiAlor (D) RS. dr. TC Hillers Maumare (C) PKM Bola Sikka RS. Yohannes(B) RS. KalabahiAlor (D) RS. dr. TC Hillers Maumare (C) PKM Bola Sikka RSU Dr R Sosidoro (B) RSU Dr Soegiri (C) RSU Dr Soedomo (C) PkmBaureno

8. Methods • Assessment teams • senior paediatrician, • a senior nurse with experience caring for children, • surveyor of hospital accreditation committee • a doctor working in the ministry of health • a health professional from the provincial health office • Visits • 2 working days, with observations during the evening or night. • The hospital director was informed in advance and agreed to the assessment

9. Hospital assessment tool • Based on generic WHO tool • Adapted in line of tools of hospital accreditation commission • Areas assessed  • Hospital support functions including drugs, supplies and equipment; laboratory, radiology and hospital information systems • Emergency care • Children’s ward • Case management on the ward • Neonatal care • Monitoring of patients in the hospital • Mother and child friendly services • Hospital support • Discharge and follow-up • Access to hospital

10.  RESULT OF ASSESSMENT 10

11. Type and number of bed of Hospital Bed occupancy in Child health care • Number of hospital 18 • Category class B = 7 • Category class C = 9 • Category class D = 2 • Number of bed 30 – 323 • Bed occupancy rate 57% • Length of stay is 4 day

12. Number of general MD by training received 12

13. EMERGENCY SERVICES IN HOSPITAL STHRENGTHS • Separate emergency unit • Emergency unit easily accessible • Examination and treatment room separated • Adequate numbers of professional staff • Availability of emergency drugs • No triage system for children • SOP not complete, especially for children • Majority no wall chart for child cases • Most of staff without training on child cases • No referral policy . WEAKNESSES

14. CASE MANAGEMENT IN PEDIATRIC WARD1. Cough or difficult breathing STRENGTHS WEAKNESSES • Most hospitals (77%) have nebulizer, X-ray, and good supply of O2 . • SOP not complete • Incorrect Dx of severe pneumonia and not complying with standard • Administration of second line antibiotics (cefotaxim) directly. • Salbutamol only available in 61% RS • Scoring system for child Tb Dx not implemented. Combined anti TB drugs for child not available self-mixing of incorrect dose of anti TB. • Tuberculin test not done. . • Non compliance of medical record by pediatrician or physician.

15. CASE MANAGEMENT IN PEDIATRIC WARD2. DIARRHOEA STRENGTHS • Availability of antibiotics and fluid • SOP not completed. No classification of the severity of dehydration and no plan of continued feeding. • All diarrhoea cases given iv fluid therapy and antibiotics directly. Antidiarrhoeals given frequently • ORS not given • Zn not available in most hospitals (67%). If Zn available, expensive (Zinc-kid Rp. 33.000/10), so not administered routinely especially for poor patients. WEAKNESSES

16. CASE MANAGEMENT IN PEDIATRIC WARD3. FEVER STRENGTH Availability of essential laboratory tests • SOP not complete • No consideration of DD • No record of the severity of DHF, excessive fluid therapy, not monitored, haematocrit test not done as routine lab test. • Thick blood smear not done as routine test • New guideline of malaria therapy not yet implemented and Artesunate & Amodiaquin not available in most hospitals • LP not done as routine test for patients suspected of meningitis WEAKNESS

17. CASE MANAGEMENT IN PEDIATRIC WARD3. MALNUTRITION STRENGTH • There were 6 physicians trained in malnutrition • No SOP /not complete SOP. Nutritional status is not assessed by height but only by weight. Scale for height not available. • Management of severe malnutrition is not compliant with guidelines. WEAKNESS

18. CASE MANAGEMENT IN PEDIATRIC WARD3. HIV/AIDS STRENGTH • Physicians and nurses are available to participate in HIV training • Guidelines or SOP were not in place for counselling, the diagnosis and staging of paediatric HIV • No HIV trained staff • HIV infected children cases are rarely diagnosed WEAKNESS

19. NEONATAL CARE 3. CASE MANAGEMENT OF SICK NEWBORN • NICU available in 3 class B hospitals and 1 C class hospitals, • trained physicians:4 on intensive care (PICU/ NICU), 4 on basic neonatal obstetrical emergency services BEONC, and 15 on CEONC • Phototherapy available in most hospitals • no SOP/SOP not yet complete • administration of 2nd line antibiotics directly • no breastfeeding promotion • assessment of jaundice based on clinical sign. No SOP to collect blood specimen for infant • Exchange transfusion not available

20. Percentage of standard achievement of 10 services in hospitals by provinces • Supporting services • Emergency services • Children’s ward • Case management in the pediatrics ward • Neonatal care • Patient monitoring • Mother and child friendly services • Hospital support • Discharge and follow-up • Access to the hospital

21. Follow up after Assesment

22. Dissemination of pocket book: 2009 25000 copies 2011 25000 copies  evaluation of reach, Training CD introducedHospital assessment tool is being revised  Improved skills for health personal by routine training  Adaptation standard operating procedures  Promote quality of health services for community Collaboration MOH,Pediatrician and WHO

23. THANK YOUFOR YOUR ATTENTION 23

24. TERIMA KASIH