Hospital Assesment
for
Quality of Care
Country experience : INDONESIA
1
OUTLINE
1.
2.
3.
4.
BACK GROUND
HOSPITAL ASSESMENT
RESULT
FOLLOW UP AFTER ASSESMENT
2
HEALTH INFRASTRUCTURE
Number of:*
-Hospitals (*2011)
-Community Health Centers
-Integrated service posts
- Maternity Huts
-Village Health Posts
(*2011)
Number of Health Personnel*
-General Practitioners
-Medical Specialists
-Obstetricians
-Pediatricians
-Nurses
-Midwives
: 1686
: 9133
: 266.827
: 28.558
: 51.996
: 25.333
: 8.403
: 1104
: 1800
: 160.074
: 96.551
3
Background
Assess and classify

The sickest children require
hospital care


IMCI assumes referral for the
sickest children
~10 (-20%) of children require
referral
Finding
Classification
Treatment
Danger signs
Severe disease
Urgent referral
Cough or difficulty in
breathing
Severe disease
Urgent referral
Diarrhoea
Disease with specific
therapy
Specific medical treatment
Disease without specific
therapy
Symptomatic treatment
Complete/incomplete
Vaccinate
Fever

Child survival interventions
depend on good referral system &
good care at referral level
Ear problem
Nutritional status/
anaemia
Vaccination status

To known situation about quality
hospital care as a based data
Department of Child and Adolescent Health
and Development
Hospital Improvement Process
1. Country Orientation
2. Hospital Assessment
3. Agreement on standards
4. Definition of interventions & area
PLAN
7. Sharing of
Information
DO
ACT
5. Improvement in
hospitals
CHECK
6. Monitoring and Evaluation
5
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

.
Methodology: stratified 2 stage random
sampling to be geographically representative
1.RSDr Doris Sylvanus
(B)
2.RS Buntok (C)
3.RS Muara Teweh (C)
1.RSDr Doris Sylvanus (B)
4.PKM Kandui
2.RS Buntok (C)
3.RS Muara Teweh (C)
4.PKM Kandui
1. RSU Raden
1.Mattaher
RSU Raden
(B)
Mattaher
2. RSU
Muara (B)
2.Bungo
RSU(C)
Muara
Bungo
(C)
3. RSU Bangko
3.(C)RSU Bangko
(C)
4. PKM.
4.Pemenang
PKM.
Pemenang
15/04/2020
1.RS Ternate (C
)
1.RS
(C )
2.RSTernate
Tidore (C)
2.RS
Tidore
(C)
3.RS Sanana (
3.RS
D ) Sanana ( D )
4.PKM
4.PKMGalala
Galala
1.RS Prov Sultra (B)
1.RS Prov Sultra (B)
2.RS Kota Bau-Bau
2.RS Kota Bau-Bau
(C)
(C)
3.RS Kab. Konawe
3.RS Kab. Konawe
(C )
(C )
4.PKM Batauga
4.PKM Batauga
1. RSU Dr R Sosidoro
(B)
2. RSU Dr Soegiri (C)
3. 1.RSU
Dr Dr
Soedomo
(C)
RSU
R Sosidoro
4. Pkm
Baureno
(B)
2. RSU Dr Soegiri (C)
3. RSU Dr Soedomo (C)
4. Pkm Baureno
1. RS. Yohannes(B)
2. RS. Kalabahi Alor (D)
3. 1.RS.
dr.Yohannes(B)
TC Hillers
RS.
Maumare
(C) Alor (D)
2. RS. Kalabahi
4. 3.PKM
Bola
Sikka
RS. dr. TC
Hillers
Maumare (C)
4. PKM Bola Sikka
7
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

Hospital assessment tool



Based on generic WHO tool
Adapted in line of tools of hospital accreditation commission
Areas assessed
1. Hospital support functions including drugs, supplies and
equipment; laboratory, radiology and hospital information
systems
2. Emergency care
3. Children’s ward
4. Case management on the ward
5. Neonatal care
6. Monitoring of patients in the hospital
7. Mother and child friendly services
8. Hospital support
9. Discharge and follow-up
10. Access to hospital
 RESULT OF ASSESSMENT
10
Type and number of bed of Hospital
100,00

Number of hospital 18
 Category class B = 7
 Category class C = 9
 Category class D = 2
90,00
80,00
70,00
60,00

Number of bed 30 – 323
 Bed occupancy rate
57%
 Length of stay is 4 day
Bed occupancy in Child
health care
B
O
R
56,98
56,40
50,00
45,83
40,00
30,00
20,00
10,00
0,00
2006
2007
2008
BOR
Number of general MD by training
received
Trained
Number of MD
Basic life support
23
Emergency services
55
ACLS
49
Resuscitation
6
BEONC
15
CEONC
5
ICU/NICU
4
Malnutrition Health Care
6
IMCI
6
12
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
STANDARD
1-4 There are triage
system, SOP triage,
1.Lay-out and flow of pediatric patient,
structure
referral system.




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 .


5.Separated emergency
unit
6. Separated of
examination and
treatment room
WEAKNESSES

PARAMETER
Summary of assessment
Need to be
To be strongly improved
Good
(60-79%)
improved
(≥80%)
(<60%)


7.Easy access to
emergency unit
2.Emergency
unit staff
1. Skillful triage staff
3.Drug and
equipments

2.Adequately
professional staff

1.Availability of
emergency drug
administration
2-3.Availability of
essential laboratory test
and medical
equipments


CASE MANAGEMENT IN PEDIATRIC WARD
1. Cough or difficult breathing
STRENGTHS
Most hospitals (77%) have nebulizer,
X-ray, and good supply of O2 .
Summary of assessment

STANDARD
PARAMETER
WEAKNESSES
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.

1. Diagnosis
assessment of
severe
pneumonia
1. Correct
assessment of
severe
pneumonia
2.Administration 1-3. Correct
administration of
appropriate
appropriate
antibiotic,
antibiotics ,
oxygen,
management of oxygen , Inhaled
bronchodilators
wheezing, TB
medication,
usng chest X-ray
4-5. Correct
provision of TB
treatment and
use of chest xray based on
clinical indication
Needs to
To be
be
strongly improved Good
improved (60-79%) (≥80%)
(<60%)



CASE MANAGEMENT IN PEDIATRIC WARD
2. DIARRHOEA
STRENGTHS
Summary of assessment
STANDARD
PARAMETER
1. Assessment of
dehydration
1.Correct
assessment of
dehydration
Correct rehydration
2. Management of
plan is chosen
rehydration,
based on the degree
administration of
antibiotics, continued of dehydration and
monitored
feeding, and Zinc
supplementation
.2. Correct use of
during diarrhea
antibiotics
Policy that
antidiarrhoeal are
not given
To be Need to be
strongly improved Good
improved (60-79%) (≥80%)
(<60%)
•
WEAKNESSES






3. Procedures for
continued feeding

4.Procedure and
policy for Zinc
supplementation

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.
CASE MANAGEMENT IN PEDIATRIC WARD
3. FEVER
Summary of assessment
STANDARD
PARAMETER
STRENGTH
Need to
To be
Availability of
be
strongly
Good
improved
improved
(≥80%)
(60-79%)
(<60%)
essential laboratory tests
WEAKNESS
1. Appropriate assessment
undertaken for all children with
febrile conditions and have a
1.Assesment and differential diagnosis for possible
differential
and likely conditions considered.
diagnosis
2. Diagnosis an
management of
fever
1-2.Correct diagnosis of Dengue
viral infection and management of
DHF with or without shock and
monitored.
3-4.Correct diagnosis and
management of severe malaria
(with complication and
appropriate antimalarial
treatment are given
5-6. Correct diagnosis and
management of meningitis and
appropriate treatment..




 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
CASE MANAGEMENT IN PEDIATRIC WARD
3. MALNUTRITION
STRENGTH
Summary of assessment
Summary of assessment
STANDARD
STANDARD
PARAMETER
PARAMETER
1. Nutritional status 1.Assesed
nutritionalnutritional
status to
assessedstatus
to all 1.Assesed
1. is
Nutritional
all
inpatient
patients
status to all inpatient
is assessed to all
patients
2. Management
2. Management
1. Correct
of
1.assessment
Correct
hypoglycemia
assessment of and
hypothermia and
to
hypoglycemia
children
with
hypothermia tosevere
malnutrition
children
with severe
To be
strongly
To be
improved
strongly
(<60%)
improved
(<60%)


(60-79%)
There were 6 physicians
trained in malnutrition
Good
(≥80%)
Good
(≥80%)
WEAKNESS



malnutrition
2.Correct
administration of
2.Correct
antibiotics and
administration of
micronutrients
antibiotics and
micronutrients
3. Correct feeding to
malnourish children
3. Correct feeding to
and feeding formula
malnourish children
is available
and feeding formula
is available
Need to be
improved
Need
to be
(60-79%)
improved





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.
CASE MANAGEMENT IN PEDIATRIC WARD
3. HIV/AIDS
STRENGTH
Summary of assessment

STANDARD
PARAMETER
1.Assesment and 1. Correct assessment
counseling for and counseling to HIV
HIV suspected suspected children
children
2. Corect nursing care
for health condition
related to HIV infected
children
To be
Need to
strongly
be
Good
improve
improved (≥80%)
d
(60-79%)
(<60%)
WEAKNESS





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
NEONATAL CARE
3. CASE MANAGEMENT OF SICK NEWBORN
STRENGTH
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
Summary of assessment
STANDARD
1.Diagnosis sepsis
in neonates
PARAMETER
1. Correct diagnosis of
neonatal sepsis
To be
strongly
improved
(<60%)

2. Management
WEAKNESS
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
2. Management procedure
of neonatal sepsis is in
place

2. Specific feeding are
give frequently to sick
young infants and those
with low birth weight.
3. Procedures are in place
to check the bilirubin level
and to manage jaundice


Need to
be
Good
improved (≥80%)
(60-79%)
Percentage of standard achievement of
10 services in hospitals by provinces
100,00
good
Supporting
services
2. Emergency
services
Need 3. Children’s
ward
Improve
4. Case
management
in the
pediatrics
ward
5. Neonatal care
strenf 6. Patient
Need 7. monitoring
Mother and
child friendly
improvement
services
8. Hospital
support
9. Discharge and
follow-up
10. Access to the
hospital
90,00
80,00
70,00
60,00
50,00
40,00
30,00
20,00
10,00
0,00
0
JAMBI
1
2
3
SULAWESI TENGGARA
4
5
JAWA TIMUR
6
NTT
7
8
MALUKU UTARA
9
10
KALIMANTAN TENGAH
1.
Follow up after Assesment
Collaboration MOH,Pediatrician and WHO
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
THANK YOU
FOR YOUR ATTENTION
Thank you
23
TERIMA KASIH
24