Abdoer Rahem Situbondo Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Before planning the initiative on Improving Public Service of RSUD dr. Abdoer Rahem Situbondo, the government of the district of Situbondo organized a workshop to identify the issues and complaints regarding the service of the hospital. Involving all stakeholders (NGOs, Community Organizations, Forum of Village heads, Associations of Market managers, Universities, schools, Islamic boarding schools, and teachers association.), the workshop was concluded with a recommendation that a complaint survey should be made. Participants of the workshop were divided into 15 groups to conduct a survey. The survey involved 19,000 respondents representing all groups of users, and as many as 17,052 respondents completed the questionnaire. Based on the data obtained from the survey, 40 types of complaints were identified. They are further categorized further into complaints related to the manner and attitude of the personnel (15 types), the process in delivering service (13 types), and the inadequacy of facilities/equipment (12 types). The result of the survey (complaints and number of respondents) is as follow: • The pharmacy does not have adequate selection of medicines and sells them at higher prices than pharmacies outside the hospital. (10,754 respondents) • Inadequate number of doctors, particularly during holidays (10,603 respondents) • Slow response from the nurses (10,225) • Too much time spent on queuing and waiting due to poor patient-doctor/specialists’ ratio (10,063) • Nurses treat patients unfairly (particularly to Askeskin patients) (9,958) • Doctors are often late to arrive at the polyclinic and to visit inpatients (9,914) • Specialists (anaesthesia, radiology, ear and throat, cardiology and lungs) are not available (9,397) • Slow service at the registration counter (9,192) • Doctors often delegate their responsibilities to nurses (9,075) • Inadequate number of outpatient registration counters (only 1 available) (8,855) • Inadequate explanation by doctors regarding illnesses and medication (8,775) • Unfriendly service at the registration counters (8,455) • Poor cleanliness and sanitation in the hospital (8,327) • Slow response to handle critical patients (by doctors) (8,297) • Inadequate equipment (USG, CT Scan, Endoscopy, X-Ray) (8,201) • Specialist are often substituted by general practitioners (7,991) • Irregular visits by doctors (7,928) • Cost for blood transfusion has to be paid at PMI (not integrated in the administration system of the hospital) (7,893) • Slow response to treat women in labour (7,675) • Unsafe and uncomfortable parking lot (7,644) • Food is not adjusted to suit patients’ needs and illnesses (7,633) • Unskilled nurses (7,597) • Numbers are not provided for patients queuing at outpatient registration counter (7,579) • No mechanism for filing complaints (7,526) • Inadequate number of toilets in the polyclinic (Only 2) (7,386) • Extra charge for Askeskin patients is not informed transparently (7,341) • Dirty toilets and bathrooms in inpatients rooms/wards (7,328) • Paid spare medicine is not given to patients (7,198) • Information on standards of service and cost is not available at the laboratory (7,085) • The waiting room in the polyclinic is too small and dirty, and the roof leaks (6,989) • Information centre is not available (6,849) • Prices of medicines change from one shift to the next (6,646) • Unfriendly doctors (6,525) • Doctors often prioritize sales representatives from pharmaceutical companies than patients (6,518) • Inaccurate/careless diagnosis (6,388) • Inadequate number of inpatient rooms/wards (all categories: first class, VIP, and third class) (6,152) • Doctors tell patients to come to their private clinic (6,055) • Doors to the inpatient rooms cannot be locked (6,044) • Mark-up on the number and cost of doctors’ visits (5,912) • Poorly maintained bed sheets and pillows (5,833)

B. Strategic Approach

 2. What was the solution?
In order to find solutions to address the identified problems, the district government organised a workshop involving selected participants, both insiders (representatives of all health care professionals, the management) and outsiders (NGOs, Community Organizations, village Head Forum, Associations of Market managers, Universities, schools, Islamic boarding schools, and teachers association.) Guided by a facilitator, participants brainstormed for possible solutions, and proposed 44 drafts of commitment to improving the service as a response to 37 types of complaints and 19 recommendations of improvement responding to 16 types of complaints. In order to ensure the realization of the commitment and to obtain supports from all stakeholders, the commitment and recommendations were signed by the Director of RSUD dr. Abdoer Rahem and endorsed by the head of the district. The chair person of the Parliament and mass media were also invited to witness and disseminate the information to public. To monitor the improvement, it was agreed that another complaint survey, using the same method and questionnaire, would be conducted after 6 months after the signing of the commitment. The result was then compared with that of the first one to find out public perception on the service. The strategy to have the declaration signed by the Director before the head of the district, head of the parliament, NGOs and mass media was also intended to obtain supports and resources. It was also meant to involve people to continuously monitor the efforts.

 3. How did the initiative solve the problem and improve people’s lives?
RSUD dr. Abdoer Rahem Situbondo was aware of the fact that most complaints were concerning the attitudes and manners of the front liners directly delivering service to public. For this reason, the hospital took the initiative to give all personnel of 539 people personality improvement and excellent service training for two consecutive days. To ensure that the training achieved the objectives and made an impact on participants’ behavior / attitude, everyone was required to take a pledge to do their best to deliver best service during the morning assembly. Another innovation to address shortage of specialists is networking. The hospital and the Faculty of Medicine of Unair (Universitas Airlangga, one of the nearest universities) have made an informal agreement, in which the latter would provide specialists on request. To address shortage of facilities and equipment, an MoU on operational cooperation with third parties was made to provide haemodialysis and laboratory service. In response to address complaints about cleanliness, the hospital developed a rubbish bank system, which is applied in every section/unit of the hospital. Regarding complaint mechanism, the hospital has developed a new unit to receive, verify, and respond to complaints both directly and via SMS.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Strategies to improve the quality of public service in the hospital include: a. Continuous quality improvement The improvement is made by realizing all the commitments continuously in stages. The first priority was implementing service improvement on 16 areas by February 2011, aiming at addressing the following complaints: “Doctors are often late to arrive at the polyclinic and to visit inpatients”; “Slow service at the registration counter”; “Doctors often delegate their responsibilities to nurses”; “Inadequate number of outpatient registration counters (only 1 available)”; “Unfriendly service at the registration counters”, “Specialist are often substituted by general practitioners”; “Irregular visits by doctors” “Cost for blood transfusion has to be paid at PMI (not integrated in the administration system of the hospital)”; “Slow response to treat women in labour”; “Food is not adjusted to suit patients’ needs and illnesses”;“ No mechanism for filing complaints”; “Dirty toilets and bathrooms in inpatients rooms/wards”; “Paid spare medicine is not given back to patients”; “Information on standards of service and cost is not available at the laboratory”; “Information centre is not available”; “Prices of medicines change from one shift to the next.” The next step was monitoring and evaluating the service for the next 6 months to find out public perception of the improvement made. The same questionnaire in the baseline survey was used to conduct another survey, and the results of the two surveys were compared in the form of Complaint Index to evaluate progress. b. Adequate funding is crucial for the implementation of the initiative, particularly to improve financial flexibility that affects its capability to respond quickly and to maintain quality service. It is even more important as the financial management, such as budget for medicine, disposable health equipment, food, maintenance of facilities, fee for specialists, training, has been under the management and authority of Badan Layanan Umum Daerah (District Public Service Board). c. Several monitoring teams have been developed to continuously monitor different aspects of the service and regularly measure them against certain standards. These teams are: - Team to measure Public Satisfaction Index (IKM) - Team to monitor Hospital’s Minimum Standards of Service (SPM). - ISO & hospital accreditation team.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Those taking part in the implementation of the initiative are: 1. The personnel of the hospital, who has pledged to improve the quality of the service to meet people’s expectation. Together with other partners, they have taken part since the first process of identifying the problems. 2. The District Government of Situbondo, particularly Organization Division. 3. LSM (NGO) Simponi akar rumput and LSM Husada Bhakti.
 6. How was the strategy implemented and what resources were mobilized?
The resources for the initiative to make the commitment formal by having the pledge signed by the Director of the hospital, endorsed and witnessed by the head of the district, chairperson of the parliament, representatives of NGOs and public figures in Situbondo include: • Funds allocated in the Budget of Situbondo district and functional income of the hospital since 2010, as allocated in Business Plan of the hospital. • Special consultants for human resource development. • Hospital personnel, 40 people who have participated in personality, leadership and team building training, 539 people of various professions who have taken part in service excellence training, 40 people who have taken medic and paramedic technical training, 10 general practitioners who are taking internship to be specialists. Efforts to mobilize the resources include: o Conducting technical training on personality development, leadership, team building. Medic and paramedic technical training to improve human resource quality, particularly to improve their skills in handling complaints related to the behavior, manner and competence of hospital personnel. o Issuing permits for doctors to study further to become specialists. Sending nurses to take further education. o Networking with the Faculty of Medicine (Unair) to provide specialists and contracting specialists to work in RSUD dr. Abdoer Rahem Situbondo. o Conducting advocacy and presenting proposal to District Government and Parliament for fund allocation in the district’s budget so as to continuously improve facilities and equipment, particularly to procure modern equipment.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Outputs of the program that can be considered the most successful are: a. All hospital personnel, including specialists, doctors, nurses and administration officers, took part in the technical training for delivering excellent service. Considering the fact that personnel is the most important resource, their enthusiasm as reflected in the pledge to improve their manner/behavior in delivering service can be considered as the most significant output. b. The development of Information and Complaint Centre (Pusat Informasi dan Pengaduan /PIP) to provide information, both actively and passively, for clients and to handle complaints. c. The hospital successfully completed Complaint Surveys, and has continued to monitor and evaluated the progress by comparing progress against the results of the survey. d. Minimum Standards of Service have been achieved in accordance with the targets of the hospital strategic plan 2011-2013.

 8. What were the most successful outputs and why was the initiative effective?
In order to monitor and evaluate the implementation of the strategy to improve public health care service, the hospital has done the following: Conducting regular complaint survey, at least every 6 months, to find out public response/perception regarding the improvements made by the hospital. Any setbacks or shortcomings are evaluated to find out the underlying reasons and the best ways to address them. The hospital continuously measures the progress in terms of Complaint Index and Minimum Standards of Service. The results are discussed in internal workshops to make recommendations on the best ways to make improvement and to identify the necessary resources for that. The recommendations are then presented to the units which have not performed according to the standards.

 9. What were the main obstacles encountered and how were they overcome?
The main constraint in realizing the commitment to providing better service is the difficulty to find specialists, particularly those required for type C hospital. Assigning general doctors to study further is an effort worth trying, but it takes about 4 or 5 years to get results from this kind of investment on human resources. Another constraint is inadequate fund to procure modern medical equipment to meet people’s expectations. Regarding shortage of specialists, the hospital has recruited some on contract and offered six months internship through networking with schools of medicine and the ministry of public health. To address the problem of inadequate up to date medical equipment, the hospital has made operational cooperation with third parties (suppliers). Examples of successful cooperation include the provision of haemodialysis service and laboratory service. In the near future, the hospital is going to work together with a third party to provide CT Scan.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The main benefits after the implementation of the initiative are: a. The personnel has shown better manner in delivering service. Before the personality improvement training, clients had the perception that front liners were unfriendly, unhelpful and unprofessional. This perception has gradually changed since the training, and to reinforce it, the training is given regularly every year. b. Improved response time. c. Availability of specialists. d. Availability of modern medical equipment. Efforts to enhance the service, particularly addressing the complaints, have made further improvement less problematic as people of Situbondo start to give positive reinforcement and show their trust to go to RSUD dr. Abdoer Rahem. The data show that not only that the number of patients, but also the satisfaction index, has increased significantly, as shown in the following table: • Number of visits to Emergency Unit increased from 17.062 visits in 2010 to 18.875 visits in 2012. • Number of outpatients also increased from 45.959 in 2010, to 65.222 in 2012 • Number of inpatients increased from 56.517 in 2010 to 60.049 in 2012; and • Satisfaction index increased from 71.80% in 2011, to 81% in 2012.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Yes, The initiative is made sustainable by people’s participation. Its sustainability is also ensured by the policy (complaint survey and pledge), fund allocation in the District Budget and hospital operational income. The complaints can be put into three broad categories: those related to human resources, system and process of delivering service, and adequacy of facilities and equipment. The personnel is continuously maintained and developed through annual technical training and continuous encouragement so as to meet clients’ expectation for excellent public service. In addition to this, they are assigned to take part in specific professional development programs supported by the District government, such as internship for doctors to become specialists. While waiting for the result of these programs, with financial support from BLUD the hospital continues to recruit specialists on contract or invite doctors for internship. Monitoring and evaluation is done continuously by measuring the progress against the Minimum Standards of Service and Satisfaction Index. To ensure the sustainability, this process involves public participation. The initiative can be replicated in other organizations which have similar characteristics.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons learned from the initiative to improve the capacity of RSUD dr. Abdoer Rahem Situbondo in delivering better service: Any organizations providing public services, such as hospitals, are recommended, or even required to monitor, evaluate and improve their services. To do this, conducting complaint surveys can be very effective, particularly when all stakeholders (NGOs, public figures, community organizations) are involved to ensure the accountability and reliability of the process. Results obtained from the surveys are then discussed in a workshop in which participants make recommendations for improvement. To ensure supports from all stakeholders, particularly financial support from the government, any commitments made by service providers should be incorporated in the policies of the government. All activities to improve the service should be continuously monitored and evaluated against the initial commitment. External monitoring can be done by NGOs appointed by stakeholders, while internal monitoring is done by Tim Survey Rumah Sakit (Hospital Survey Team). Networking is crucial to quality improvement, particularly in the development of human resources and procurement of sophisticated equipment. Through networking, procurement of supplies and expertise will be less costly and less troublesome. The success of the initiative is ensured when the head of district government give the commitment and supports, in the forms of accommodating policies and provision of necessary resources. Another factor to ensure successful implementation of the initiative is stakeholders’ participation in all stages, from planning to monitoring/evaluation.

Contact Information

Institution Name:   Abdoer Rahem Situbondo Hospital
Institution Type:   Government Agency  
Contact Person:   Tony Wahyudi
Title:   Director of the RSAR Situbondo  
Telephone/ Fax:   +62-338-671028
Institution's / Project's Website:  
Address:   Jl. Anggrek 68,
Postal Code:   68312
City:   Situbondo
State/Province:   East Java

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