Sumberasih Community Health Center

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Probolinggo District is located in East Java, Indonesia, has area of 1,696.16 km2, with population of 1,140,480. In 2015 data, Probolinggo’s human development index was relatively low (63.04) at rank 35 of 38 districts/cities in East Java, the average of education level is elementary school, 21% of population was the poor, above the National average of 10,86% . Primary health services in Probolinggo was covered by 33 community health center (Puskesmas), and 19 of them have inpatient services, including Puskesmas Sumberasih. In 2016, the outpatient number at all puskesmas in Probolinggo reached 721,204 persons. Up to year 2017, Puskesmas Sumberasih is the only health service mainstay for 67,142 people in Sumberasih subdistrict area, also serves outpatient services for its surrounding areas. This high number of visits caused several problems that made an uncomfortable condition and raised many complaints. Frequent problems before this initiative were: 1. Long queing at registration counter (30 minutes even more), caused: • Patients were restless, scrambled and commotion at registration counters • The sick patient worse and vulnerable group (pregnant women, disable, elderly people) couldn’t be able for scrambled queuing • Patient tired, the worsen condition, disease transmission risk during the jostle at registration counter. • Some patients back home without obtain health services and wouldn’t come back anymore. 2. Some patients obtained the services without registration (collution with Puskesmas staff), caused: • Unrecorded outpatient visits • Unfair treatment among patients • Unrecorded medicine spending 3. Difficulties of patient identification, caused: • Long identification process (inefficient) • Misidentification / inaccurate 4. Difficulties to find the previous medical records, caused: • New medical record prepared, so the diagnose ignoring the previous data • Unsustainable/discontinue diagnosis and treatments • Ineffective treatments (not cured), sometime should repeat the treatment from the beginning. 5. Hand writing doctor’s prescription given to the patient, caused risk of: • Misreading that lead to inadequate treatments (medicine type, number, dosis) that risky for patients • Patients cheated/add medicine number at their prescription • The prescription loss/damage/wet because of the patient careless 6. Difficulties in monitoring the medicine stock, caused: • Unknown / less medicine stock • Patient received the medicine replacement. The main factors of difficulties in controling the long queing are: 1. Culture a. Most patients have more than one names, usually use nick names that different from the name on identity card. b. Unaccustomed bringing identity and or medical card c. Less education patients, difficult to understand requirements d. Less awareness of queuing culture and tend for scrambling 2. System a. Many administration books should be completed b. Manual medical record using patient status card 3. Facilities a. Manual administration process, complicated, spend much time b. No available medical records archieve keeper, no safety insurance Most suffered groups affected by this conditions were: the poor who have no relation, the vulnerable people (disable, elderly, sick people), pregnant women and less educated person who difficult to understand the requirements

B. Strategic Approach

 2. What was the solution?
The solution and innovative approach has been conducted is: the ultilization of finger/thumb scan as the registration facility that has been integrated by the patient’s data and medical records, to ensure the easy, fair, transparent and accountable services for all patients.

 3. How did the initiative solve the problem and improve people’s lives?
By this Smart Thumb Facilities, the patients will receive an easy and fast services at Puskesmas Sumberasih. The problems were caused by the difficulties of patient identity identification, affected by the different name in the identity card could be solved, so the registration services could be very fast and comfortable for the patients without staying at long queuing. This registration facilitation makes the patients/community become active and diligent to check their health condition at Puskesmas Sumberasih. Further more, especially for elderly and or low education patients (who usually don’t concern to their legal identity aspects), through this initiative keep them being served by the available health services although they didn’t bring identity or medical card, because they forget to bring or keep it. The initiative provides a fair, transparent and accountable services for all people, because all the services steps: since the registration, diagnose and medicine conducted in computerized way. In the other side, the accuracy of medical record could be kept completely at database system of Puskesmas Sumberasih, and the mishandling that caused by an inappropriate identification of medical records could be eliminated. This is very important for the doctors and health workers in handling the patients adequately, because the medical records could be accurately and exactly accessed. The initiative has made an important contribution for community health development index, in line with SD’s 3 : Ensure healthy lives and promote well-being for all at all ages, especially for goals (3.8) : Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all, through: • The ease access of health services for all society • Fair and nondiscriminatory services for all patients, especially for the poor, less educated, elderly, disability, women, pregnant women with their limitation • Facilitate the pregnant women, so they will more active to check their pregnancy, that the detection of high risk pregnancy could be anticipated so the mother mortality rate could be decreased • Better access for baby and toddler to obtain the health services without long queuing registration • Ensure the appropriate service, because of the accuracy and completeness of medical records and the data of medical treatments • Easiness for doctors and health workers to access medical records and minimize the manual misreading data • Appropriate doctor’s prescription to avoid inappropriate medicine and bad impact of the patient carelessness. • Precision monitoring of medicine stock, to fix the medicine supply and avoid the corruption.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Smart Thumb Facility initiative is creative and innovative, because of: • The registration for repeated visit patients do not need identity card or medical card, and could be conducted independently through fingerscan / independent registration machine (Anjungan Loket Mandiri-ALM) • Fingerscan is used for patient identification and determine the queuing number Generally, fingerscan is used by the institutions or corporation for the staff presence, but Puskesmas Sumberasih succeed to develop and utilize this fingerscan technology for patient registration, and integrated by puskesmas information system (simpustronik) that covered all patient medical records. • Paperless services The integration of fingerscan and electronic information system enable all the services at Puskesmas Sumberasih became paperless. This paperless service consists of: 1) Paperless outpatient registration service 2) Paperless medical record 3) Paperless doctor’s prescription 4) Paperless medicine management • All patient medical record save in the electronic information system database and could be accessed by health workers fastly and easily, so the treatment could be effective and appropriately.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Puskesmas Sumberasih is the implementator of Smart Thumb Services or integrated fingerscan-electronic information system, supported by Probolinggo Local Government (especially Probolinggo District Health Office/DHO) and multi stakeholder forum, as the representative of religious leader, community leader, community organization and KINERJA USAID support. This initiative also provides a significant impact for all 46,294 patients visited at Puskesmas Sumberasih. The increased number of served patients at Puskesmas Sumberasih also increase significantly (15.3%), and the average visited patients at last 3 years (after this initiative) reaches 45,306 patients/year. Data 2016, showed the number of patients visited at Puskesmas Sumberasih is 46,294 patients, with the composition of :18,289 is the poor (39.5%), elderly patient of 1,709 (3.7%) and 723 pregnant women. Besides that, the number of patients from outside Puskesmas Sumberasih service area is relatively high, reaches 6,303 people/year or 13.6% from total patients at Puskesmas Sumberasih. This initiative has also be replicated at others 19 community health center/puskesmas in Probolinggo district, and this Smart Thumb Services has benefitted for 162,766 patients or 22.6% of total visited patients at all community health center in Probolinggo district.
 6. How was the strategy implemented and what resources were mobilized?
• Starting with the strong commitment of Puskesmas Sumberasih to provide an excellent service, Puskesmas Sumberasih opened itself to know any community complaints, and formed Public Service Improvement Team that includes complaint handling team. • Initial Meeting for Public Service Improvement Multi stakeholder meeting, incorporated in Healthy Probolinggo Forum, consisting community leaders in village, sub district and district level together with Puskesmas Sumberasih, facilitated by KINERJA-USAID Program, was a starting poin to change community perception. They agreed that service users have rights to involve in health service policy, oversight, and puskesmas needs community inputs to improve the services. Complaint survey as one of efforts to accommodate the community complaints on Puskesmas Sumberasih’s service. • Multi Stakeholder Forum (MSF) Establishment Then, Puskesmas Sumberasih established MSF on Novermber 2012, as the representatives of service users that has role & function to mobilize community to give inputs for puskesmas services, overseeing and monitoring the service improvements and conducting the advocacy to Local Government to support the items that couldn’t be conducted by Puskesmas. MSF also actively participate in community complaint survey, involve in analyzing complaint survey results, and the preparation of service charters as the response of community complaints. • Workshop: Complaint Handling and Questionaire Preparation The workshop discussed community complaint handling and preparing complaint survey questionnaire, attended by all MSF and community representatives at Puskesmas Sumberasih working area. Questionare was prepared in participatory manner, by accommodating all complaints that frequent experienced or often complained by Puskesmas Sumberasih patients. • Community Complaint Survey, Puskesmas Sumberasih in cooperation with MSF held the complaint survey by interview method on January 2013. Total of 140 respondents (pregnant women/ mother who has baby under 2 years, and other patients who got the puskesmas services) were randomly interviewed. Then, MSF tabulated the survey results into Community Complaint Index, and analysed the most frequent complaints as the priority of solution. One of the frequent complaint was: Long Queuing at Registration Counter. • Workshop: Analysis of Complaint Survey Results. Complaint survey results was analysed by Puskesmas Sumberasih together with MSF. Each cause of frequent complaints was analysed, to find solution alternatives • Preparation & Service Charter and Technical Recommendation Signing Complaints which could be solved internally was included into Service Charter, as the reference for service improvements, while some items that couldn’t be solved internally, were included in Technical Recommendation of Service Improvement and formally submitted to DHO. • Service improvement efforts to realize the Service Charter Refer to the commitment of the service charter, Puskesmas Sumberasih conducted improvements, preparing human resources, structure /infrastructure and trials the new initiative idea as agreed, including Smart Thumb Facilities. The improvement, development and trial conducted within 6 months. • Monitoring and Evaluation the Implementation of Service Charter and Technical Recommendation conducted by MSF It is aimed to control the service charter and technical recommendation realization. The results were reported to the head of Puskesmas, then MSF conducted advocacy for unrealized items. • Research through Working Culture Group (KBK) Puskesmas Sumberasih assigned KBK to held a research to prove the customer satisfaction changes. The result shows the significant changes, from 81.97 (before innitative) became 96.2 after initiative conducted. Resources to realize the initiative were: - Preparation step (workshops, complaint survey) was funded by Puskesmas supported by MSF and KINERJA-USAID technical assistance - Implementation step: Structure/infrastructure procurement (computer, fingerscan, software application, LAN cable): Rp. 60 million (Local Budget 2014). Human resources capacity building (trainings, technical assistance): Rp. 5 million under Puskesmas budget - Development step: Independent Registration Machine: Rp. 41 million (Local Budget 2016) - Maintenance /operational: Rp. 12 million/year under Puskesmas fund.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The stakeholders involved were: (1) Main actors of Smart Thumb Facility: • The Head of Puskesmas Sumberasih and working culture team (KBK) designed the initiative to integrate fingerscan and electronic puskesmas information system (simpustronik). The implementor of this initiative, at once conducts the monitoring, evaluation and systemic sustainable development to keep and improve the quality service. • Multi stakeholder forum (MSF) who actively sounding the community complaints and involve at the discussion of this initiative, disseminate the initiative and conduct the monitoring of puskesmas services. Ensuring that the service chaters have been implemented as the response of community complaints. (2) Working units: • Probolinggo District Health Office (DHO), supported the procurement of fingerscan, computers and provide technical guideline, budget and human resources neede for the implementation. DHO also raised the policy to replicate Smart Thumb Facility to all community health center (puskesmas) • Probolinggo District Organization and Governance Division office, who facilitated several cross sectoral and motivated puskesmas to conduct the innovation for public service quality improvements. • Sumberasih sub district leader discussion (Musyawarah Pimpinan Kecamatan-Muspika) together with religious and community leader, women activators and community organizations participating for disseminating this innitiative to the community. • Supporting Organization Kinerja-USAID and Probolinggo Child Protection Organization (Lembaga Perlindungan Anak (LPA), supported the technical assistance for public service improvement and the effort for decreasing mother and baby mortality rate.

 8. What were the most successful outputs and why was the initiative effective?
The real outputs achieved through this initiative are: 1) A set of integrated thumb scan/fingerscan with simpustronik has been provided and functioned, which able to guarantee the fairness, transparent and accountable health services for all society, especially for vulnerable people, who have difficulties to access the health facilities, caused by their limitation, e.g : the poor, illiterate, disability, women and elderly groups. The team who handle the thumb scan- simpustronik was legitimated by Probolinggo District Head Decree. 2) Better service and monitoring system: a) Service System The initiative creates a new system of registration services up to medicine management in paperless services by utilizing information technology of finger scan – simpustronik, a simplified procedure and ease patients to receive the best services, and to facilitate the officer in delivering the best services as well. b) Monitoring System There are 3 (three) new monitoring system established: • Computerized Monitoring, this initiative is able to monitor the queuing number, number of patients and number of medicine stock, is a new case at puskemas service. • Internal Monitoring, through the establishment of Manager on Duty (MOD) team, who conducted a daily direct monitoring to the service process to the patient. • External Monitoring, through multi stakeholder forum, endorsed by sub district head. 3) Provided Standard Operational Prosedur (SOP) to optimally the services at Puskesmas Sumberasih, e.g :  SOP for patient registration  SOP of general clinical services  SOP of Mother & Child Services  SOP of Farmacy /medicine Services  SOP of Medical Record Management  SOP of Medicine Management at Warehouse  SOP of Manager On Duty (MOD) The obedience officers in delivering the services based on SOP at Puskesmas Sumberasih guarantees that all patients without any discrimination will be served by the applicable standard, to provide an excellent service and the faster health recovery. 4) The availability of Public Service Improvement Team, that includes complaint handling services team, who is fully caring to the services at Puskesmas Sumberasih, especially for vulnerable people who requires extra services of their limitations, and always ready to reveive the community complaints as the inputs for better services. 5) Better partnership among Puskesmas, cross sectoral and community, formally tide by Head of Puskesmas Decree on Multi stakeholder forum (MSF) establishment, which also known as Badan Pertimbangan Kesehatan Kecamatan (BPKK), and the Memorandum of Understanding (MoU) between Puskesmas and BPKK as the representation of service users.

 9. What were the main obstacles encountered and how were they overcome?
• Technical obstacle: Thumb Service Facility is an initiative based on finger scan-simpustronik information technology. As usual, the utilization of new technology raised the technical obstacle both from software and hardware as well. The main factors are human resource (operator) skills, who still not mastery the application yet, and the software trouble caused by the virus or limited capacity. This problem just raised at the beginning of implementation, and when operators have better skills, this problem could be soluted. The overcome was conducting capacity building for puskesmas officer through some intensive trainings to all operators, and cooperation with third party for technical assistance support during the trial process. Puskesmas Sumberasih also recruited special IT operator, and provided a programmer and network training to officer who has a specific interest to information technology aspects. For the time being, all technical obstacle could be handled independently and quickly by Puskesmas. • Part of staff’s commitment is low at the beginning of implementation. This is natural, not every people ready for changes, the lack of understanding of its beneficiaries is the main factor of this low commitment. The manager of Puskesmas Sumberasih continually ensured the staff/officer that this initiative is not just the demand of users that should be fulfilled, but furthermore, this initiative benefitted the officers to deliver the service easily and very useful for any other tasks. Now, the officers be motivated. • Patients felt strange with this initiative At first, some patients were afraid to use the fingerscan, and some of them were confusing how to use Independent Registration Machine (Anjungan Loket Mandiri-ALM). The solution is: every day Puskesmas Sumberasih assigned one staff as Manager on Duty (MOD) to assist patients who have difficulties in technology (elderly, illiterate, disability) and guiding them personaly. Finally, they were familiar and very comfortable.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1. Service users or patients obtain more fast and easy services The changes of service speed could be enjoyed by the patient for registration services at the counters. Before this initiative, especially in the morning peak hours, registration process consumed 30 minutes even more, but nowadays, the registration process just need maximum 3 minutes for new patients, and maximum 5 second for patient repeat visit. The previous long time of registration services was caused by the officer should complete several administration proccess manually (5 steps) and time consumed, as follows: 1) Patient Identification, by checking the required identity cards (population /medical card/health insurance) 2) Preparing medical card, for new patients or the patient who loss his/her card 3) Recording/registration, based on the medical card, the officer recorded the patient’s name on register book. 4) Searching the medical record, for patient repeat visit. 5) Checking and providing queuing number, before the medical record document submitted to health officers, a confirmation should be held to ensure that the document was appropriate with patient identity. Then, the officer provided a queuing number. Through Smart Thumb Facility, the long process above was replaced by one step process, whereas the patient just put his/her tumb on finger scan-simpustronik, (as the patient identification), then all data (name, address, age, health data, medical record) directly appears on the monitor. Even, the queuing number could be known by the patient and officer at the same time, and the patient could directly go to desired service. 2. Service users obtain a fairly services This registration system has succeeded to increase the customer trust for fairly services. The computerized and automatic calling system, aviod the officers to prioritize such patients who have special relationship. The data entry process could not be provided if the patients not yet be called automatically through the computer. The officer could not be able to manipulate the patient queuing number. 3. Easiness access for vulnerable and the poor The service users, especially the elderly, illiterate, disability and mental disorder patients were fully benefited by this access, who were the most suffer and be ignored before this initiative, because their queue were snatched. The other suffered group was pregnant women, who need to check her pregnancy periodically. By this initiative, pregnant women will obtain ante natal care (ANC) easily and quickly, so high risk pregnancy will decrease through an early detection. Before this initiative, the poor and less educated who didn’t concern to legal documents (no identity cards or forget where they put in), caused unclear identity and potentially wrong in determining the medical records. 4. Easiness for puskesmas delivering the services, efficiently, easy, fast, accurate, free of phsicological burden affected by long queuing and commotion. The benchmark of success was measured through the complaint data, that no complaints about long queuing at registration counter at last 3 years. Customer satisfaction survey conducted by MSF, shows the increasing points, from 88.97 (before the initiative) became 96.2 in year 2015.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative has been able to increase the integrity and or accountability in delivering the services as follows: • Through the Smart Thumb facilities for registration process, the number of queue could be looked directly by the patients and impossible to be changed by the officer • No opportunities for patients giving bribes to the officer to obtain the earlier services. • Medical record data and treatments given to the re-visit patients directly appear on the doctor/health worker’s monitor, as of the sustainability of accountable, transparent, appropriate and accurate treatments. • Medicine stock data could be known exactly, so the medicine given to the patient will be available to the medical needs and current medicine stock • No opportunities for manipulation and corruption related to medicine stock, because all in-out medicine data has been recorded in database system (simpustronik) • Guarantee all Puskesmas reports is real data from fingerscan-simpustronik data, e.g : the conformity of the number of visits and retribution and or treatment revenue could not be manipulated, also the puskesmas performance data.

 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)
To ensure this initiative gave the benefit for the service access, everyday Puskesmas Sumberasih assigns a staff to conduct the duty as manager on duty (MOD), who are ready to guide and assist patient for registration process. Especially for women, the poor, vulnerable, special needs patients including the illiterate patients. By this initiative, a separate registration counter for special needs patients didn’t be required anymore, because the registration process just need maximum 3 minutes for the new patients and just few seconds for re-visit patients.

Contact Information

Institution Name:   Sumberasih Community Health Center
Institution Type:   Other  
Contact Person:   Arif Budiarto
Title:   Head of Quality Manajement  
Telephone/ Fax:   +62335427268
Institution's / Project's Website:  
Address:   Jalan Sukapura no.01 Sumberasih
Postal Code:   67251
City:   Probolinggo District
State/Province:   East Java

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