Questions/Answers

Death numbers as recorded in the official data in Tulungagung Regency, East Java Province in 2015 were high as follow: the number of heart attacks was 88 cases and 19% died, strokes were 645 cases and 24% died, the traffic accidents were 788 cases and 173 death, the maternal mortality rate was 131.79 per 100,000 live birth, far below the SDGs’ target. There were cases of denial or exclusion of poor people from medical treatments because unable to pay. A breakthrough is needed to overcome the problems. Therefore, dr. Iskak Tulungagung General Hospital aims to solve the problems by introducing a new concept of public hospital management named "Hospital Without Wall". “Without Wall” means that the hospital working area is not limited by space and time facilitated by the information technology. It has ability to serve patients in the whole region by utilizing collaborative resources. It has successfully connected a public hospital with the central and regional government, police, military officials, private hospitals, other public hospitals in neighboring regencies, civil society organizations, education institutes, and society in general. The innovation targets to improve health services for the community and to ensure public comfort and safety without discrimination and fast response time. The patients are worry-free under the principle of low cost and high quality. It ensures pre-hospital, inter-hospital, and intra-hospital treatments. The hospital has built the public service innovation gradually since 2015 by initiated some program namely Modern Emergency Installation, Public Service Center, Integrated Acute Coronary Syndromes Service Facility, and other program. Due to its success, the innovation has been replicated in 202 public hospitals across Indonesia. The latest recognition came from the 2019 International Hospital Federation of the 43rd World Hospital Congress in Oman that prized the hospital a Gold Award in Corporate Social Responsibility category.

“Hospital without Wall” is a management concept of dr. Iskak Tulungagung General Hospital in expanding the reach and responsibility of Hospital management to conduct monitoring and delivery of patient care assistance in the community without discrimination. Geographical, religious, racial, ethnic and social economic differences are not obstacles. The innovation provides the best health service to the community. The values emphasized are cost efficiency, high quality and social responsibility. The scope of the hospital is transformed not only within the reach of the hospital area, but also covers the entire regency area.

The concept innovation of Hospital without Wall in line with the Sustainable Development Goals (SDGs), as follows: Goal No 3: Good Health and Well Being, To secure healthy life and to increase health /welfare for all ages. Indicator 3.6.1: Death rate due to road traffic injuries, with PSC services, the number of deaths due to road accidents can be reduced because the community can directly use the service of one telephone number to get a quick response. Indicator 3.8.1: Coverage of essential health services, creating integrated health services that reach the strata of society, especially for heart health that is crucial, with the innovation of the Integrated Acute Coronary Syndromes Service providing rapid relief services for heart attacks directly to the people who need right away. Provide counseling and access to heart disease information. Objective 16: Peace, Justice and Strong Institutions, Creating an integrated and reliable hospital management system that is integrated with the surrounding community for sustainable community development. Indicator: 16.6.2: Proportion of population satisfied with their last experience of public services, by implementing Hospital without Wall the index of community satisfaction increases from 75.04 to 83.05 in the last 5 years.

The innovation sustainability has been guaranteed as supported by several factors: a. Socially: society demands toward the health services have ensured the continuation of the innovation. b. Economically: the innovation adopts a low cost strategy. Financial ability is generated from hospital operations c. Environmentally: the collaboration network has enabled the innovation to sustain and expand because it creates a cooperation among key partners and stakeholders. d. Regulation: the innovation has been endorsed by the government by enacting a number of regulations/acts. In case of financial difficulty occurs, the government have to bail out the hospital.

The innovation has addressed several failures in the public health provision in Indonesia. Firstly, it improves public health accessibilities by employing a borderless service, beyond the hospital wall. Thus, society can access the public health wherever they are. Secondly, it provides a equitable and quality services regardless the socio-economic situation of the patients. Therefore, everyone will enjoy the same treatment in the hospital without discrimination. Thirdly, the innovation has triggered a strong collaboration among medic and non-medic environment. dr. Iskak Tulungagung General Hospital is being the hub of synergy among parties and stakeholders. Therefore, by applying the innovation, the community satisfaction index has increased over the past 5 years from 2014 to 2018, from 75.04 to 83.05. The number of heart attack visits has increased where previously was low due to lack of public access to hospitals, especially for heart disease services. After the innovation, the number of visit has increased from 88 (2015) to 451 (2018) frequencies. It means that public awareness and access of heart disease treatment is increasing. The innovation features has reduced the maternal mortality rate from 131.73 (2016) to 34.12 per hundred thousand (2019).

There is no gender difference in accessing services from Hospital Without Wall. All are equally treated to get the best service. For example, if there is an incident a woman has a heart attack, then the closest person can call 119 / 0355-320119, the call center officer will guide you to the nearest health facility or send help. If a heart attack is suspected, it will be directed by the call center officer to the nearest health facility and or picked up by the pre-hospital care team, and heart scanning results will be sent to the call center.

This initiative aims at the people of Tulungagung Regency, based on the location of dr. Iskak Tulungagung General Hospital. Adopting the “Hospital without Wall” concept, virtually the hospital services reach all levels of society in all districts without regard to race, religion, gender, ethic groups, and economic capability. If there are cases of patients’ emergency such as heart attacks, strokes, or accidents on the road, anyone can utilize the Public Service Center facility. It provides one phone number and emergency button installed in android application as a center for security, safety, and comfort of the community. The service is integrated with Modern Emergency Installation services to ensures that the response from the hospital can run quickly. If indicated a heart attack happens, then there will be a special team who is dispatched directly to the location with a standardized protocol. The public is given education and knowledge about critical illnesses such as heart disease and stroke. The hospital also engages the Safe Community Movement as a civil service organization to encourage people to be healthy, safe and prosperous.

To support the creation of the concept of Hospital Without Wall, the initial step taken by hospital management is to improve management for integrated and accredited hospital management. In 2018 RSUD dr. Iskak Tulungagung accredited by Plenary Version SNARS version 1. Hospital management innovation starts from 2015 with the use of information technology to ensure openness and transparency in hospital management, including: Administrative management; Pre-Hospital services (Call Center, Emergency Button), electronic drug information systems, floating slips, online and independent registration, utilization of population data, handling complaints, strengthening human resources, maintenance of facilities and infrastructure systems. In the field of clinical management; innovation is carried out with procedures that prevent antimicrobial resistance and wise antibiotic administration. With these various innovations so as to achieve the goal of a low-cost, but high-quality hospital that carries social responsibility to the community. Until 2019, the hospital continues to innovate in the form of superior features that reach the community so that the role of social responsibility to the community can be reflected there.

The initial development phase begins with the creation of a Hospital Management Information System for the accountability process. Obstacles encountered include difficulties in calculating production costs to compile the tariff patterns of each service. To overcome them, a calculation system based on Activity Based Costing is applied, in addition to implementing a performance-based remuneration system and risk factors. At the implementation stage, the obstacles faced are the lack of interest and awareness of the community in accessing health facility services. The way to overcome them is to conduct public dissemination and counseling to the community.

The program is innovative because several factors. Firstly, before the innovation, this type of health service was unknown. After the innovation, the community is guaranteed access to effective and efficient health services. Secondly, collaboration and integration has been in place among stakeholders who are responsible for public health and public safety. It is an anti-thesis of coordination failure in Indonesia among institutions. Also, it makes the activities flow becomes easier and faster. Thirdly, it utilizes information technology to reach community access to health services virtually. The approach has proven the benefits of technology adoption in public services.

This innovation has been inspired from the public health services in advanced countries. They have standardized procedures in treating patients, response time, and the whole activities to cure patient’s illness. Therefore, dr. Iskak Tulungagung General Hospital is committed to benchmark the quality services and adapted in the Indonesian context. The establishment of medical emergency facilities, public safety center, and heart disease treatment center are exemplary from dr. Iskak Tulungagung General Hospital dedicated work. Local contents have been adopted by incorporation of values and local stakeholders in the hospital management. Ultimately, information technology is utilized to create the “Hospital without Wall”.

Hospital without Wall has been adopted in hospitals across Indonesia. It is rebranded as the Emergency Medical Service concept and has been established as a national and mandatory program by the Ministry of Health. It utilizes a national single call number 119 under the flag of Indonesian National Command Center. To date, it has been replicated by hospitals in 202 among 405 regencies in Indonesia (almost 50% replication rate).

This innovation is very likely to be replicated in other cities or countries. Its features will attract developing countries to adopt the new public hospital management concept.

The financial resources used: 1. IDR. 13 billion are used for the construction of a modern Emergency Installation; 2. IDR. 9 billion is used for the purchase of medical equipment and medical equipment, IDR. 3.5 billion to build pre-hospital public service center. 3. IDR. 900 million for making public service center software. Human resources play a role in this innovation, including: 1. Internal hospital which consists of doctors, nurses, and medics, etc. 2. External Hospital consists of doctors and nurses of public health center and ambulance drivers; 3. Relevant stakeholders

The initiative is sustainable in terms of financial and institutional: Financial: The hospital has sustained financially from business operation and bail-out supports from the government, if necessary. Under a special entity framework, the hospital can conduct businesses in more flexible way compared to other public institutions. Institutional: The regulations from central and regional government have supported the existence of the innovation i.e. Presidential Instruction concerning the Road Safety Decade Program, Minister of Health Regulation concerning the Integrated Emergency Management System, Regional Regulation of Tulungagung Regency on Public Services, and Regulation of Regent Tulungagung concerning the Integrated Emergency Management System.

Yes

Internal evaluation every semester is conducted by the internal control unit of dr. Iskak Tulungagung General Hospital. They measures the achievement of each unit’s performance within the hospital. External evaluation is carried out by an independent external agency from universities selected every year. They conducted surveys to measure customer satisfaction index. In addition to that, some organizations act as independent external agency namely the Working Group on Intensive and Acute Cardiovascular Care of the Indonesian Heart Association. They conducted survey on the implementation of Integrated Acute Coronary Syndrome services.

Internal Evaluation: Indicators: 1. The number of heart or stroke attack (visit and response time) 2. Maternal mortality rate 3. Infant mortality rate 4. Traffic accident patient visit rate 5. Emergency medical call rate Tools: observation, interview. External evaluation for customer satisfaction surveys: Indicators: 1. Completion time 2. Fees 3. Handling complaints 4. Facilities and infrastructures Tools: questionnaire, interview. Working Group on Intensive and Acute Cardiovascular Care Indonesian Heart Association: Indicators: 1. STEMI (ST-Elevation Myocardial Infarction) Patients load per year. 2. Primary PCI (Percutaneous Coronary Intervention) Amount 3. Reperfusion time improvisation Tools: medical report evaluation.

Main findings from the internal evaluation are as follow: 1. The number of death rates from maternal and infant has declined. It demonstrates the positive impact from “Hospital without Wall” implementation to reduce maternal and infant mortality rate. The hospital must maintain the level of service to consistently reducing the rate. 2. The number of traffic accident visit has increased. This number is not under control of the hospital. However, the data may say that traffic accident treatment is getting better. Therefore, the recommendation is to increase the pre-hospital care spending to handling more victims in the spots. Main findings from the external evaluation are as follow: 1. The customer satisfaction index has increased. Thus, the hospital must maintain the level of service to consistently. 2. The rate of visit on cardiac facilities has increased. This figure may reveal that heart disease diagnose and treatment is becoming more common in society. Poorer people can access the facility in affordable costs, therefore, the number of patients will increase from time to time. The recommendation to the hospital is to improve health education and healthy life style in the society. Thus, the hospital needs to expand the funding availability.

At first, it was not easy to implement the initiative, especially in a low trust society alike Indonesia. The innovator team must convinced a number of influential keypersons in various institutions. Politicians are among the indispensable parties to determine the fate of the innovation. Due to resources’ scarcity and budget limitation, the innovation team has faced huge challenges in the beginning of the implementation. “The Hospital without Wall” implementation has enabled collaboration work among vertical and horizontal level of government. Eventually, excellent performance from the innovation is gradually winning support from the main stakeholders. Vertical level of government has endorsed the innovation to be adopted nationwide. The horizontal level of government has supported the innovation either from medical or non-medical functions. The private hospitals are working closely with the innovation team because they reap benefits. Currently, the innovation is on the media spotlight because it won a prestige recognition from an international organization. This situation has eased the innovation to fit in with the institutional landscape both in regional or central government.

The concept of Hospital Without Wall is a proactive and integrated health service to serve patients without any discrimination and by increasing response time it highly depends on the collaboration from various parties. The partnership was established through the support from various parties including the central government, regional governments, private hospitals, non-governmental organizations, and society. The involvement of various parties includes aspects of the design, implementation and evaluation of this innovation. Technical team evaluations are conducted every 3 months and comprehensive evaluations every 6 months. dr. Iskak Tulungagung General Hospital works very closely with the Ministry of Health, the Police, the Regional Disaster Management Agency, the Fire Department, the Civil Service Police Unit, the Department of Transportation and Military Command, the Community Health Centers, Hospitals in several districts of neighboring Tulungagung, Private Hospitals, and non-governmental organizations. Furthermore, training on the provision of basic life support is also provided to all levels of society, ranging from elementary schools, junior and senior high schools, housewives, in addition to government office employees and all related agency personnel. In this collaboration, dr. Iskak Tulungagung General Hospital is the center for all activities including designing the programs, use of information technology, and financing.

The innovator team realizes that the successful implementation of an innovation lies not only in the quality of innovation but it is also in collaboration with various interrelated parties. The success of the sustainable innovations was carried out by the dr. Iskak Tulungagung General Hospital by the integration process of pre-hospital, intra-hospital and inter-hospital activities which had proved the strength of partnerships from the central government, regional governments, private hospitals, non-governmental organizations, and society. This excellent synergy causes the concept of Hospital Without Wall to be implemented which allows patients to enjoy the low-cost quality service delivery without any discrimination. In addition, the innovator team also found the optimal role of the dr. Iskak Tulungagung General Hospital was an enabler for the hospital environment and as the partner for all parties. Without making private sectors bankrupt, this innovation empowers all available potencies to improve the quality of hospitals that promotes patient safety. To make this innovation perfect, post-hospital services are currently being developed.