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Analysis on Implementation of Clinical

Performance Standard Tool in Delivery Room

Panyabungan District General Hospital of
Mandailing Natal District North Sumatera Province
1 2 3
Liza Mouliza , Khairuman Yahya , Fatni Sulani
Public Health Faculty,3EMAS Program North Sumatera, 1,2Sumatera Utara University.
Medan North Sumatera, Indonesia
Correspondence should be addressed and

Abstract─ Maternal deaths in the world including in Indonesia is

still quite high, in Indonesia, many death cases occur in emergency I. INTRODUCTION
conditions during labor or postpartum both in the time of pre-
referral or in the hospital. The Health Ministry of Indonesia has Maternal mortality in the world is still quite high,
already issued Guidelines of Emergency Obstetric and Neonatal
Comprehensive Services (PONEK) 24 hours in the hospital to
according to a study released by The Lancet on 8
standardize the service on maternal emergency and the newborn. October 2016, the number of maternal deaths on
However, some PONEK hospitals still have not implemented this worldwide in 1990 amounted to 390,185, in 2015
standard well because there is no standard system of monitoring maternal death is 275,288 (down to 29%). In
and evaluation for the implementation. Since 2015 Panyabungan Indonesia, in 1990 the number of maternal deaths is
District Hospital is already implementing a self-assessment system 18,715 and then in 2015 maternal death is 8,937
using Clinical Performance Monitoring Tool (APKK/Alat Pantau
(down to 52%). However, maternal mortality rate in
Kinerja Klinis) to assess the PONEK standards in the delivery
room. APKK is a tool that initiated by a cooperation program by Indonesia is still quite high compared to the MDGs
the Ministry of Health of Indonesia through EMAS (Expanding target by 2015 (102/100,000 live births) and the
Maternal and Neonatal Survival) Program funded by USAID. SDGs target on 2030 (70/100,000 live births).
The purpose of this research is to analyze the effectiveness of Maternal deaths often occur in prereferral, referral
implementation of APKK to improve the quality of maternal and in health facilities. The Ministry of Health has
emergency services and the newborn in the delivery room. This
issued numbers of policies to reduce maternal
research was conducted with qualitative approaches through the
in-depth interview and observational design. Informants in this
deaths, like Integration of Obstetrics and Neonatal
study were 10 midwives on duty in the delivery room with Basic Emergency Services (PONED) in first level
triangulation informants were the Head of units: Delivery, health facilities and Obstetrics and Neonatal
Emergency, Perinatology, Operating Room, Deputy Director of Emergency Comprehensive Services (PONEK) in
Health Services and the Director of RSUD Panyabungan. The referral health facilities for 24 hours and 7 days a
result of this research; there is no legal policy of APKK team;
week.[2] At referral hospitals, to carry out the policy
there is a special team responsible for conducting the self-
assessment routinely per three months in delivery room; the self-
the government has issued the PONEK guideline,
assessment results become the basis for decision making by the trained the health workers and prepared the
hospital management to complete needs of medicines, medical infrastructure and medicines for obstetric and
equipment and supporting facilities needed to improve the service neonatal care.
in the delivery room. The APKK helps the hospital to identify the In the implementation some hospitals that have
needs of supporting facilities, human resource, and other needs to been designated as PONEK hospitals still have not
improve service quality of PONEK hospital. Policy from the
hospital management to support the sustainability of the APKK
implemented all the PONEK indicators, this is
implementation in RSUD Panyabungan is still required. happening because there is no monitoring and
evaluation system for PONEK hospitals. In 2012 the
Keywords─Self-Assessment, Clinical Performance Monitoring Ministry of Health launched the Expanding Maternal
Tools, Monitoring & Evaluation
and Neonatal Survival (EMAS) Program which is
funded by USAID and implemented in 6 provinces This cycle begins with data collection and analysis.
that contributed the largest number on maternal and The purpose of the data collection and analysis is to
neonatal deaths in Indonesia i.e.: North Sumatra, identify gaps between existing conditions with the
Banten, West Java, Central Java, East Java and desirable conditions/standards in maternal and
South Sulawesi. The approach taken in this program neonatal emergency services. The activities carried
are: 1) Improvement in Clinical Emergency Services out together with the team and the actors in the
in health facilities; 2) Increase the Efficiency and the health facility which consists of head/deputy head of
Effectiveness of the Referral System and 3) the related units, the head of related departments,
Accountability Strengthening to improve policies including the committees, the assessment baseline
and resources. EMAS Program develop one form conducted with participatory assessment
standard evaluation tool for clinical emergency system, so that officers at all levels involved from
services in health facilities called Clinical the beginning within efforts that related to quality
Performance Monitoring Tool (Alat Pantau Kinerja improvement on framework for implementation of
Klinis/APKK) to evaluate quality improvement of good clinical governance.[1]
services in order to standardize and develop the The APKK is a tool to build managerial capacity,
professionalism of health workers in hospitals to the performance capabilities of health personnel,
accelerate the reduction of maternal mortality rate standard medicines, medical equipment, facilities
(MMR) and infant mortality rate (IMR). and infrastructure needed to provide obstetric and
Quality improvement process aims to change newborn emergency care in a hospital. There are 4
"actual practices" to "best practices" through the APKK clinical indicators for a hospital: maternal
quality improvement cycle called Plan-Do-Check- indicators, neonatal indicators, governance
Action (PDCA). There are some important keys that indicators and infection prevention indicators that
can make this quality improvement process ongoing, are used to push the entire structural and functional
i.e.: components to improve maternal and neonatal
 The involvement and ownership of all officers / emergency services.
staff. The method of APKK implementation is
 Patients Oriented independently by the person who responsible in the
 Focusing on systems and processes delivery room and within discussion every three
 Be aware of costs and efficiency. months to evaluate the progress and make plans to
 Continuous learning, development and capacity achieve performance indicators consist in APKK.
building The application of the tool is to identify performance
 Sustainability of the quality improvement gaps that should be minimized or eliminated.
Managers and officers can analyze the causes of the
Meet those keys, the process of quality improvement gaps and implement appropriate interventions to
can be run following the cycle as shown in Figure 1. improve it - for example; The emergency trolleys are
not ready, emergency medicines and equipment are
not always available, maternal and neonatal death
Make a follow-up
Assesment and
plan (Plan)
and or near miss cases study are not done, lack of
Analysis (Action)
knowledge and skill of the midwives and others.
Managers are encouraged to make action priority
and start with a simple intervention in order to
achieve an early tangible result so as to create a
momentum for change and acquire update skill and
Monitoring and
Evaluation (Check)
Implementation of knowledge on the management of maternal and
the follow-up plan
(Do) neonatal emergency cases.
Panyabungan District Hospital of Mandailing
Figure 1. Quality Improvement Cycle Natal is one of the model hospitals to be among five
other hospitals in North Sumatra province that were
intervened by EMAS Program. The APKK used as a II. RESEARCH METHODOLOGY
tool in concept to help facility to improve and at the
same time can be used as an evaluation tool for1. 1. Research Subject
PONEK hospital standard. The subjects of this study were taken purposively
Based on results of baseline data at the time the to get information in line with the purpose of
program intervention started in Panyabungan research. Based on predetermined criteria that are
hospital in September 2015, obtained the result: served in Panyabungan hospital with working period
maternal indicators 28%, neonatal indicators 20%, > 1 year, was not on leave or are continuing their
governance, and infection prevention indicators education.
were 0%.
From the results of the assessment using APKK 2. Research Method
found: Primary data were collected by in-depth
1. Maternal and neonatal indicators: no emergency interview with 10 midwives in the delivery room as
team, medicines, equipment, standard key informants and interview with triangulation
procedures (SOP), knowledge and skill on informants, i.e. the Head of the delivery room, head
maternal and neonatal emergency management. of Perinatology room, head of the emergency room,
2. Governance indicators: the dashboard and and head of Operating room, Deputy Director of
death/near miss cases review have not been Health Services and Director Panyabungan Hospital.
implemented; no Standard Chartered services Furthermore, the observation and analysis of the
and patient satisfaction mechanism yet. Performance achievement standards in line with
3. Infection Prevention/IP indicators: no standard APKK.
infection prevention equipment, standard
procedures (SOP), no team and guidelines of 3. Data Analysis
PPIRS (Hospital Infection Prevention and Data was processed in line with the
Control) yet. characteristics of content analysis: data processing
and data reduction by making the coding and
Based on the pre-survey results conducted in early categories, data presenting and make a conclusion.
January 2016 together with Management Team and
Head of Delivery Room Unit Panyabungan III. STUDY RESULT
Hospital, found that APKK is very helpful in
identifying the needs of completeness emergency Implementation of APKK in the delivery room was
service standards in the delivery room to improve the not run optimally. There is already a team responsible
quality of maternal and neonatal services. for the implementation of APKK but there is no
Therefore, researchers wanted to see more about the legality / decree (Surat Keputusan/SK) of APKK
effectiveness of APKK as a tool to evaluate PONEK team. APKK assist management in identifying the
policy implementation in the delivery room of resource needs of a hospital to run the service i.e.
Panyabungan Hospital. medicines, medical equipment, human resources and
For a policy can be implemented effectively, it must infrastructure necessary to improve the quality of care
meet the "four right", i.e.: 1). Policies Right; 2) in PONEK hospitals.
Implementing Right; 3).Target Right; and 4)
Environment Right.[3] 1. Team Legality
In the delivery room, there is a team of three
midwives who perform independent assessments
using APKK, 5 out of 10 key informants stated that
there is no legality/decree (SK) issued by the
hospital management related to the implementation
team. Another 3 informants stated they did not
know about legality / SK for APKK team . 2 then report it to the management to improve the
informants did not even know about APKK team. quality of maternal and neonatal services. So to
This is related to the statements from informants in ensure the implementation of APKK, legality in the
Box 1. form of SK Team is necessary.

Box 1. 2. Implementation of APKK

"APKK team? What is it kak? ... "(I6) In APKK there are four indicators considered:
maternal indicators, neonatal indicators,
"... Who made a checklist right? yes there are governance indicators and infection prevention
midwives who do the checklist, about the SK I do not indicators. A thorough assessment of the four
know for sure... "(I10) indicators is carried out routinely every 3 months to
identify the needs of medicines, emergency
"... yes ... there is a team of three midwives, but we equipment, and infrastructure needs for maternal
do not have the SK, we just do the check list then we and neonatal emergency services. The assessment
report ..." (I2) carried out independently by the APKK team in the
delivery room. The assessment results reported to
"... There is still no SK ...we wanted to make one ... the hospital management to meet the needs of
but somehow it still on process..." (IT1) medicine, equipment, facilities and infrastructure
that is needed for the services.
"the SK is yet to be made but there are midwives All key informants stated the assessment result
appointed for the APKK implementation" (IT5) by APKK is helpful in identifying the needs of the
delivery room as seen on the statement in Box 3.
The depth interview can conclude that the team for
implementation of APKK is already designed in the Box 3
delivery room, but not their legality /no official "...After we do the checklist, it will appear
decree issued by the hospital management. medicines what is lacking, what tools we have not
The absence of an official decree on the APKK team had, how many of our human resources are lacking,
cause less responsibility of the team member for the which SOP we do not have yet ..." (IT1)
implementation of APKK. To complete a
responsibility, a Decree (SK) need to be issued by "... We do the checklist in ER because for early
the hospital management which contains the official admission the patient management performed in the
designation to certain people as the implementation ER ... and then the patients were taken to the
team including their duties and responsibilities. This delivery room" (IT3)
is reflected in the statements in Box 2.
APKK usage not only perceived benefits in the
Box 2. delivery room. This is also done in 3 other rooms,
"... Usually, they made it every three months, Perinatology room, emergency room/ER and
sometimes they made it some time they did not..." obstetric operating room because of these three
(I3) rooms are closely related to the handling of cases of
maternal and neonatal emergencies. This is
"actually it should be made every three months... consistent with the statements of three triangulation
sometimes if you have not been asked by the head of informants ie head of perinatology unit, Emergency
the unit we just forget ..." (I1) unit, and obstetric operating room.

APKK need to be used routinely to assess the quality 3. APKK Activities

of service in the delivery room. APKK need to serve Maternal indicators assessment identified needs
as a policy which makes the midwives in the fulfillment in terms of:
delivery room identify the needs in the room and
a. Emergency response hospital management for the fulfillment of their
Related needs of equipment, drugs, human needs.
resources, SOPs, job aids / algorithms. According to three key informants and one
b. The third stage active management (MAK3) of triangulation informant the reporting results will be
labor, postpartum hemorrhage, severe pre- followed up by hospital management, but in the
eclampsia/eclampsia, sepsis and obstructed process, it is not as smooth as expected, sometimes
labor. the fulfillment was easily obtained, but sometimes
c. Increase midwives competency in the delivery they also have to wait for budget adjustments. This
room through training / emergency cases drill is in line with the statement of the triangulation
and clinical skills assessment of midwives for informant 5 and 6 which stated that the procurement
the maternal emergency cases management. of medical equipment and medicines should follow
the rules as stated in Box 4.
Neonatal indicators assessment obtained:
a. Emergency response on neonatal emergency Box 4.
cases including equipment needs, medications, "... The medicines are sometimes available but
SOPs, human resource, job aids / algorithm. sometimes runs out ... it takes time and we need to
b. Sepsis case management, complications of wait for the medicines procurement... sometimes we
premature, early breastfeeding initiation, need to ask the patients to buy the meds first" (I5)
exclusive breastfeeding, and kangaroo care
method. "It is hard to ask for tools, our incubator had broken
c. Increase midwives competency through training for a long time but not replaced instead ..." (I2)
/emergency cases drill and clinical skills
assessment of midwives on neonatal emergency "For the tools/medical equipment, we need to follow
cases management. the e-catalog procedure ... we have to wait the new
budget period to buy new tools" (IT6)
The governance indicators assessment obtained:
a. Monitoring of clinical performance by making 4. Communication
the delivery room dashboard to monitor and Two out of 16 informants stated that
evaluate trends of activity and quality of the communication is not well established, they said that
service. APKK that have been prepared are not well
b. Study on maternal and neonatal death and or socialized to all midwives. One informant stated
near miss cases for learning in order to improve good communication already established with other
the quality of services. midwives. As shown in Box 5.
c. Assessment of patient satisfaction through the
provision of media for delivering advice and Box 5.
complaints. "... The APKK was not well described so I think
the communication was not so good ..." (I5)
Infection prevention/IP indicators appraised:
a. Guidelines, hospital infection prevention team, "It does not seem well ... for example no
completeness SOPs of Infection Prevention. dissemination of the contents of APKK, what is
b. Direct assessment and observation on IP our responsibility, we work according to a routine
practices in the delivery room. shift, we read the information on the board and
c. Preparation and implementation of ward notebook, and we discuss the cases. If there
decontamination and sterilization. is a problem in our room we consult to our
d. Medical waste management. supervisor ... "(I3)
"..We used to fill the APKK matrix with a checklist
Once the assessment is done using the APKK the and analyze it on a computer, some other indicator
team will discuss the findings before reported to the results were explained to the staff." (I2)
Three informants stated communication with the head Box 8
of the unit is good. It can be seen from the actions "We do not know about the funds and the problem
taken such as providing warning and conduct joint connected to the funds"(I8)
discussions if there are problems in implementing the
tasks, as contained in Box 6. But there are two informants declared that the
source of the funds was from EMAS Program, but
Box 6 they do not know the amount of the funds
"The head of the maternity ward is quite good, if there provided. As mentioned in Box 9.
is a mistake we will be warned, but there are some
midwives who work carelessly, patient information, Box 9
midwifery notes is not filled properly. If there is no "We did not receive any funds, all the activities are
settlement we consult it to the hospital director "(I4) still supported by EMAS, and it all manage by the
It is not in line with two triangulation informants hospital management."(I2)
stated that socialization of APKK has not given in This is in line with the statement of three
detail because of the head of the unit was too busy. triangulation informants that the funding comes from
As shown in Box 7. EMAS. As shown in Box 10.
Box 7
Box 10
"It has been socialized e.g. about emergency "Sources of funding for the APKK training, the visit to
team in the delivery room as I have already a model facility in Deli Serdang district and the
explained....I have explained about APKK but not to mentoring activities are supported by EMAS."(IT6)
all of them, I do not have much time...I also have
many other things to do ..."(IT1) Resources within the Program implementation of
APKK is a major factor in the success of the program.
Program socialization needs more improvement Therefore we need a reliable resource. Not only
and needs more effort to achieve strong limited to human resources, but also other resources
internalization values from the staff. Because of such as financial and material. Insufficient funds are
vague understanding of the policy makes the one factor that contributes to the implementation of
implementation not working well as expected. APKK. Instead, an immediate or timely incentive is
Existing forums such as monthly meeting should be going to be one of the motivating factors for the
used optimally to confirm the purposes and benefits employees to work well and continuously.
of implementation of APKK to the midwives in the
delivery room. b. Human Resources
Head of the delivery room has been trying to There is one informant who claimed that there
communicate all problems that occur in the service was a training on APKK implementation program
and try to find the resolve together. Communication once in 2015, the personnel in charge of APKK
is the source of program information, carried out by implementation already pointed but there is still no
all midwives and other staff in the delivery room. So legal decree. As disclosed in box 11.
the communication problem can be overcome and the
policy can implement easily, smoothly and precisely. Box 11
"To support APKK implementation there was a
5. Resources training once. APKK benefits are in terms of
recording and reporting when we proceed it if there is
a. Fund/Budget
a case we have notable evidence. APKK is good for us
Five informants did not know the source and the
to improve the midwives performance, but not very
amount of the funds/budget in each program e.g.
actively used because of less routine training on how
APKK. As disclosed in Box 8. to use it, but yes we do not have the decree from the
hospital director... "(I1)
This is in line with the statement of two triangulation Without it, the tasks cannot be performed and
informants, the training for the midwives obtained the goals cannot be completed as intended. The
during the visit and mentoring by EMAS Program availability of infrastructure is an important
mentors. As shown in box 12. determinant of performance policy. The
implementor must receive the resources needed
Box 12 to keep the program running smoothly.
"The human resource is still lacking, especially for Although the policy has clear objectives and
running APKK program, so far only a few people are targets, in the absence of adequate resources,
given the responsibility to fill the APKK in the delivery the policy only stay at the paper documents.
room."(IT6) Actually, infrastructure (equipment / facilities)
of a program are the type, quantity, adequacy,
Generally, all midwives in the delivery room know appropriateness and feasibility of the physical
about APKK when they were visited and assisted by facilities owned by a hospital. [6,7]
the EMAS Program mentors. The midwives in the
delivery room feel overload in the workforce, they APKK is one effective method to evaluate PONEK
have difficulties in carrying out the tasks due to the standards in hospitals. With the simple filling
midwives are in charge for several programs at once method and can be referenced in discussions
including patient services, administrative tasks such ranging from the executive level in the delivery
as preparing reports, and many other routine tasks room to management level, to see the achievement
di delivery room. and the target indicators of the standard expected.
Based on the results of APKK that have been
c. Medicines, Medical equipment,
implemented in Panyabungan hospital since
September 2015 until September 2016, visible
Out of seven, four key informants stated
achievement of clinical standards of ongoing
medicines, medical equipment and infrastructures
improvement, as seen in Figure 2-5. This proves
provided to the fulfillment of the indicators in APKK
effectivity of APKK used in quality improvement
as disclosed in box 13.
cycle of service with the concept of Plan-Do-check-
Box 13 Action.
"In terms of medicines, medical equipment, and
infrastructure I think we are getting better now,
emergency medicine was more complete, we use the
standard in clinical monitoring tool ..." (I4)

"Protective equipment are still less, sometimes we do

not wear gloves, some were torn so it is not good
anymore...we want to wear it but we do not have the
good gloves..." (I6)

It is not compatible with the information

expressed by three triangulation informants that
infrastructure is already available as evaluation Figure 2. Trend of Clinical Indicator Performance Standard Achievements on
results of the APKK assessment. Indicators of RSUD Panyabungan (Sept 2015 until Sept 2016)
medicines compliance, medical equipment,
facilities and infrastructure already following
standard indicators for PONEK hospital.
Achieving PONEK goals policy should be
supported by the availability of medicines,
medical equipment, and infrastructure needed.

Implementation of Clinical Performance

Monitoring Tool (APKK) in the Delivery Room of
Panyabungan hospitals Mandailing Natal effectively
assist in the evaluation of the PONEK hospital, even
though its implementation in delivery room of
Panyabungan hospital is not running optimally
because not all health workers/midwives in delivery
room involved, there is no legality / SK for APKK
team. The implementation of APKK in
Figure 3. Trend of Clinical Hospital Performance Standard Achievements on Panyabungan hospital as evidenced by the following
RSUD Panyabungan (Sept 2015 - Sept 2016) results:

1. There is no legality for APKK team yet, it makes

the member of team or person in charge has not
met responsibility for routine assessment.
2. Implementation of self-assessment within APKK
perceived advantage for team member and
hospital management in terms of identifying the
needs of human resources, medicines, medical
equipment, facilities, and infrastructure needs to
improve the quality of care in the delivery room.
3. Activities undertaken to improve the quality of
hospital services in line with the indicators of
APKK, such as: meet the needs of equipment and
Figure 4. Trend of Fulfillment on Maternal Emergency Trolley medicine, additional health personnel, training of
handling emergency cases of maternal and
neonatal, clinical skills assessment for each
officer to improve the competency in delivery
room, update skill and knowledge by obstetrician
and pediatrician, death and or near miss cases
review to learning for health professionals and
hospital management.
4. Communication in APKK implementation is still
not running well because there is still the lack of
socialization of APKK to all health workers in the
delivery room, APKK task load is only delegated
to only limited people in charge in the delivery
5. APKK resources which consist of the fund,
Figure 5. Trend of Maternal Death and Near miss Cases Review
human resource, medicine, medical equipment
and infrastructure in the hospital. Since the
implementation of APKK from September 2015
until September 2016, the fund is fully
supported by the EMAS Program unless the
fulfillment of human resources and the need for
medicines, medical equipment, facilities and
infrastructure already provide by hospital
resources (district budget)
6. From the results of the initial assessment
(baseline) to the last assessment in September
2016, the trend of clinical performance standard
are increased quite significant. This proves that
the assessment method routinely and
continuously through APKK will give an idea
how far the achievement and positive impact on
the standard of service improvement in the
delivery room in particularly and hospitals in


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