CHAPTER I

INTRODUCTION

Health Development Goals is the achievement of the ability to live a healthy life for every citizen
in order to achieve the optimal level of public health, as one element of the general welfare of
the National Objectives. For that we need increased efforts to expand and bring health care to
people with good quality and reasonable costs.

In addition to increasing education and socioeconomic circumstances, then the system of

values and orientations in masyarakatpun began to change. People are starting to tend to
demand better public services, more friendly and better quality, including health care. With the
increasing demands of society will the quality of hospital care the service function of the
University of Indonesia Teaching Hospitals need to be increased gradually to become more
effective and efficient and to provide satisfaction to patients, families and communities.

In order for efforts to improve the quality of service teaching hospital as the University of
Indonesia can be expected should be formulated to guide quality improvement efforts of
Education Service Hospital the University of Indonesia. This handbook is a concept and service
quality improvement program the University of Indonesia Educational Hospital, compiled as a
reference for managers of the University Teaching Hospitals Indonesia in implementing efforts
to improve the quality of hospital services. Described in this manual on the principles of quality
impr
ovement efforts, implementation steps and equipped with quality indicators.

CHAPTER II

HISTORY OF EFFORTS TO INCREASE QUALITY CARE HOSPITAL

Efforts to improve the quality of health care actually is not new. In the year (1820 -1910)
Florence Nightingale was a nurse from the British emphasis on aspects of nursing in improving
quality of care. One of the famous to the present teachings are "hospital should do the patient
no harm", the Hospital not to harm or injure the patient.

In the United States, efforts to improve the quality of medical services initiated by the surgeon
Dr. E.A.Codman of Boston in 1917. Dr.EA Codman and several other surgeons were
disappointed with the results of surgery are often poor, because of frequent complications. They
concluded that the complications that occur due to conditions that do not qualify at the Hospital.
For that there needs assessment and refinement of all things related to the surgery. This is the
first attempt to try to identify a clinical problem, and then find a way out.

Continuation of this effort in 1918 The American College of Surgeons (ACS) to construct a
Hospital Standardization Program. Standardization program was first organized effort with the
goal of improving the quality of service. This program was very successful in increasing the
quality of hospital care so much interested to participate. With the development of science and
technology outside of the surgical specialties of medical science evolving rapidly. Therefore, the
standardization program should be expanded to include other disciplines in general.

In 1951 the American College of Surgeons, American College of Physicians, American Hospital
Association work together to form a Joint Commission on Accreditation of Hospital (JCAH) a
joint body to assess and accredit hospitals.

At the end of 1960 JCAH is no longer simply specify minimum requirements and essential to
overcome the weaknesses that exist in the Hospital, but has spurred hospitals to provide quality
of service of the highest in accordance with existing resources. To meet the demands of the
new accreditation standards between the years 1953-1965 was revised six times, once held the
next couple of years of revision.
The success of the JCAH in improving the quality of service, the Federal Government legislated
to give the highest recognition in the "Medicare Act". These laws legalize Hospital accreditation
by the standards set by the JCAH. Since then the hospital is not accredited by the JCAH can
not join the federal government's health insurance program (Medicare), whereas in the U.S.
insurance Hospital utilization is crucial because only 9.3% cost of the Hospital from direct
payments by patients.
Since 1979 JCAH create an additional standard, that is to be able to pass the accreditation of a
hospital must also have a quality control program is executed properly.

In Australia, the Australian Council on Hospital Standards (ACHS) was established with difficulty
in 1971, but until the year 1981 a new agency is successfully operating in 3 states. But gradually
ACHS acceptable attendance and recognized its benefits in improving the quality of service, so
now ACHS activities have included all states. Implementation of quality improvement in
Australia is essentially about the same as in America.

In Western Europe's attention to the improvement of service quality is very high, but the
problem is still a new thing with that is still somewhat vague concept to most health professions
personnel. While the American approach difficult to apply because of differences in the health
system in each country in Europe. Therefore, the WHO Regional Office for Europe in the early
1980's took the initiative to help European countries to develop approaches to improve the
quality of service tailored to the health care system each.

In 1982 the regional office has published a book about efforts to improve the quality and
organization of the symposium in Utrecht, the Netherlands about the methodology of improving
the quality of service. In the month of May 1983 in Barcelona, Spain a working group
established by WHO has been meeting to study the quality improvement specific to Europe.

Although the regional WHO has made various efforts, but in quality improvement symposium in
May 1989 there is an impression that a national quality improvement efforts in various countries
of Western Europe is still in early development.

In Asia, the first country that already has a quality improvement program and a national hospital
accreditation is Taiwan. These countries apply the methodology of many Americans. As for
Malaysia to develop improved quality of service with the help of expert consultants from the
Netherlands,

In Indonesia, a very basic step that has been conducted and directed the Department of Health
in an effort to improve the quality of the classroom setting through a government hospital
No.033/Birhup/1972 Decree of the Minister of Health. In general, several criteria have been
established for each class of hospital A, B, C, D. These criteria are then developed into
standards. Then over the years developed a variety of good standards regarding service,
workforce, facilities and infrastructure for each class of hospital. Besides the standard, the
Department of Health also issued various guidelines in order to improve the appearance of
hospital services.

Since 1984 the Ministry of Health has developed a range of indicators to measure and evaluate
performance (performance) Hospital C-class government and private hospitals within the
framework of the equivalent of the National Health Day. These indicators every two years to be
revisited and refined. Performance evaluation for 1991 has been equipped with an indicator of
cleanliness and order and the Hospital to be evaluated but also class C class D and class B as
well as the equivalent of private hospitals. While the 1992 performance evaluation was also
equipped with instruments to measure the ability of the service. Hospital performance evaluation
is the first step of the concept of Continuous Quality Improvement (CQI). Unlike the traditional
concept of QA in monitoring and evaluation where dititik beratkan to the achievement of
standards, then the focus is more directed to the CQI organizational performance through the
assessment of the owners, management, clinical and support services. Fundamental difference
is the involvement of all employees. Cipto Mangunkusumo Hospital to use reasonable efforts to
drug use. Jakarta Islamic Hospital used an integrated quality control (TQC) and Quality Circles
(QCC Quality Control Circle =). Several other hospitals have also been trying to implement
Quality Circles, although no one has reported results.

In line with the above then the Ministry of Health has held a Training Hospital Service Quality
Improvement in a Hospital. Based on the above data it can be concluded that awareness to
enhance the quality was quite widespread, although in practice there is often a difference.

CHAPTER III

QUALITY IMPROVEMENT EFFORTS TO BASIC CONCEPTS HOSPITAL SERVICES

INDONESIA EDUCATION UNIVERSITY

In order for efforts to improve the quality of education at the University Hospital of Indonesia can
be carried out effectively and efficiently it is necessary to the unity of the language of the basic
concepts of service quality penigkatan efforts.
A. HOSPITAL SERVICE QUALITY EDUCATION university INDONESIA
1. Definition of quality
Understanding of diverse quality and below there is some sense that it simply describes
what the essence of quality.
a. Quality is the degree of perfection of a product or service.
b. Quality is the expertise, or expertise, and attachment (commitment) which has always
been focused on the job
c. Quality is an activity with no one to do the job.

2. Definition of Hospital Service Quality Education the University of Indonesia

Is the degree of service excellence the University Teaching Hospitals Indonesia to meet
the needs of the consumer society for medical care in accordance with professional
standards and service standards by using the potential resources available in the
University Teaching Hospitals Indonesia fairly, efficiently and effectively and be given
safely and satisfactorily accordance with the norms, ethics, law and taking into account
socio-cultural limitations and capabilities of the University Teaching Hospitals Indonesia
and the consumer society.

3. Stakeholders parties with Quality

Many interested parties with the quality, namely:

a. Consumer
b. Payer / company / insurance
c. Hospital Management of the University of Education Indonesia
d. Employees of the University Teaching Hospitals Indonesia
e. Community
f. Government
g. Professional ties
Any interest above different point of view and its importance to quality. Because it is
multi-dimensional quality.

4. Dimensions of Quality
Dimensions or aspects are:
a. Professionalism
 b. Efficiency
c. Patient Safety
d. Patient Satisfaction
e. Social and Cultural Aspects

5. Related Quality of Input, Process, Output and Outcome

Measurement of quality of health services can be measured using three variables:
1) Input, is all the resources necessary to perform health services, such as power,
money, drugs, facilities, equipment, materials, technology, organization, information,
and others. Quality health services requires the support of quality inputs as well.
Structural relationship with the quality of health services is in the planning and
mobilization of health service delivery.
2) Process, an activity in the work, is a professional interaction between the service
provider to the consumer (patient / community). This process is an important variable
quality assessment.
3) Output, is the number of services performed by the work unit / hospital.
4) Outcome, is the result of health care, a change in the consumer (patient /
community), including the satisfaction of the consumer.

 Hospital of the University of Indonesia Education is a complex health care institutions, labor-
and capital-intensive expert. This complexity arises because of service in the University
Teaching Hospitals Indonesia address a wide range of service functions, and includes various
levels and types of discipline. In order for the University of Indonesia Teaching Hospitals
capable of performing such a complex function, must have a professional human resources
both in the technical field of medical and health administration. To maintain and improve the
quality, the University Teaching Hospitals Indonesia must have a size that ensures quality
improvement at all levels.

Measurement of quality of health care teaching hospital with the University of Indonesia started
teaching hospital accreditation assessment of the University of Indonesia to measure and solve
problems at levels of inputs and processes. In this activity the University Teaching Hospitals
Indonesia have set the standard input, processes, outputs, and outcomes, and standardize all
standards established procedures. Hospital of the University of Indonesia Education be
encouraged to assess themselves (self assessment) and provide services in accordance with
the conditions set. As a continuation to measure the results of the background work necessary
to measure the other, the instrument of service quality teaching hospital of the University of
Indonesia to assess and solve problems on the results (outputs and outcomes). Without
measuring the performance of the University Teaching Hospitals Indonesia is not known
whether both inputs and processes that have produced good output as well. Indicators of the
Educational Hospital of the University of Indonesia are intended to measure the performance
quality of the University Teaching Hospitals in the real Indonesia.

B. QUALITY IMPROVEMENT EFFORTS TO HOSPITAL SERVICES INDONESIA

EDUCATION university.

Efforts to improve the quality of health care can mean the overall efforts and activities in a
comprehensive and integrated monitoring and assessing the quality of services the University
Teaching Hospitals Indonesia, solve existing problems and find a way out, so the quality of
services the University Teaching Hospitals Indonesia will be better.

Education at the University Hospital of Indonesia efforts to improve the quality of service is an
activity that aims to provide care or services as well as possible to the patient. Efforts to improve
the quality of service the University Teaching Hospitals Indonesia would be very meaningful and
effective if quality improvement efforts into day-to-day destination of each element in the
teaching hospital of University of Indonesia, leadership, managing direct services and support
staff.

Quality improvement efforts, including activities involving quality of care or services to use
resources appropriately and efficiently. Although it was realized that the quality does cost
money, but it does not mean better quality always cost more or less the cost of low quality.
Based on the above definition is drafted and the purpose of improving the quality of service the
University Teaching Hospitals Indonesia
1. Definition of Quality Improvement Efforts Hospital Service Education the University of
Indonesia:
Is the overall effort and a comprehensive and integrative activities involving input, process and
output in an objective, systematic and continuing to monitor and assess the quality and fairness
of service to patients, and solve the problems revealed that the service provided at the
University Teaching Hospitals Indonesia powerless effective and efficient.

2. The purpose of Quality Improvement Efforts Hospital Service Education the University of
Indonesia
General: Improving health care services through improving the quality of education the
University Hospital of Indonesia to effectively and efficiently in order to achieve optimal health.

Special: The achievement of improving the quality of teaching hospital services through the
University of Indonesia:

a. Optimization of personnel, facilities, and infrastructure.

b. Service delivery in accordance with professional standards and service standards are
implemented in a comprehensive and integrated according to the needs of patients.

c. Use of appropriate technology, research and development of health services.

3. Indicators of quality
Indicators of the quality of education the University Hospital of Indonesia include clinical
indicators, indicators and time-oriented indicators are based on effectiveness ratio
(effectivenes), efficiency (efficiency), safety (safety) and feasibility (appropriateness).

4. Strategy
To improve the quality of health care teaching hospital is the University of Indonesia drafted a
strategy as follows:

1) Each officer must understand and appreciate the basic concepts and principles of service
quality of the University Teaching Hospitals Indonesia so as to implement measures of
quality improvement efforts in each of its businesses.
2) Give priority to improving the competence of human resources at the University of Indonesia
Education Hospital, as well as efforts to improve the welfare of employees.
3) Create a culture of quality in. Hospital of the University of Indonesia Education includes
preparing teaching hospital quality program with the University of Indonesia PDCA cycle
approach.

5. Problem Solving Approach

Approach to problem solving is a process cycle (cycle) is continuous. The first step in the
process of this cycle is the identification of the problem. The identification problem is a very
important part of the whole process cycle (cycle), because it will determine the further activities
of this problem solving approach. Problems will arise if:

 The results achieved in comparison with the existing standard deviations are
 Not satisfied to be the deviation.
 Feeling responsible for the deviation.

Having explained how to solve the problem so corrective action can be done. But that problem
solving can be completed, after extensive remedial action needs to be assessed again if there
were any left. From the revaluation it will get problems solved and the problem still remains a
problem, so the cycle will repeat itself starting the first phase.

CHAPTER IV

BASIC PRINCIPLES OF IMPROVEMENT EFFORTS QUALITY OF SERVICE

The basic principles of service quality improvement efforts is the selection of aspects to be
improved by setting the indicators, criteria and standards used to measure the quality of
services the University Teaching Hospitals Indonesia

Indicators:
Is the size or how to measure that showed an indication. Indicator is a variable that is used to
see the changes. A good indicator is a sensitive but also specific.

Criteria:
Is the specification of indicators.

Standard:
 The level of performance or circumstances that can be received by a person authorized in
that situation, or by those who are responsible for maintaining the level of performance or
condition.
 A norm or approval of the state or a very good achievement.
 Something the size or benchmarks to measure the quantity, weight, value or quality.

In carrying out efforts to improve the quality of service then it should consider the following basic
principles:
1. Selected aspects to be improved
 Professionalism
 Efficiency
 Safety of patients
 Patient satisfaction
 Facilities and physical environment

2. The selected indicators

a. Preferred indicator for assessing output rather than input and process
b. General nature, ie better indicator for the situation rather than to individuals and groups.
c. Can be used to compare with other hospitals, both at home and abroad.

d. Can encourage intervention at an early stage on selected aspects to be monitored

e. Based on existing data.
3. he criteria used
The criteria used must be measured and quantified in order to assess the indicators, so it can
be a boundary that separates the good quality and the quality is not good.

4. Standard used
Set the standard used by:

a. References from various sources

b. Hospital Benchmarking with the equivalent
Based on the trend for the better

CHAPTER V

QUALITY CONTROL SERVICES

Control is the whole function or activity that must be done to ensure the achievement of
corporate objectives in terms of quality of products and services are produced. Service quality
control is essentially a work of quality control activities and processes to create customer
satisfaction (quality os customer's satisfaction) by any person from any part in the Hospital
Education University of Indonesia.

Sense of control over the quality of service refers to the control cycle (control cycle) with a
rotating cycle of "Plan-Do-Check-Action" (PDCA) = Relaxation (plan - execute - check-action).
PDCA pattern is known as "Shewart cycle", because it was first proposed by Walter Shewhart
some twenty years ago. But in its development, analytical methodology more often disebuit
PDCA "Deming cycle". This is because the Deming is the man who popularized its use and
broaden its application. By whatever name it is called, PDCA is a useful tool for continuous
improvement (continuous improvement) without stopping.

The concept of PDCA is a guide for any manager to process quality improvement (quality
improvement) are rerus constantly without stopping, but increased to better circumstances and
executed throughout the organization, as shown in Figure 1.
In figure 1, the identification of the problem to be solved and the search for causes of action
determination and correction, should always be based on facts. It is intended to avoid any
element of subjectivity and decision-making that is too fast and an emotional decision. In
addition, to facilitate identification of the problem to be solved and further improvement as the
benchmark company must establish standards of care.

Relationship with improvement of service quality control improvements based on the PDCA
cycle (Relationship Between Control and Improvement under the PDCA Cycle) is shown in
figure 2. Quality control based on the PDCA cycle can only function if the information system is
running well and the cycle can be described in six steps as shown in figure 3.

solving the problem

A P and increased
C D

Standar
A P
Pemecahan masalah
C D dan peningkatan
Standar

Figure 1. PDCA Cycle and Process Improvement

Plan Do Check
Action

Follow-up
 Action

Improvement

Gambar 2. Relationship Between Control and Improvement Under P-D-C-A Cycle

Berencana Melakukan Check

Tindakan

Menindaklanjuti
Perbaikan tindakan

perbaikan

Gambar 2. Hubungan Antara Kontrol dan Perbaikan Siklus PDCA bawah

 Plan
(1)
MenentukanTujuan dan sasaran
Action (6)
Mengambil tindakan
yang tepat
(2)
Menetapkan
Metode untuk Mencapai tujuan

Menyelenggarakan
(5)
Pendidikan dan
Memeriksa akibat latihan
pelaksanaan
Check
(4)
(3)
Melaksanakan
pekerjaan Do

Gambar 3. Siklus PDCA

Plan
ncana
(1)
Determine the goals and objectives
Action (6)
act
the right
(2)
set
Methods for Achieving the goal

(3) organize
(5) education and
exercise
examine the effect
implementation
Check
(4)
(3)
implement
work Do
 Figure 3. PDCA cycle

The sixth step PDCA contained in figure 3 above can be explained as follows:

a. Step 1. Determine the goals and objectives → Plan

Goals and objectives will be achieved based on the policy set. Goal setting is determined by the
Chief or Head Hospital Division. Setting targets based on supporting data and information
analysis.

Targets are set in concrete in the form of numbers, should also be disclosed to a specific
purpose and distributed to all employees. The lower level employees to be achieved by the
deployment of policies and goals, the more detailed information.

b. Step 2. Determine methods to achieve the goal → Plan

Setting goals and objectives with the right will not necessarily been achieved without the
appropriate method to achieve it. Specified must be a rational method, applicable to all
employees and no employees to use it complicate. Therefore, in determining the method to be
used should also be followed by standard-setting work is acceptable and understood by all
employees.

c. Step 3. Education and training → Do

Methods to achieve goals made in a standard form of employment. In order to be understood by

the relevant officers, conducted training programs for employees to understand and work
standards established program.

d. Step 4. Do carry out the work →

In the implementation of the work, always associated with the conditions encountered and labor
standards may not be able to follow the conditions are always subject to change. Therefore, the
skills and experience of the employees may be authorized to address the problems that arise
due to imperfections in the implementation of labor standards that have been set.

e. Step 5: Check the result of the implementation → Check

Manager or supervisor needs to check whether the work is carried out properly or not. If all
things were in accordance with the goals set and follow standards of work, does not mean
checks can be ignored. It is to be presented to employees on the basis of what the examination
was performed. In order to distinguish which of fraud and irregularities which are not, then the
basic policies, goals, methods (standard work) and education must be clearly understood by
both employees and managers. To find out irregularities, can be seen from the consequences
arising from the execution of work and after that it can be seen from the cause.

f. Step 6: Take appropriate action → Action

Examination through the impact aims to discover irregularities. If the irregularities have been
found, the cause of the deviation must be found to take appropriate measures to prevent
irregularities happen again. Rule out underlying factors that have resulted in a significant
deviation is a concept in quality control services.

The concept of PDCA with the sixth step is an effective system to improve the quality of care.
To achieve quality of service that will be needed to achieve the participation of all employees, all
parts and all processes. Participation of all employees in quality control services required
seriousness (sincerety), the attitude that denies the purpose of solely useful for yourself or reject
the way of thinking and doing is purely pragmatic. In the attitude determination which
necessitated not only the targets to be achieved, but also the way a person acts to achieve
those goals.

Participation of all parties in control of the quality of services covering all types of employee
groups together to feel responsible for the quality of service within the group. Participation of all
processes in service quality control is intended to control not only on output, but the results of
each process. The service process will produce a high quality service, may only be achieved if
there is quality control in every step of the process. Where in every step of the integration
process can be guaranteed, good cooperation between groups of employees by management,
as a collective responsibility to produce the quality of the work of the group, as the chain of a
process.