evaluation of hospital accreditation in indonesia by the hospital ...

EVALUATION OF HOSPITAL ACCREDITATION IN INDONESIA BY THE
HOSPITAL ACCREDITATION COMMISSION (KARS) : PERCEPTION OF
HOSPITALS AND ISQUA STANDARD
SUMMARY
By :
Intan Irfianti
09/293449/PKU/10960
GRADUATE PROGRAM
MASTER OF HOSPITAL MANAGEMENT
MEDICAL FACULTY OF GADJAH MADA UNIVERSITY
YOGYAKARTA
2011

EVALUATION OF HOSPITAL ACCREDITATION IN INDONESIA BY
HOSPITAL ACCREDITATION COMMISSION (KARS): PERCEPTION RS
Evaluation Accreditation HOSPITAL OF THE HOSPITAL IN INDONESIA BY
COMMISSION Accreditation (KARS): PERCEPTION OF Hospitals
ABSTRACT
Intan Irfianti 1, Adi Utarini 2, Hanevi Djasri 3
Background: One of the external assessment of the quality of hospital healthcare were
conducted through KARS accreditation. Accreditation program in Indonesia was started in
1996 and were conducted by KARS (Hospital Accreditation Commission) that were
established by the Ministry of Health. Although the benefits of accreditation were felt by
several parties, by 2011 only 720 (42,4 %) out of 1699 hospitals in Indonesia have
participated in accreditation, whether it’s the 5, 12 or 16 services. The effectivity of
accreditation can be assessed through the perspective of hospitals by assessing experiences
or the perception of individuals/staffs of hospitals after they participated and managed to
picture the benefits of accreditation program. Other assessment can be measured through
objective indicators that showed the statistical comparation of the difference of
performance/indicators before and after they implemented the accreditation standards.
Objective: (1) to evalluate the effectivity of hospital accreditation by KARS in Indonesia (2)
Assessing the impact of hospital accreditation towards the quality of hospital healthcare in
Indonesia
Method: this is a descriptive research. The subject of the research were KARS’ accreditated
hospitals in Indonesia. Data collection regarding the impact of accreditation towards hospitals’
quality were conducted through mailed questionnaire that were developed from previous
researches. The questionnaire were delivered to 181 hospitals that were selected as
samples. The questionnaire also contained open questions to gather information regarding
how the accreditation affected the hospitals’ quality and suggestions for improvement of
KARS’ accreditation system.
Result : Generally, respondents agreed that accreditation managed to provide impact to the
improvement of hospital’s quality. 95.8% hospitals agreed that accreditation has encourage
the participation of hospital staffs and 83.9% hospitals agreed that accreditation has impacted
the effort to improve the quality of hospitals. However, only 61.5% hospitals thought that
accreditation could affect the clinical performance of hospitals. As many as 67.9% of the
hospitals managed to identify various forms of accreditation’s effect to the hospitals’ quality.
Answers to open questions provided information on suggestions of improvements to the
accreditation systems, such as stewardship, assessment and follow ups, accreditation
standards and the consistency of accreditation surveyors.
Conclusion: According to the hospitals’ perception, the KARS accreditation system were
effective in encouraging staff’s engagement, adequately efffective in ecouraging the effort to
improve the quality of hospitals but were less effective towards clinical performance of
hospitals. However, there were other less effective aspects such as in the post-accreditation
evaluation, the employed standards and accreditation’s surveyors.
Keywords: healthcare quality, KARS accreditation, hospital, impact of accreditation
1. Hospital Management Graduate Program, Faculty of Medicine, Gadjah Mada University, Yogyakarta
2. Department of Public Health, Faculty of Medicine, Gadjah Mada University, Yogyakarta
3. Centre for Health Service Management, Gadjah Mada University, Yogyakarta

Introduction
In Indonesia, to get external assessment of hospital quality service can
be done through an accreditation body called KARS. Accreditation program in
Indonesia began in 1996, and performed by KARS (Hospital Accreditation
Committee) set up by MOH 1. Despite the benefits of accreditation, in 2011
only 720 hospitals (42.4%) out of the 1699 hospitals in Indonesia, have been
accredited for 5, 12 or 16 services. 2
Accreditation system in Indonesia today, has several drawbacks. First,
the nature of the accreditation program conducted by the government creates
a conflict between the government's role as a regulator or as an assessor in
the accreditation. Second, the standard used is still focused on input
indicators. Thus, in its application is more likely for the occurrence of error and
manipulation, and limit the impact on the quality of the service itself. The third,
the standard that is published by the Ministry of Health, which is used for
accreditation standards and clinical indicators, were not developed in a
synchronized and integrated manner. The application of different standards
separately, with monitoring and evaluation systems are different, does not
motivate healthcare organizations to implement these standards. 3
The effectiveness of accreditation can be assessed through the
perspective of hospitals, namely by assessing the perception of hospital staffs
after experiencing accreditation programs. These perceptions then should be
compared statistically with objective performance indicators, before and after
applying accreditation standards. 4
Recommendations to improve the effectiveness of accreditation
programs, among others: (1) accreditation program must have a good
standard of accreditation, (2) national accrediting agencies should be
autonomous, have skilled human and financial resources that are sufficient to
operate effectively and well established; ( 3) Accreditation should pay
attention to an ongoing series of treatment processes (Continuum of Care)
and pay attention to the limitations in the provision of care and service to
patients, and (4) accreditation should be based on the needs of patients and
healthcare providers and can create a culture that is open to learning and
improvement. 5

MATERIAL AND METHOD OF RESEARCH
This study is a descriptive study. Subjects were KARS accredited
hospitals in Indonesia. Data collection of the impact of hospital accreditation
on quality of hospitals conducted by mailed questionnaire that was developed
from previous studies 7 and sent to 181 hospitals selected as a sample. This
questionnaire also contained open questions to obtain information about how
accreditation influenced the quality of hospital and suggested improvements
to the accreditation system developed by KARS.
RESULTS AND DISCUSSION
Respondents who responded to the questionnaires were 84 hospitals
(46, 4%) out of 181 hospitals that were in the sample frame. Most of the
hospitals who returned the questionnaire were private ones (47 or 56%). Most
of them are type C hospitals (52.4%) while type A hospitals are least to return
the questionnaire (4.8%) and most of them (39.3%) are from hospitals that
have 100 – 200 beds. In addition there were 10 hospitals (11.9%) who
declined to provide answers in detail.
RESULTS
Impact of Accreditation
Respondents generally agreed that the accreditation have an impact
on hospital quality improvement. A total of 95.8% RS agreed that
accreditation encourages the involvement of hospital staff and 83.9% RS
agreed the impact of accreditation on hospital quality efforts. But the number
of hospitals that agree on the impact of hospital accreditation on clinical
performance is only 61.5% (Table 1).
Table 1. Average Hospital Perceptions on Impact of KARS Accreditation
Statement Disagree Agree
S % S %
A. Hospital staff involvement (Up to Executive) In the 4 4.2 80 95.8
process of hospital accreditation.
B. Impact of KARS Accreditation on Hospital Quality 13 16.1 70 83.9
Efforts
C.Impact Of Hospital KARS Accreditation on 32 38.5 52 61.5
performance

There was no difference in perception between hospital type A and B
to type C and D and between the private hospital and the Government
hospital. On average, respondents agreed with the involvement of staff and
the impact of hospital accreditation on quality. But only 52% of private
hospitals agreed that accreditation had impact on the performance, as
compared to 73% of government hospitals.
In Group A statements regarding the involvement of staff in the
accreditation process, almost all of them (4 statements) are agreed by the
hospitals. Even 98.8% hospitals agreed that the recommendations provided
by KARS accreditation is an opportunity for hospitals to change.
While in the Group B statements (16 of them) regarding the benefits of
accreditation of hospital quality efforts in general, there were varying results,
47,0 to 95.2% of the hospitals agreed. As an illustration, as much as 95.2%
agreed that the accreditation enables improved patient care and 94% RS
agreed that accreditation encourages teamwork, but only 47% agreed that the
accreditation increase revenue.
Impact of hospital accreditation on clinical performance (group C) also
varied (26.2 to 78.6%), with the proportion of respondents who agree in
general lower than that from the statements in group A and B. For instance as
much as 78.6% of respondents agreed that accreditation can improve the
quality of nursing services and 76.2% agreed that after the accreditation the
hospital managed to maintain the quality of health services. However, only
26.2% of respondents who agreed that accreditation can reduce the number
of sectio Caesarian surgery and 41.7% who agreed after the accreditation
hospital showed decreased mortality.
Types of Influence and Suggestions to the current Accreditation System
Based on answers to open questions about how accreditation influence
of hospital accreditation on quality, a total of 67.9% hospitals can identify the
existence of various types of influence on the quality. However, other
hospitals (29.8%) were hesitant or unable to identify the type of influence of
hospital accreditation on quality. Hospitals who stated the accreditation is
influential, explained that it encourage staffs’ compliance with standards or

egulations. In addition, some hospitals also stated that the accreditation is
also useful in motivating human resources to enhance their competence, to
create a conducive environment, helping to introduce the quality of hospitals
to the community and also enhance communication systems in the hospitals.
Table 2 below summarizes the suggestions for accreditation system.
Table 2. Categories Suggestions for Improvement KARS Accreditation
System
Category
Management
assessment
Accreditation surveyors
Accreditation standards
of
Accreditation system in
general
Suggestion
Evaluation, guidance, information and
dissemination, involvement, the survey process,
cost and time
Consistency and Surveyor’s competence
KARS standards and standards of JCI
Accreditation system, implementation, credibility
and accountability, the evaluation system.
DISCUSSION
Perceptions about the impact of hospital accreditation on quality and
Clinical performance of Hospital
Accreditation program is considered to have successfully influenced
the increase or improvement in the hospital organization in general. The
program stimulates internal motivation and commitment to self assessment
and changes 8. In this study 95% agreed that during preparation for
accreditation there was involvement of all staffs and 97.6% of hospitals
agreed that the hospital staffs participated in the implementation.
The study shows that 53.0% of hospitals did not agree that the KARS
accreditation can increase hospital revenues. Benefits of accreditation for
hospitals, among others, is 'marketing', to improve the image and public trust
for the hospital and as a tool for negotiating with third parties such as
insurance company as well as other companies 6. Of course, these benefits
may indirectly increase the income of RS. But it seems it has not been
realized, because most of the private hospital said that the government should
set a reward for the hospital that is accredited. The kind of reward that the
government should give is by endorsing companies to have contracts with
accredited hospitals 11. This needs attention from the government, because

accreditation will be more responsive if it has the financial implications 12.
Most hospitals did not agree that there were positive impacts of KARS
accreditation on clinical performance of the hospitals. The study shows, as
many as 73.8% RS do not agree that after the KARS accreditation, the
hospital showed decreased number of Caesarian section and 58.3% of
hospitals did not agree that after the accreditation, hospital showed reduced
hospital mortality.
Previous research conducted in Indonesia found no significant
relationship between accreditation scores with hospital performance 13. While
research conducted in South Africa found that COHSASA, the Council for
Health Services Accreditation of Southern Africa had effectively changed
structure, administrative procedures and organizational processes, but did not
improve measured service indicators 9. It also explained that in a review of
hospital accreditation conducted by Ducket in 1983, physicians are the group
that experienced the least change when associated with accreditation.
Additionally physician behavior is the most difficult to change. It
became one of the reasons why there was no impact of accreditation on
clinical indicators. This is because hospitals that join the accreditation
program will only concentrate on improving the structure and procedural
standards. As a results, there were little attention to clinical processes and
outcomes. Hospital staff found it easier to implement structures, standards
and procedures, because it does not require the involvement of doctors 9.
Another consideration is because accreditation is the process of improving the
quality as a dynamic and ongoing process, Therefore it is difficult to determine
a proper way to measure the outcomes of accreditation 10.
While in Indonesia, the absence of clinical performance impact is likely
because the committee did not measure clinical performance indicators, both
at the time of accreditation surveys and post-accreditation monitoring. This
corroborate with the fact that currently there are no national data on quality
outcomes. 12. By not measuring clinical indicators in the accreditation process,
it is not in accordance with clinical governance. Activities to implement the
basic concepts of clinical governance consist of activities as follows: clinical
audit, providing a good quality clinical data, outcome measurement, clinical
risk management, practice based evidence, poor clinical performance

management, and mechanisms to monitor outcomes of service 16. According
to Utarini (2011) in Indonesia the development of quality management
systems and clinical governance runs parallel without meeting point 12.
Currently the trends in the quality development efforts is to focus the
attention to clinicians to develop and maintain service standards. This concept
looks at clinical governance initiative, which emphasized that any initiative in
the quality of health services in the future should be directly related to the
quality of services 12. In Australia, this is done by putting the clinical indicators
as part of accreditation. The accreditation standards consist of three
components, namely the assessment of 35 types of assessments, monitoring
of clinical indicators, as well as organization and management 3.
There was no difference in perception between hospital type A and B
to type C and D. In average, they agreed with the involvement of staff in the
accreditation process and agrees that the impact on the quality of hospital
accreditation. These results differ from those in Lebanon where there are
differences in perception between large hospitals with a small hospital. Smallmedium
hospital more able to feel the impact of accreditation, as compared
with large hospitals 7. It is interesting for further study because of large-scale
organizations (large hospitals) more appreciative and feel the benefits of
accreditation than a small hospital because they are not burdened with the
cost of accreditation surveys 14.
Type of Influence and Suggestions to Accreditation System
The majority of suggestions from the respondents were about
evaluation, that indirectly intended as a coaching process of accreditation.
The absence of KARS evaluation system is also found in previous studies 3.
This needs serious attention because the evaluation or review after the
accreditation process is essential to stimulate hospital to continuously
improvement efforts in the period between accreditation, which is usually 3
years, because if not, the organization will be off guard and the hospital can
no longer make internal improvements. Eventually the quality of the hospital
will decline 8. In addition, the accreditation program will be very effective when
the evaluation process is combined with consultation / mentoring / coaching to
help hospitals improve the quality of service 14.

In this study there were many suggestions relating to the
implementation of accreditation surveys (management assessment) by KARS.
The process of external evaluation of the accreditation agencies is very
important, because without an external evaluation process, the necessary
autonomy, objectivity and transparency, the agency simply run the licensing
process not a process of accreditation 15. Based on that, the management of
KARS need to improve the organization so that the purpose of accreditation
process is achieved.
Problems in surveyors’ inconsistency and competence are major
issues as outlined by the respondents. Surveyors’ inconsistency problem is
also found in previous studies 3. Surveyor is the key to credibility, objectivity
and sustainability of the accreditation program. Therefore recruitment
process, selection, development and performance of the surveyors will assist
institutions in providing quality services 8. Besides, one of the factor that
influence accreditation success is the credibility of surveyor. The use of
accreditation as a means to compare the behavior of the organization or
service is highly dependent on the consistency between surveyors in their
assessments 4.
The study also found there are problems with accreditation standards
KARS. This is evident from the number of hospital respondents who gave
some suggestions related to the accreditation standards or instruments. Some
hospitals felt that the accreditation standards KARS do not focus on patients,
including the principle of continuum of care. One of the most important in
realizing the quality of health services is a standard of the continuum of care 3.
Accreditation standards should be revised periodically as a process of
continuous improvement 8 . Since 1996 to 2000 standards / accreditation
instrument of KARS has been revised 4 times, based on feedback from
surveyors and professional organizations and associations involving the
hospital 3. Lack of user involvement in the revision of standards is likely to be
the reason why many respondents felt less satisfied with KARS current
accreditation standards.

CONCLUSIONS AND SUGGESTIONS
According to the perception of hospitals, KARS accreditation system is
quite effective to encourage the involvement of staffs and promote effective
quality improvement efforts as well as having an impact on clinical
performance of hospitals. But there are some aspects that are less effective,
namely in terms of post-accreditation evaluation, the standard used and
accreditation surveyors.
Based on these conclusions, it is necessary to improve the
accreditation system periodically primarily related to the process of evaluation
and monitoring of RS; the process of recruitment, training, evaluation and
monitoring of surveyors; process of the preparation, revision and
dissemination of periodic accreditation standards and to evaluate the impact
of accreditation on the quality of the hospital periodically
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