AN ANALYSIS OF THE HEALTH CENTERS READINESS FOR ACCREDITATION IN BREBES DISTRICT IN 2018 *Deny

The accreditation of health centers is an endeavor by the Ministry of Health to improve the quality and performance of health centers regulated by Permenkes No. 4/2015. Of the 38 health centers in Brebes, only 10 has been accredited. We wish to discover how prepared are the health centers to be accredited based on the resources available and pre-accreditation survey. Data was obtained through in-depth interviews and documentary research. Results indicated that there was sufficient funds, facilities and equipment for the accreditation. However, the assessment scores for human resources sufficiency and documentary completeness was low.


INTRODUCTION
To improve the quality of primary healthcare facilities, the staff in the facility are expected to increase and optimize their promotive, preventive, curative, and rehabilitative efforts according to the managed care principles in the national health system (NHS). 1 According to the Republic of Indonesia Minister of Health Regulation no.71/2013 on Healthcare Services in National Health Insurance, Primary Healthcare are non-specialistic personal healthcare services, which includes outpatient and inpatient care.In Indonesia, the primary care facility are health centers. 2 However, as the primary health facility of the nation, health centers should prioritize health promotion and prevention in order to improve public health quality in their areas. 3ronically, there were complaints beginning from the convoluted service flow to unfriendly staff and inferior quality of care.
To improve the quality of care, improve performance, and implement risk management continuously at the primary facility, particularly the health centers, the Ministry of Health issued regulation no.46/2015 on the accreditation of Health Centers, primary care clinics, private doctor practices, and private dentist practices.Therefore, evaluation from external parties are necessary.The health centers must be accredited once every 3 years.It is one of the credentialing requirements for a primary healthcare facility that collaborates with the Social Security Bureau (BPJS), if the facility has not been accredited by 2019, the BPJS will stop their partnership with it. 4creditation is a standardized work system based on the current rules and regulations, therefore, the health center must prepare to work according to those standards. 4The 9,740 health centers in Indonesia will be accredited in stages, 5,600 are scheduled to be accredited by the end of 2019.Brebes has 38 health centers, 23 provides inpatient care and 15 only provides private primary healthcare facilities.Most of the funds from the 2018 DAK was used for transportation and accommodation during the accreditation survey preparation, which included internal auditing workshops, patient safety workshops, survey preparation meetings and guidance), district accreditation coordination meetings, and counselors.While in 2017 the funds were mostly used for acquiring consultants for the accreditation process at the 10 health centers.

Facilities and Equipment
To acquire facilities and equipment, health centers must obtain the approval of the BLUD, and the proposal was derived from discussions during the planning and development meeting (musrenbang) at the villages.However, not all will be approved.In addition to the limited budget, bureaucracy at the BLUD and the delivering of the equipment is another problem.Some health centers even had to renovate and shuffle the rooms that they currently have to make it comply with standards.From what we observed and the documents, the facilities were sufficient for the public health and curative services as stated in Permenkes No. 75/2014.

Health Center Accreditation Preparation Workshops at the Health Center
The workshops at the health centers that were attended by all their staff and cross-sectors would be considered a success if all the staff agree to a written commitment.All the informants at the health centers stated that the health staff are 100% committed to the accreditation and has signed an agreement.The workshop is the first step for accreditation and has been done since 2016, but not all the centers have immediately prepared themselves for the accreditation.The cause was the lack of comprehension on accreditation even within the health office, the lack of clear goals, and the large amount of programs that were more prioritized at the centers.Also, the long period between the workshop and the accreditation survey, which halted the preparation process.

Workshop on Accreditation Standards
These workshops comprises of internal auditing, management review meetings, and patient safety workshops, which was performed by the district accreditation counselor team in early 2018.All the workshops were performed in 3 separate occasions in January to February 2018 for the internal audit and management review and February to March 2018 for the patient safety workshops.The trained staff should be able to teach other staff at the center.To improve their comprehension on accreditation, the center is expected to perform their own trainings, so that the details on the accreditation, its instruments, and the self-assessment, would be outpatient care.However, by 2018 only 10 have been accredited.
In 2018, 27 health centers would receive accreditation.The Health Office would directly appoint which center would be accredited, disregarding whether or not the center would be prepared or not, in terms of documents, assessment scoring, human resources, funding, facilities and equipment.Most centers admitted that they weren't ready and feel pressurized.The problem is that no one has ever analyzed their preparedness for accreditation, and this would cause ineffective management of resources.Therefore, to improve their preparedness, an analysis of the input, process, and output aspects of the health center is necessary.

METHOD
This qualitative study was performed from March to April 2018.The research was performed at Brebes.The data was obtained through in-depth interviews and documentary research.8 informants were involved, 2 from the Brebes District Health Office (the head of the health office and the head of the healthcare services division as the health center accreditation counselors), 6 health center staff (3 were the head of the health centers and 3 from the health center accreditation team of Kaliwadas, Bandungsari, and Wanasari health centers).

Resources Human Resources (HR)
Health centers are not authorized to acquire their own staff, they are still dependent on the regional or central government.From the quantity, the ratio of several types of staff are lower than standards and some held positions that did not match their proficiencies.Another problem is the absence of trainings to improve their skills and quality.

Funding
The accreditation in Brebes was funded by the national budget (APBN) through non-physical specific allocation funds (DAK), the regional budget (APBD), and regional public service agency (BLUD).The DAK funds allocated in 2018 was larger than what was planned in the Cost and Budget Plan (RAB), to facilitate the accreditation of the health centers in Brebes, the Rp 2,900,000,000,-proposed grew to Rp 5,336,000,000,-.Funding from the APBD also increased from Rp 5,400,000,-in 2017 to Rp 63,475,000,-in 2018.Although only 78.14% was used for the accreditation (Rp 49,600,000,-), the rest was used for socialization programs and workshops for the comprehended by all and the instructors are the staff that participated in the previous workshops.But this was not done because some of the original participants were no longer involved in the accreditation preparation process, either because they were transferred to another institution, were on study leave, or had different jobs.

Self-Assessment
To evaluate whether the center was prepared to be accredited, a self-assessment was performed at the beginning and the following month.The scoring system used was 0 for none, 5 partially completed, and 10 for completed.The scores was then categorized into 3 groups: ≤ 20% none, 21 -79 % partially complete, and ≥ 80 % completed.At the beginning, most of the staff scored low in the self-assessment questionnaire, particularly in the activity documentation and the second survey did not yield significant improvements (please see table 2).This may be caused by the short period between surveys (2-4 weeks).None of the three health centers were prepared for the accreditation all were less than 65% (51.48% vs 40.53% vs 56.06% for Kaliwadas, Bandungsari, and Wanasari).

Preparing the Required Documents
The health centers in Brebes has endeavored to complete all the documents necessary for the accreditation according to the evaluation standards.Internal and external documents have mostly been completed, but the problem was in the collection of the activity records.Some centers have not created their five year planning (Renstra), nor have they written the activity guidelines (KAK) according to the standards.The accreditation counseling team also provided guidance on how a decree (SK), the standard operating procedures (SOP), KAK, and guidelines and quality control manuals should be written.

Implementation of Standardized Activities
The fifth step is implementation.Most of activities were not implemented 100% because most personnel do not comprehend in detail the policies, quality, guidelines, and SOP of the accreditation activities.Accreditation is not only a documentary evaluation, the center is required to control and monitor the performance of activities periodically through internal and external evaluations.These activities were accomplished through mini workshops, meetings, and direct supervision.

Pre-Accreditation Survey
The total scores of the simulation survey of the three health centers for chapter I and II was <75 %; for chapter IV, V, and VII was <60%; for chapter III, VI and VIII was ≥ 20 %; and for chapter IX was <20%.However, at all three health centers, of the 9 chapters required, only chapter III, VI, and VIII has satisfied the criteria of the accreditation.

DISCUSSION
Adequate resources are necessary for a health center to receive respectable accreditation.Indicators are used to discover whether the human resources, funding, and facilities of a center are sufficient.One important input element is human resources.Policies require qualified staff in its implementation. 5The problem at Brebes is the lack of manpower and the lack of qualifications of the available manpower.To satisfy this, adequate planning is necessary.This would also prevent overwork and stress, which may reduce their performance. 6nding is also important.Without adequate funding, a policy cannot be implemented effectively and accurately.Health centers received funding from the BLUD, but the amount provided does not always match the amount needed.In Brebes, budget planning only increases by percentage, for the next year budget plan, the amount spent the previous year was multiplied with a fixed percentage.This was caused by the lack of data on how the funds was used, fund manager, provider, function, budgetary items, and beneficiary of each activity. 8Not all facilities necessary to provide standardized healthcare services were available, and the accreditation is provided based on that. 9We discovered that complying with the standards was difficult for certain health centers, especially with the limited budget allocated for them to change or renovate the buildings to comply with the standards.Another problem is that not all the proposed items in the proposal to the BLUD would be realized.In addition, bureaucratic problems and delays in the delivering of materials also became a problem.The center had to shuffle rooms and modify it to meet the standards.
The accreditation involves an accreditation survey and accreditation assignation.Pre-accreditation guidance and evaluation is done before the process begins.At the preparation stage, the center can request guidance from their District/City Health Office. 10The toughest step is implementing a policy.Because it is during this step the problems begin to emerge.Inconsistent implementation is another problem.Inadequate planning would make the goals of a policy impossible to achieve. 11 The pre-accreditation survey begins with a workshop.This is to increase awareness of the importance of the quality and comprehension on the standards of accreditation and its instruments.It is also to obtain commitment in improving the quality of the health center. 10the problem at this stage that the commitment stage went to a halt.Because of the lack of communication and coordination between the center and the Health Office, which produced different perceptions on accreditation.Indirect transmission of information and multilevel information structure would cause many miscommunications. 12l the personnel at the health center must participate in the accreditation standard and instrument training.This training was performed by trained personnel from the center or by the district guidance team. 13We discovered that the internal auditing and management review workshop, and the patient safety workshop was performed by the district guidance team in early 2018.The former lasted for 3 days and the latter lasted for 2 days.28 health centers, represented by 8 staff (in the accreditation team) per center participated in the workshops.However, they failed to disseminate the information that they received, either because they were no longer in the accreditation team, personnel transfers, study leave, or now held different positions.
After the workshops, the centers had to perform a selfassessment based on each evaluation element.Each element is scored according to the current conditions and each workgroup cannot evaluate itself.Each workgroup would evaluate the other.This was also supervised by the accreditation guidance team.The results of the self-assessment is then discussed and an action plan is created. 13However, in Brebes, the one that performed the self-assessment was the guidance team, and since there was 776 EPs, they were unable to complete it.
Another problem is the incomplete recording and reporting of program activities.Although all programs were documented, some basic internal documents were incomplete, for example the activity implementation documentation.Several centers have not even created the necessary standardized Renstra or KAK.Although the guidance team has provided an example.At this stage, the staff should identify what documents are necessary for each element, how it is written, the facilities, which is then followed with control and improvement of the documents and systems at the center.
Next is the implementation phase.This stage determines the accreditation process.Each EP must be implemented.The documentation is completed when the activities are performed.This takes about 3-4 months.We discovered that the implementation wasn't optimal, because most of the personnel has not completely comprehended how to implement the accreditation activities, quality guidelines, guidelines, KAK, and SOP.Each EP was socialized to each relevant workgroup, it performed was according to the standard.As a follow up, a management review meeting was performed.
From the simulation survey, we discovered that the coverage of the three centers for chapter I and II was <75 %; chapter IV, V, and VII was <60%; chapter III, VI and VIII was ≥20 %; and chapter IX was <20%.While the criteria for lowest accreditation, basic accreditation, was completing chapter I and II >75%; chapter IV, V and VII >60%; and chapter III, VI, VIII, and IX ≥20%.Therefore, of the 9 chapters that must be completed, only chapter III, VI and VIII satisfied the criteria.This meant that Kaliwadas, Bandungsari and Wanasari health centers has not satisfied the criteria for basic accreditation.

SUMMARY
The health centers at Brebes were lacking in manpower, some were still under the standard ratio and some did not have the qualifications for their jobs.Staff held more than one position.There was adequate funding for the accreditation, although still under the old fund allocation scheme.However, the centers did not have adequate funding to updating their facilities up to standard.On the other hand, the current facilities are considered adequate.The documents for accreditation was also adequate, although most were incomplete.In short, the centers are capable of passing through the accreditation process, although the self-assessment survey stated otherward.

Table 1 .
Self-assessment Scores Comparison for Health Center Accreditation Preparedness