The Key Solution for Quality Improvement of Patient Safety in the

Intensive Care Unit: A Quality Assurance Study

at Budhi Asih Hospital, Jakarta, Indonesia

F. E. Selanno

, H. F. Rachmat

, H. P. A. Purwanto

, S. A. Diva

, S. Susilawati

and M. S. Muchtaruddin

General Practitioner, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

sukmasusilawati@gmail.com, muchtaruddin.mansyur@gmail.com

Keywords: Intensive Care Unit, CPPT, integrated patient development records, paramedic ambiguity, quality assurance

Abstract: The management of Intensive Care Unit (ICU) patients need a high standard of service and collaborative

inter-multidisciplinary therapy. Every issue in the quality of service in the ICU is very essential. Therefore,

a comprehensive analysis is required to improve the quality of care and patient safety. This qualitative study

was conducted in November 2017 at Budhi Asih Hospital, Jakarta. Data was taken through general

observation and systematic review. We used Standard Operating Procedure, indicator, and target from the

Hospital as the basic standard for ICU service. All data were analyzed using a quality assurance method.

The decision for the main issue have been made through IxTxR method, and the ambiguity of paramedic

was chosen. The cause of the problem then identified by fishbone diagram and prioritized by IxTxR

method, and obtained that integrated patient development sheet has not filled complete enough by the

doctors. The solution was determined by (MxIxV)/C method, using printed media such as banner and

pamphlet as a reminder for the doctors, and evaluated by the qualitative method. We conclude that

Intervention by applying printed media was effective as a reminder for the doctor to fill integrated patient

sheet more complete and to help decrease paramedic ambiguity in performing medical instructions.

1 INTRODUCTION

Intensive Care Unit (ICU) is an independent part of

the hospital that be equipped with a special and

important device in order to observe, care, and treat

the patient in acute or injured condition, patient with

complication, patient with a life-threatening

condition or potentially life-threatening with the

expected reversible condition. Patients in ICU are

patients with an expected reversible condition that

need to be observed strictly and post undergo the

invasive procedure with deterioration risk

(Kemenkes RI, 2010).

In Indonesia, type C hospital or higher as a

referral service provider must have an ICU with

professional service and patient safety.

There are

several Standard Operating Procedures (SPO) and

protocols in service organizing that include various

criteria and service guideline such as facility,

medical service technique, patient disposition flow,

human resources in ICU, et cetera. SOPs and

protocols also affect patient prognostic, length of

stay, and nosocomial infection prevention.

Pertaining to that, appropriate therapy,

communication among medical staff, and complete

Integrated Patient Development Sheet have

significant roles in the ICU service.

However, these

criteria might have not well implemented in several

settings due to a few conditions, which are really

crucial to the patient's safety. Build upon that, the

aim of this study is to improve the quality of care

and patient safety in ICU. Authors realized the need

to perform further review so that service quality in

the ICU of Budhi Asih Government Hospital can be

improved, so the medical service in the ICU can

always meet a high standard and comprehensive

procedure (Kemenkes RI, 2010).

Selanno, F., Rachmat, H., Purwanto, H., Diva, S., Susilawati, S. and Muchtaruddin, M.

The Key Solution for Quality Improvement of Patient Safety in the Intensive Care Unit: A Quality Assurance Study at Budhi Asih Hospital, Jakarta, Indonesia.

DOI: 10.5220/0009859500870093

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 87-93

ISBN: 978-989-758-469-5

2 METHODS

This quality assurance is held from November 1

November 10

, 2017 at the ICU of Budhi Asih

Hospital, Jakarta, Indonesia. Targets in this quality

assurance were paramedic, the doctor in charge, and

medical staff of the ICU. Study staff collected data

by observing the facility, and all 25 paramedics and

15 doctors who were in charge through the 3 weeks

of the study. Authors also analyzed the SOPs

(Kemenkes RI, 2010), program indicator and

achievement in the ICU (official webpage RSUD

Budhi Asih, 2019), and performed a deep interview

to find the problems that were not stated in the

SOPs. All data were then compared with national

and international standard. Problem identification

was created to list the problems. All of the problems

list formulated using a scoring system to determine

the priority issue.

The priority of problem is determined from the

calculation with several components, such as

importance (I), technical feasibility (T), and

resources availability (R) or IxTxR method

(Departemen Ilmu Kesehatan Komunitas Fakultas

Kedokteran Universitas Indonesia, 2017). Problem

with the highest score is selected to be the priority of

the problem. Importance shows how important to

solve the problem. There are several components

that affect the value of importance; Prevalence (P)

which is determined from the exact prevalence of

the problem or gap between target indicator and

achievement, Severity (S) shows how bad is the

impact if the problem is not solved immediately.

Then, Rate of increased (RI) shows how fast the

problem would increase if the problem is not solved.

Degree of unmet need (DU) shows the magnitude of

the people desire that is not fulfilled if the problem

is not solved. Social benefit (SB) shows the

magnitude of benefits to society. Public concern

(PB) shows the magnitude of public concern or

interest in the problem if the problem is solved. The

last one is Political climate (PC) that shows the

current political condition that can be a support of

problem-solving.

3 LITERATURE REVIEW

3.1 Quality Assurance

Based on the International Standard Organization

(ISO), the definition of quality assurance is “all

those planned and systematic actions necessary to

provide adequate confidence that a product and

service will satisfy given requirement for quality”.

Quality assurance is important to identify the

problem in quality services and find the available

resources with measurable implementation

(Departemen IKK FKUI, 2017).

The purpose and benefits of quality assurance are

to improve service quality and patient satisfaction

and also assisting the organization or institution of

the service provider through quality improvement.

The implementation of good quality assurance

requires the active participation of the parties service

providers. Assessment of output must be thorough,

objective and relevant. Thus, the result will give

significance to real change and perceived by the

providers. Ultimately, the evaluation of the target

implementation of the solution should also be

appraised appropriately (Departemen IKK FKUI,

2017).

The steps done in the process of making a quality

assurance are identification of the problems and list

the priority, look for the cause of the problems use

the fishbone diagram and determine the priority,

identify alternative solution and determine the

priority, conduct an intervention and evaluate

according to the target set (Departemen IKK FKUI,

2017).

3.2 Integrated Patient Development

Sheet

Integrated patient development sheet is inner sheet

completeness of a status containing all patient

development records, which may be starting at the

inpatient room, ER, or outpatient clinic. This sheet is

filled by all health personnel involved in patient

care. Record of the progress of patients data (follow

up data) can be written by S-O-A-P method, namely:

S (subjective), O (objective), A (assessment), P

(planning) which contains the current complaints,

results of physical examination, analysis of the

problems or a diagnosis of the disease, and patient

care and management plans, respectively (Karniasih,

2019)

In addition to this method, there are also methods

namely ADIME (Assessment, Diagnosis,

Intervention, Monitoring, and Evaluation) and the

DART method (Description, Assessment, Response,

and Treatment) (Departemen IKK FKUI, 2017).

This sheet has a very important role as a media

bridging communication between the parties

involved in patient care. It also contains important

data to evaluate the effectiveness of therapy and

record any medical history received from the patient.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

Incomplete or error entry of the sheets can lead to a

fatal effect on the patient’s therapy and the patient’s

prognosis (Karniasih, 2019; Puspita, 2019).

3.3 Media Socialization

Media is defined as a tool or means of

communication. Media socialization is all parties

which are the mediator or means of socializing or

disseminating certain things. Some forms of media

socialization among others family, social

community, place of education, work environment,

and mass media (KBBI, 2019)

The use of mass media later become more

effective because of technology development. The

mass media is divided into two: print media and

electronic media. The print media includes banners,

tabloid, magazines, etc. The use of banners or

pamphlets as printed media are aimed to give

information easily that can be seen by many people

and lasting longer in the target area.

3.4 Profile of Budhi Asih Government

Hospital

Budhi Asih is a type B hospital with non-teaching

category, in accordance with the Decree of the

Minister of Health of the Republic of Indonesia

Number: 434 / Menkes / SK / IV / 2007.8 Hospital

located at Jalan Dewi Sartika, Cawang III No. 200,

Jakarta Timur, DKI Jakarta.

4 RESULTS AND DISCUSSION

4.1 Problem Identification

Identification of problems for quality assurance in

the ICU of Budhi Asih Government Hospital was

through data assessment, field observations,

paramedical interviews, and discussions with field

supervisors. There was also ICU indicators in the

Budhi Asih Government Hospital.

Table 1: ICU Indicators Budhi Asih Government Hospital.

No. Indicator Target Achievements

1. Readmission of

patients within

<72 hours

<3% 0 %

2. Nosocomial events

in ICU

<10% 3%

3. Doctor in charge

visit

> 75% 100%

According to the data from field observations,

paramedical interview, and discussion with the

supervisor, there were some problems occurring in

the ICU of Budhi Asih Government Hospital: the

ambiguity of paramedics in carrying out medical

instructions, transition room of the ICU, and human

resource management of the ICU nurses.

4.1.1 The Ambiguity of Paramedics in

Carrying Out Medical Instructions

There are some factors that influence the ambiguity

of paramedics in running medical instructional:

doctor in charge does not conduct routine patient

visits, irregular schedule of doctor in care visits,

short time of patient visits, the writing of medical

instructions is too short and does not describe the

patients condition completely, did not read another

review instruction from other departments, and did

not read back to the post from doctor in charge from

other department.

4.1.2 Transition Room of the ICU

Based on the technical implementation of Intensive

Care Unit (ICU) at the hospital by the Ministry of

Health Republic Indonesia mentioned that in the

structure of ICU, it is necessary to have transition

room that is separated from the patient care room

(Kementrian Kesehatan RI, 2010). Based on field

observations, there was no effective transition room

with room restrictions and clear access in the ICU of

Budhi Asih Government Hospital.

4.1.3 Human Resource Management of the

ICU Nurses

Based on the standards for ICU in the United

Kingdom, each patient in the ICU must be treated by

one ICU nurse. It aims to monitor the patient’s

progress and implementation of medical instruction

more carefully and precisely. Based on field

observation and interview to the ICU heads, it was

found that the numbers of ICU nurses in Budhi Asih

Government Hospital were sufficient.

The Key Solution for Quality Improvement of Patient Safety in the Intensive Care Unit: A Quality Assurance Study at Budhi Asih Hospital,

Jakarta, Indonesia

4.2 Selection the Priority of Problem

Table 2: Selection Priority of Problem.

Problem

T R Sum

P S

The

ambiguity

paramedics

in carrying

out medical

instructions

5 5 3 5 5 23 5 5 575

Human

resource

managemen

t of ICU

nurses

5 4 3 5 4 21 3 3 189

Transition

room

3 3 3 2 2 13 3 2 78

Abbreviations and acronyms:

I = Importance

P = Prevalence

S = Severity

RI = Rate of increase

DU = Degree of unmet need

PB = Public concern

SB = Social benefit

PC = Political climate

T = Technical feasibility

R = Resources availability

4.3 Identification Cause of Problem

Table 3: Identification Cause of Problem.

Man



Limited od human resources;

 Doctor in charge handle more than

one patients;

 Nurses sometimes have to observe

more than one patient.

Method



Write, Read, and Confirmation

method between doctor on duty and

nurse had not gone well;

 The communication mechanism

regarding medical instruction

between the doctor in charge and

the nurse had not gone well;

 Doctor’s writing in integrated

patient development sheet is hard to

read

Money



Limited funds for training of ICU

nurses

 Limited funds for procurement

completeness status

Material



Cardex sheets are not practical

Planning



Unpredictable time visit of a doctor

in charge

 Commitment for meetings between

the doctor in charge and nurses

Organizing



Collaboration between department

 There is no SOP on mandatory

meetings to discuss the case of ICU

patients

 Human resources management of

ICU nurses

 There is no SOP about

communication between

department

Actuating



There are no regular meetings at

least every week to discuss ICU

patients

 The incomplete and unclear

integrated patient development

sheet filling by the doctor in charge

 Difficult to confirm the treatment

of the patient to the doctor in

charge

Controlling



There is no routine evaluation of

filling integrated patient

development sheet

 There is no evaluation of SOP from

RSUD Budhi Asih

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

Figure 1: Chart the Cause of Problem.

4.4 Selection the Priority of the Cause

of the Problem

Table 4: Selection of the Priority of the Cause of Problem.

Problem

T R

Sum

mary

(I x T

x R)

P S RI DU PB SB PC Sum

weekly

meetings

to discuss

the case

of ICU

patients

5 3 4 2 2 3 19 3 2 114

The

incomple

te and

unclear

integrate

d patient

develop

ment

sheet

filling by

the

doctor in

charge

4 5 5 3 2 5 24 5 5 600

Doctor

on duty

had other

busyness

3 2 3 4 3 3 18 2 2 72

Lack of

nurses

2 2 2 1 3 3 13 1 1 13

Abbreviations and acronyms:

I = Importance

P = Prevalence

S = Severity

RI = Rate of increase

DU = Degree of unmet need

PB = Public concern

SB = Social benefit

PC = Political climate

T = Technical feasibility

R = Resources availability

4.5 Selection the Priority of Problem

Solution

Table 5: Selection of the Priority of Problem Solution.

Problem M I V C

Summary

((M x I x

V) / C)

Socialization of

integrated patient

development sheet

through formal meetings

3 4 2 3 8

Use banners or

pamphlets as a reminder

to fill an integrated

patient development

sheet

4 5 3 4 15

Integrated patient

development sheet

evaluation periodically

4 2 4 3 10,6

Abbreviations and acronyms:

M = Magnitude

I = Importance

V = Vulnerability

C = Cost

The Key Solution for Quality Improvement of Patient Safety in the Intensive Care Unit: A Quality Assurance Study at Budhi Asih Hospital,

Jakarta, Indonesia

The intervention was held between November 6th

and November 11th, 2017 by putting the banner and

pamphlets on the table of each bed in the ICU of

Budhi Asih. We hoped by reading the banner when

entering the ICU room and the pamphlets on the

table of each bed, the physician in charge would fill

the ‘Integrated Patients Development Sheet’ well,

clearly, and completely. These are very important to

do, as stated in the Standard Operation Procedure

(SOP) of Budhi Asih hospital regarding the

importance of effective communication, and

according to the World Health Organization (WHO)

about patient safety. Therefore, ICU in Budhi Asih

hospital was able to perform WHO standardized

patient care, especially in medication safety and

effective communication.

Table 6: Evaluation Results of Intervention Using Banner

and Pamphlet About Integrated Patient Development

Sheet at ICU Budhi Asih hospital.

Questions

Response

1 2 3 4 5 6 7 8 9 10

Physician

in charge

read the

banner and

pamphlet

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Duration of

a physician

in charge

read the

banner and

pamphlet

< 1

min

ute

< 1

min

ute

< 1

min

ute

1-5

min

utes

< 1

min

ute

< 1

min

ute

1-5

min

utes

< 1

min

ute

< 1

min

ute

< 1

min

ute

The banner

and

pamphlet

are easy to

understand

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

The

banners

and

pamphlet

help the

paramedics

to perform

the

instructions

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

The

instructions

from a

physician

are charge

is better,

clearer and

complete

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

We evaluated the intervention by using

questionnaires to the paramedics (Table 6). The

responders said that all physicians read the banner

and pamphlets with duration time about less than

one minute to five minutes. All the responders

agreed that the banner and pamphlets were relatively

easy to understand, helped them perform the medical

instructions, and the instructions from the physician

were better, clearer and more complete. Some

physicians also filled the ‘Integrated Patient

Development Sheet’ by themselves, while they

previously did not. The hospital management also

agreed to multiply the banner and pamphlets so this

method could be adapted to other units.

In consideration of time available during the

study, we did not perform the quantitative evaluation

on the ‘Integrated Patient Development Sheet' before

and after the intervention. We also have some other

considerations: the amount of patient in ICU Budhi

Asih hospital is unpredictable and changed over

time. In the case of limited numbers of patients, we

also had limited time for observation. On the other

hand, not all patients fitted our inclusion criteria that

every patient should have been visited by at least

two different physicians in charge.

The quantitative evaluation of ‘Integrated Patient

Development Sheet’ was done by comparing the

completeness of the form before and after the

intervention, whether any improvement of the

‘Integrated Patient Development Sheet' percentage

that has been filled well, clearly and completely. We

also compared the ambiguity level of paramedics

before and after the intervention. Our aim was to

achieve a better quality of written instructions in the

‘Integrated Patient Development Sheet’. Less or no

ambiguity level from paramedics was also one of

our goals. With that, hopefully, Budhi Asih

Government Hospital could fulfill all of the

requirements in the SOP.

5 CONCLUSION

We found that banner and pamphlets as a reminder

to the doctors in charge to fulfill the Integrated

Patient Development Sheet are the key solution to

improve the quality of patient safety in the ICU

room of Budhi Asih Government Hospital. The

banner and pamphlets should be distributed to more

units other than the ICU. Furthermore, there should

also be a routine evaluation of ‘Integrated Patient

Development Sheet’ and ambiguity of the

paramedics in performing medical instructions

written on.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

REFERENCES

Kementrian Kesehatan RI [PDF], 2010. Petunjuk teknis

penyelenggaraan Intensif Care Unit (ICU) di rumah

sakit.

Official Webpage RSUD Budhi Asih Jakarta Timur, 2018.

RSUD Budhi Asih Jakarta Timur. Available from :

http://www.rsudbudhiasih.com

Departemen Ilmu Kesehatan Komunitas Fakultas

Kedokteran Universitas Indonesia, 2017. Slide kuliah

Quality Assurance.

Karniasih, P., 2019. Penulisan SOAP. Available from:

https://www.scribd.com/doc/279351988/Penulisan-

SOAP-Keperawatan-Dra-Pipih-Karniasih-MKep-pdf

Puspita, D., 2019. Panduan Pengisian CPPT. Available

from: https://kupdf.com/download/panduan-pengisian-

cppt_59f4b2e4e2b6f5a03b299e8e_pdf

Kementrian Pendidikan dan Kebudayaan Republik

Indonesia, 2019, Kamus Besar Bahasa Indonesia.

Available from : https://kbbi.kemdikbud.go.id

The Key Solution for Quality Improvement of Patient Safety in the Intensive Care Unit: A Quality Assurance Study at Budhi Asih Hospital,

Jakarta, Indonesia