AHS Implementation in Universitas Gadjah Mada

Rukmono Siswishanto Dr. Sardjito Hospital/ Fac. of Medicine

Outline

① Introduction

② Why do we need AHS

③ The risk of not being integrated

④ The underlying concept

⑤ Implementation of AHS

⑥ Challenges ahead

Yogyakarta Special Region

• Located in the central part of Java Island

• Population: more than 3.5 million

• Four districts and 1 city:

– Yogyakarta city

– Sleman

– Bantul

– Kulonprogo

– Gunungkidul

FACULTY OF MEDICINE

UNIVERSITAS GADJAH MADA

Universitas Gadjah Mada (UGM)

established on December 19, 1949

Faculty of Medicine UGM

established on March 5, 1946

General Profile Faculty of Medicine UGM

• 3 undergraduate programs

• 6 master programs

• 1 doctoral program

• 20 clinical specialization programs

• 32 Departments

• 14 Research centers-WGs

• >1,000 staff (teaching and administrative)

• >500 new undergraduate students

• >600 new graduate students and residents

Human Resources

Lecturers: 673*

• 303 (45%), full time

– 209 (government civil servant) and 94 (university-based)

• 156 (23%) clinical teachers from Sardjito

• 214 (32%) clinical teachers from other teaching hospitals

*Excluding part-time lecturers from non-teaching hospitals and 77 retired lecturers

Quality Assurance Systems

Internal

• Quality assurance office (University level)

• Quality assurance unit (Faculty level)

• Academic standard committee (Study program level)

External

• National accreditation – Public health graduate program

accreditation: A

• International accreditation – IMIA (HMIS, provisionally

accredited)

– PAASCU (Medicine, in process)

– FERCAP (IRB)

– JCI for AMC (Sardjito hospital)

– ISO certification 9001:2008 (Faculty administration)

5 Hospital 1927 beds++

Sardjito General Hospital

• Ministry of Health owned hospital in Yogyakarta

• 750 beds capacity

• Top referral hospital for Yogyakarta Special Province and southern part of mid Java Province (23 million population)

• Cardiac and Cancer excellence services

• JCI accreditation for AMC

Soeradji Tirtonegoro Hospital

• Ministry of Health owned hospital in Klaten (30 kms east of Yogyakarta)

• 400 beds capacity

• Located in rural/ suburban area

• Geriatric excellence services

Universitas Gadjah Mada Hospital

• University owned hospital

• 200 beds capacity, secondary services

• Official opened in 2012

• Disabled child growth excellence services

Hardjolukito Hospital

• Air-force military owned hospital

• 400 beds capacity, tertiary services

• Located at eastern part of Yogyakarta city

• Special in Flight Medicine

Banyumas Hospital

• District government owned hospital

• Located in rural area, 200 kms west of Yogyakarta

• 300 beds capacity, secondary services

• Comprehensive Mental Health excellence services

② WHY DO WE NEED AHS

1/13/2017

Legislation related to AHS

• UU no 12 tahun 2012 tentang pendidikan tinggi • UU no 12 tahun 2013 tentang pendidikan kedokteran • UU no 44 tahun 2009 tentang rumah sakit • UU no 29 tahun 2004 tentang praktek kedokteran • UU no 36 tahun 2014 tentang tenaga kesehatan • UU no 5 tahun 2014 tentang ASN • PP no 93 tahun 2015 tentang RS Pendidikan • Permenristekdikti no 26 tahun 2015 tentang

pendidikan • Permenristekdikti no 2 tahun 2016 tentang

perubahan permenristekdikti no 26 tahun 2015

Mission

Disruption?

• Changing in societal needs and values

• Disease patterns

• Economics

• Globalization

• Politics

• Population demographics

• Market consolidation

• Consumer empowerment

• Policy changes

• Enterpreneurism

16

Wartman: The Transformation of Academic Health Centers (2015)

① Free trade of AEC (31 December 2016)

② Legislation

③ Medical & information technology

④ Customer orientation

⑤ JKN (BPJS & referral system)

⑥ Remuneration system

⑦ AHS/ AMC/ AHC 17

Current Situation

Faculty of Medicine

• Clinical educator

• Cost of medical education

• Unmet need of clinical educator (focus on health care, quota)

• Clinical & translational research , not optimal

• Low contribution on medical/ health science

• Community services less comprehensive

Hospital

• Less priority on educational activity (not included in remuneration system)

• Quota of HR based on case load

• Research is not priority

• Un-strategic choice of featured services (inefficient)

• Less responsibility to foster the others

Other problems

- Limited facilities: patients booming long waiting list

- Limited budget: Hospital priority

- Different Regulations between Institutions/ hospitals

- Administration system

- Remuneration

Education

Research

Healthcare

Community

③ THE RISK OF NOT BEING INTEGRATED

① Less adaptive in dynamic world

② Failure to thrive

④ THE UNDERLYING CONCEPT

Large-scale social change requires broad cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organizations

(Kania & Kramer, Collective impact, 2011)

Vision

i

Mental Models

Systemic structure

Patterns

Events

Generative

Reflective

Creative

Adaptive

Reactive

Leverage increases

Level of perspective

Action mode

Carter R.: A need for systems thinking in public health, 2016)

Collective Success

① Common agenda

② Shared measurement systems

③ Mutually reinforcing activities

④ Continuous communication

⑤ Backbone support organization

(Kania & Kramer, Collective impact, 2011)

Scope of AHS

International National Regional zone AHS Stakeholders

Sharing experiences

Standard setting

Leadership

Agenda

Integrated information

system

Capacity building

Aligning patient care, teaching,

& research

Perceived benefit

Primary Secondary Tertiary Public Health & Health Promotion

Counseling, Support, & Care continuum

Clinical care

1

2

1

2

2

3 1

3 3

Plan &

treat recurrence

Wellness,Pr

omotion/

Prevention

Early

Detection

Treatment Management:

• Initial

diagnosis

• Determinat

ion of

treatment

• Treatment

Follow

up care

End of

life

care

Optimal Patient journey:

facilitated by information, coordination, supportive care, service linkage

Modified from Healthcare Management Advisors (HMA) for the Northern Territory Government Department of Health and Families, Australia

Involving primary, secondary, tertiary care

Integration: Functional PP 93/2015 (ps 21)

FK

RS

Perjanjian kerjasama tertulis

Integrasi Fungsional Koordinasi & kolaborasi dalam perencanaan, pelaksanaan, &

evaluasi: pendidikan, pelayanan, penelitian, & abdimas

Integrasi Struktural

Penyatuan institusi menjadi satu kesatuan kerja

Harmonization: Health care System & Health Professional Education

Puskesmas RS lainnya

FKTP lainnya

Kemenkes Dinkes

Tertiary

Secondary

Primary

Selfcare

AHS Concept of UGM

Health office

Lab Res.Unit

PHC

District Hosp

MD

MD specialist

Nursing

AHS UNIVERSITAS

PRACTICE

PLAN

Main Teaching Hospital

Teaching Hospital

Teaching Hospital

Teaching Hospital

Faculty of Medicine Dentistry

Nutrition

Pharmacyst

⑤ IMPLEMENTATION OF AHS

Partnership & vehicles

Synergy of program

Organization

Partnership & Vehicles

• 10 Hospitals – Combine for MD& Specialist training

• 32 Hospitals – For Specialist training

• Sister hospitals – Bajawa, Balikpapan, Jayapura, etc.

• Health Office

• Public Health Center

Synergy of Program Education

-Share education facilities, IT

-Standardized curricula for undergraduate,

profession and residents for teaching and

partner hospitals

-Capacity building for staffs in teaching hospitals : TOT

-Quality control in education

Sample AHS Agenda for Spesialist Training

• Involving related stakeholders:

– GCU, Vaccination

– Insurance

– Insentive

• Working hours (referring to ACGME)

• Professional behaviour

Teleconference: AHS Management

Case Teleconference (Dept. of Skin & Venerology)

Library Sharing

• Library facility sharing: Connection between UGM & Dr. Sardjito Hospital

Synergy of Program

Research

- Coordinated Ethical Committee in Faculty of Med and University Hospital

-Sharing research budget, scholarships

-Sharing Laboratory Facilities

-Capacity building for researchers: GCP, GCLP

-Organize clinical trial

2014-Project Highlights

Oral Rv3 rotavirus vaccine research in

Indonesia (Bill&Melinda Gates

Foundation)

Malaria Transmission Consortium

(Bill&Melinda Gates Foundation)

Monitoring progress Family Planning 2020 (Future Institute and Bill&Melinda Gates

Foundation)

USAID-TBCTA Regional Training

Centre for TB control & Neglected Infectious Disease Diagnostic

Consortium (EU)

Primary Care Accelerator Program and InterUniversity

Consortium on Global Health (New Proposal)

Knowledge Sector Initiative, HIV-AIDS,

Sister hospital (Ausaid), Health policy

network (Ausaid, IDRC)

Eliminate Dengue Project-Tahija

Foundation and Dengue Waening

Signs (WHO-TDR)

Fever Study-INA Respond (NIH USA R&D in collaboration with MOH & Teaching

Hospitals)

Translational research on Nasopharyngeal Cancer and other types of Cancer (IRAC, AvL and

partners)

Our Partners

• 62 international partners

• 51 new national partners

• Leading national consortiums

Synergy of Program

Health/ Patient Care • Center of Excellence

• Improvement quality (JCI Accreditation)

• Sharing Facilities: CT Scan, MRI, Gamma Camera, ICU – not only 3 hospitals

• Sharing health professionals: send specialist to referral hospitals

• Send senior residents for health services and training

• Referral system

Organization of UGM Academic Health System

Advisory Board

Board of Directors

Education Coordinating Board

Research Coordinating Board

Patient Care According to each hospital

(Department & Group of Medical Staff)*

Education Coordinator

Research Coordinator

Health care Coordinator

Community Service Coord.

Functional coordination

system

⑤ CHALLENGES AHEAD

1. Share vision on common agenda

2. Forming the leadership team & shaping its accountability

3. Include all stakeholders in the process of integration

Synergy of operational governance: patient

care, education, research (including

recruitment, capacity building, career path,

accountability, & insentive)

Synergy of organizational structure and

financing

Summary

• Academic Health System, with one established faculty of medicine, university hospitals, referral hospitals, and primary care in surrounding areas seems promising because lack of facilities, workforces, and funding could be shared together to improve community health care

• All effort should be made to share the idea to all

stakeholders: government, universities, all ministry involved to fasten the program

• Key success factors of AHS: Optimal Leadership, Strategic Organization, & Good Governance

Acknowledment

• Prof. dr. Ali Ghufron Mukti, MSc., PhD. • Prof. DR. dr. Teguh Aryandono, SpBK (Onk) • Prof. dr. Ova Emilia, PhD. • dr. M. Syafak Hanung, MSc., SpA • Prof. dr. Arif Faisal, SpRad • Prof. dr. Budi Mulyono, SpPK, PhD. • Prof. dr. Laksono Trisnantoro, PhD. • dr. Alida Lienawati, Mkes. • et all.