Syntax Literate: Jurnal Ilmiah Indonesia �p�ISSN: 2541-0849 e-ISSN: 2548-1398
Vol. 7, No. 12, Desember 2022
ANALYSIS OF IMPLEMENTATION OF PATIENT
REFERRAL PROGRAM AT NAILI DBS HOSPITAL PADANG
Tuti Gusra, Rima Semiarty, Ida Rahmah Burhan ���
S2kesmas/Universitas Andalas, Indonesia
Email: [email protected], [email protected], [email protected]
Abstract
ReferBack Program is one of BPJS health flagship program. The implementation of the ReferBack Program will benefit many parties, be it patients, FKTP, or FKTL. The high referral rate is not balanced with the referback number which makes the buildup of patients in the hospital. Data from BPJS Padang in 2020 the totally of patients referred to FKRTL in 2019, and 2020 was 409,567 and 204,886 while the ReferBack figures were only 4,620 and 1,806 which showed referral rates of only 1.1% and 0.5%, meaning that from 100 visits to FKRTL there are as many as 1-2 patients who are then referred back to FKTP. This study aims to see the Refer Back Program in Naili DBS Hospital which is viewed from the input, processes, and outputs. This Research is qualitative research using system approach methods. The research was conducted at Naili DBS Padang Hospital in February - June 2021. The implementation of referback program at Naili DBS Padang Hospital in 2021 has not been carried out properly. In the input component there is no specific flow for patients with potential diagnosis of PRB. Input personnel are not competent, socialization to patients does not exist yet and has not optimal monitoring and evaluation from the leadership so that the implementation of the referback program has not been carried out in accordance with the target set by BPJS.
Keywords: implementation, referback program, qualitative.
Introduction
Individual health services that are the rights of
BPJS participants consist of first-level health services, second-level health
services and third-level health services. To get all these health services,
each participant must follow the service flow set by BPJS. Every health
facility in carrying out health services is required to carry out a referral
system by referring to the applicable laws and regulations (BPJS, 2014).
In order to improve access to advanced public
health services, BPJS implements a health service referral system, namely the
implementation of health services which regulates the delegation of tasks and
responsibilities of reciprocal health services both vertically and horizontally
that must be carried out by participants of health insurance or social health
insurance and all health facilities. The health service referral system is
carried out in stages according to medical needs starting from the first level
of health services by the FKTP, if further services are needed by specialists,
the patient can be referred to a second level health facility. Likewise with
third-level health services in tertiary health facilities, services can only be
provided on referrals from secondary health facilities and primary health
facilities (BPJS, 2014).
The utilization of health services through health
facilities in partnership with BPJS Health has increased from year to year,
both for the use of Primary Health Facilities (FKTP) and Advanced Referral
Health Facilities (FKRTL) (BPJS, 2017). In 2014, the total utilization of health
services was 92.3 million visits from 133.4 million BPJS Health participants
(69%), an increase in 2015 of 146.7 visits from 156.79 million participants
(93%) and an increase utilization visits again in 2016 were 162.9 visits from
171.9 participants (94%). It is concluded that BPJS health is widely accessed
by the public, both FKTP and FKRTL services. The high number of visits by BPJS
Health patients who access health services also raises several problems (BPJS, 2017).
One of the problems in health services that
partner with BPJS is the high number of visits to FKTRL but the low number of
patient referrals to FKTP, resulting in a spike in FKRTL which makes waiting
times long. The Padang City BPJS report stated that the number of patient
referrals referred to FKRTL in 2019, and 2020 were 409,567 and 204,886 while
the Referback Rates were only 4,620 and 1806 which showed a referral ratio of
only 1.1% and 0.5%, meaning that from 100 visits to the FKRTL there are as many
as 1-2 patients who are then referred to the FKTP (BPJS, 2020). Handling
chronic diseases takes a long time and costs a lot, so a program is needed to
prevent accumulation in secondary and tertiary health facilities (BPJS, 2014).
Referral Program is a health service provided to
patients with chronic diseases with stable conditions but still require
long-term treatment or nursing care carried out at first-level health
facilities on the recommendation/referral of the treating specialist/sub-specialist.
Types of diseases included in the referral program are diabetes mellitus,
hypertension, heart disease, asthma, chronic obstructive pulmonary disease
(COPD), epilepsy, schizophrenia, stroke and systemic lupus erythematous (SLE).
Participants in the referral program are participants with a diagnosis of
chronic disease that has been determined to be in a controlled/stable condition
by a specialist/sub-specialist (BPJS, 2014).
According to Dianita Pertiwi, there are three
factors that influence the implementation of the Referback Program implementation,
namely communication between specialist doctors and general practitioners,
limited human resources and program structures that are not in accordance with
SOPs (Dianita, 2017) while according to Oktavybudi, based on
the results of his research, the factors that play a role are through analysis
of man (human resources), material-machine (facilities and infrastructure),
method (method), market (environment), money (finance) and time (time). The
most influential factors are the availability of DRR drugs at the Puskesmas,
there is still a buildup of patients in FKRTL, human resources are still
lacking, notification of the status of patients who have the potential for DRR
in the BPJS program at FKRTL is ignored, still not compliant in filling out
referral letters from the FKRTL from related medical personnel and BPJS who
often experience budget deficits (Oktavybudi, 2020).
Naili DBS Hospital Padang is one of the Private
Hospitals of West Sumatra Province which is located in the city of Padang. The
hospital which started operating on April 4, 2016 as a Type C General Hospital.
This hospital which has a capacity of 52 beds is a reference from the FKTP in
the city of Padang and the FKTP in West Sumatra. Naili DBS Padang Hospital is
strategically located in the city center so it is very easy to reach by the
public (Naili, 2018). Based on a preliminary survey conducted
by researchers in January at Naili DBS Hospital in Padang by interviewing the
deputy director of medical services at Naili DBS Hospital in Padang, it was
found that the Referral Program has not been going well. This can be seen from
the data inputted to the West Sumatra Health BPJS that Naili DBS Hospital in
Padang did not reach the target number of Referback patients that had been
determined by BPJS Health. The patient's target for the Referback Program at
Naili Hospital DBS Padang is 40 patients in January 2021, but only 2 patients
are referred back (Naili, 2021).
Many things affect the implementation of the
Referback program, which makes the Referback Program not run well, including
those that have been obtained from the preliminary survey. This makes the
researcher want to do further research on the implementation of the Refer Back
Program at Naili DBS Hospital in Padang. Based on the explanation of the
problems above, the low referral rate at Naili DBS Hospital in Padang, the
researchers are interested in researching and digging deeper into the implementation
of the referral program at Naili DBS Padang Hospital based on a systems
approach that includes aspects of input, process and output (output).
Metode Penelitian
����������������������� This type of research is qualitative, aiming to get a deeper picture of information about the implementation of the referral program at Naili DBS Hospital in Padang. This research was conducted at Naili DBS Hospital Padang starting from February to July 2021. Informants in this study were directors, specialist doctors, PRB team. Informants in FGD (Focus Group Discussion) are patients. The tools used in this research are interview guide, FGD guide, observation sheet, document review, tape recorder and camera. Sources of data come from primary data and secondary data.
����������������������� Primary data were
obtained from direct observations, in-depth interviews with informants and from
the results of Focus Group Discussions, while secondary data came from written
sources in the form of documents related to the implementation of the referral
program at Naili DBS Hospital, Padang.
Hasil dan Pembahasan
Results
Informant Identity
In table 1 it can be seen
that in this study, primary data was taken using in-depth interviews, Focus
Group Discussion (FGD) methods with informants related to the Referral Program
in outpatient cases of National Health Insurance patients at Naili DBS Hospital
Padang. In addition, there is secondary data used to analyze the object of
research. The identity of the informants in this study are as follows:
Table 1. Identity of
research informants Analysis of the implementation of the Referback Program at
Naili Hospital DBS Padang in 2021
|
Code |
Informant |
Gender |
Years of service |
Pddkn terakhir |
|
Inf 1 |
Director |
Female |
6 th |
Master Degree |
|
Inf 2 |
Internist |
Male� |
3 th |
Specialist |
|
Inf 3 |
Internist |
Male� |
1.6 th |
Specialist |
|
Inf 4 |
Neuro specialist |
Female |
3 th |
Specialist |
|
Inf 5 |
Cardiologist |
Male
|
3 th |
Specialist |
|
Inf 6 |
Lung specialist |
Male
|
1.5 th |
Specialist |
|
Inf 7 |
Ka. installation RM ( Reni ) |
Female |
3 th |
Bachelor Degree� |
|
Inf 8 |
Officer PRB� (Linda) |
Female |
5 th |
Bachelor Degree� |
|
Inf 9 |
Ka. Outpatient Installation (ori) |
Female |
5.6 th |
Deploma |
|
Inf 10 |
Patient |
Female |
- |
Bachelor Degree� |
|
Inf 11 |
Patient |
Female |
- |
Deploma |
|
Inf 12 |
Patient |
Female |
- |
Senior High School |
|
Inf 13 |
Patient |
Male |
- |
Deploma |
|
Inf 14 |
Patient |
Male |
- |
Senior High School |
|
Inf 15 |
Patient |
Male |
- |
Senior High School |
The
flow of outpatient registration at Naili DBS Hospital
in Padang starts from the patient arriving (coming in person, referral from
another hospital, referral to puskesmas / FKTP 1,
etc.) getting a queue number at the registration counter, waiting at the
polyclinic, after treatment someone goes home, re-control, referred or treated.
Referral patients who still return to the hospital for re-control will receive
a control letter from the hospital. So that patients come to the hospital for
the next visit only bring a control letter. Referral patients who have received
therapy from a specialist doctor, and are declared stable, will be registered
for the Referback Program. The flow of the referral
program at Naili Hospital DBS Padang is shown in
Figure 1, namely:
Alur Pelayanan Fasilitas Kesehatan BPJS Kesehatan
Image 1. BPJS
patient service flow at Naili DBS Hospital in Padang
A.
Component Input
1.
Human
Resources
Naili DBS Hospital Padang has assigned a team for referrals and
concurrently from Specialist Doctors, pharmacy staff, Medical Record officers,
and nurses. The officer on duty at the PRB corner is the pharmacy officer. The
data entry clerk in the registration from the general section is not a medical
record officer or medical personnel.
2.
Policy
The hospital has a policy, flow and SOP for the referral program.
The policy issued by the Director in 2019, namely the Decree on the
determination of the DRR team, Flow and SOP. This policy was issued in an
effort to improve the quality of hospital services. But there has been no
update since the pandemic.
3.
�Infrastructure
Facilities and Infrastructure The results of the document review,
observation, in-depth interviews and FGDs revealed that the completeness of
infrastructure facilities in the implementation of the referral program was
completed and in accordance with the rules of the bPJS. The facilities in
question are all correspondence and the infrastructure referred to is the DRR
corner.
B.
Process components
1.
Communication
The PRB Team's communication with
officers is only limited to the wa group, there has been no face to face since
the pandemic. The officer reports the number of participants to the leadership,
to the staff via whatsapp group.
DPJP communication, and staff to
patients is good. The DPJP explained to the patient if he would be referred
back, and continued by the pharmacy staff who educated the patient, explained
the patient's participation flow, how to take medication and repeated visits to
the FKTP.
2.
Knowledge
The staff's knowledge of the
referral program is good. While the patient's knowledge about the referral
program is not yet. This is illustrated by the focus group discussion that most
patients do not know about the referral program.
3.
Leadership
Leadership at Naili DBS Hospital
Padang in the implementation of the DRR Program is in accordance with the
leader's function in monitoring evaluation. Monitoring evaluation directly to
the director, but not optimal because only through the WhatsApp group there is
no monitoring in the form of regular face-to-face meetings, both online and
offline.
C.
Output
Table
2 shows that the implementation of the DRR program has not met the targets set
by BPJS. From the results of in-depth interviews and observations as well as
the annual report, it was found that the target achievement was still very low.
Table 2. Achievements of
the Referback Program at Naili DBS Hospital Padang
|
Month |
Target |
Achievements |
Conclusion |
|
January |
47 participant |
0 |
0% |
|
February |
47 participant |
4 participant |
8.5% |
|
March |
47 participant |
5 participant |
10.6 % |
|
April |
47 participant |
1 participant |
2.1 % |
|
May |
47 participant |
3 participant |
6.4% |
|
June |
47 participant |
1 participant |
2.1% |
Discussion
Input Component
Human ResourcesThere is no special PRB officer at Naili DBS
Hospital in Padang and is an officer with concurrent positions. The Refer Back
Program can run well even though the implementing officers are double jobs (Oktavy, 2020). Human resources are one of the important things that must be
met, for the implementation of the program properly (Mutia, 2015). The division of work in the implementation of DRR at Naili DBS
Hospital in Padang, namely, the PRB team is tasked with socializing to all
parts of the Hospital, while in the field implementation, starting from the
registration officer who inputs data on potential DRR patients, the DPJP
examines the patient, determines whether the patient is stable or not, and
write prescription drugs to be taken at the pharmacy. This was then continued
by the pharmacy staff / PRB corner registering PRB patients, registering to
google docs, making copies of prescriptions for drugs to be taken for 23 days,
giving drugs for 7 days, and filling out the PRB patient control book.
The division of work at the Naili DBS Hospital in Padang is in
accordance with the PRB participant service flow published by (BPJS, 2017) participants come to register at the administration, are served
at the polyclinic by the DPJP, declared stable by the DPJP, a prescription is
written by the DPJP, then in the PRB corner SEP entry dispensary clerk (Vclaim) and google doc, fill in the completeness of the PRB
form and write a copy of the prescription on the SRB (BPJS, 2020).
Based on the results of research on officers who served in the
administration/data input section, data obtained that officers in the
administration from the general public were not medical personnel and were not
medical record officers who knew the patient's diagnosis. The officer inputs
the main diagnostic data repeatedly every time a patient comes. This has an
impact on the potential number of DRR which will increase, because the BPJS
system determines targets based on the patient diagnosis data base at the
Hospital. It finds that the officers on duty at the data entry desk for the new
patient registrations are not medical personnel but general officers. So that
at the time of inputting data for re-control patients, it was found that
patients would repeat themselves with the main diagnosis, which had a high
impact on the target of BPJS. So that the output of DRR implementation at Naili DBS Hospital in Padang has not reached the target set
by BPJS. Officers who are competent in their fields will make data entry
well done (Oktavy, 2020) This will have an impact on notification of potential DRR
patients. The correct diagnostic input will make the notification appropriate,
while the inappropriate input will increase the notification while the patient
cannot be referred back.
Policy
The existing policies at Naili DBS Hospital in Padang have not been updated since
the policy was first issued in 2019. Given the different conditions in the
field since the pandemic, mid 2019, but there has been no update to adapt to
the current pandemic conditions which is part of efforts to increase target
achievement. DRR. With clear guidelines, the achievement of an activity or
program will be better (Hasibuan, 2005) besides
that the policy must be consistent and optimal. Consistent in implementing
policies will make the program optimal. So that policies can be implemented
properly, must be consistent and sustainable in order to achieve what we want
to achieve (Jajat, 2020). Written
policies are important to the public so that the flow becomes certain so that
they can be implemented according to existing policies, besides the success of
implementing policies who make policies (Hasibuan, 2005).
Policy is the behavior of
officials, groups, government agencies or leaders in a particular field of
activity, related to the interests of groups, whether from the government level
or the general public. The policy in question is a regulation, decision,
instruction, circular or guideline that supports readiness in providing health
services in a referral program, a good and implemented policy will have an
influence on the implementation of a program (Hasibuan, 2005).
The SOP for the referral program at Naili
Hospital DSBS Padang is in accordance with the standards set by BPJS, and the
implementation of DRR is in accordance with standard operating procedures.
While the PRB flow is in accordance with the bpjs
flow, and has been implemented according to the flow. The plot has also been
displayed in the corner of the polyclinic. However, there is no specific flow
for chronic patients who are the criteria for PRB (BPJS, 2017).
Infrastructure
Facilities and infrastructure are important resources in supporting the implementation of the duties of officers working in health services in hospitals. With adequate facilities and infrastructure, officers will be able to work comfortably. The comfort of the workplace atmosphere will make the officer's performance better. The facilities and infrastructure in question are the availability of Referback Forms, control books, SEP, copies of prescriptions filled out by officers or DPJP and rooms used specifically for DRR rooms. Infrastructure facilities are already available at Naili Hospital DBS Padang. All forms are available and ready to be filled out by the officer.
The division of tasks for
filling in the flow of referrals for participants can be summarized in the
table below:
Table 2. Division of tasks for the
implementation of the referral program
|
Administration |
Polyclinic |
Drug store |
FKTP |
|
Entry Data dan SEP pasien |
Pemeriksaan oleh Dokter Jaga
/ DPJP Jika Stabil dituliskan di status untuk pasien rujuk balik dan
ditulis resep |
1. Entry
vclaim 2. Entry
google docs 3. Mengisi
formulir SRB 4. Memberikan
obat 7 hari 5. Membuat
copy resep� untuk mengambil obat di
FKTP |
Peserta
datang membawa buku kontro; SRB dan copy resep untuk mengambil obat 23 hari |
Facilities that support work will be related to the performance of officers. The available facilities and infrastructure will increase productivity (Herman 2016). Facilities are the most important aspect in the smooth running of the organization. In an effort to increase comfort, it is necessary to have supporting facilities so that it can provide satisfaction to patients.
Naili DBS Hospital Padang provides a PRB corner which is combined with the Pharmacy room. This is in accordance with the rules of BPJS (2017), the PRB corner is combined with pharmacies in order to optimize services to patients and make patients not have to go back and forth in the management of Referback. So that the service becomes more efficient (Dianita, 2017).
Process Components
Communication
The communication studied in this study is the communication of
the PRB team to the officers and the communication of the DPJP and the officers
to the patients about DRR. Communication to officers is provided in the form of
socialization, follow-up and ongoing counseling. Since the Pandemic, the
communication between the PRB team and officers/DPJP has only been limited to whattsapp media. The importance of communication here is in
accordance with the two-way research that communication is important in
influencing the implementation of back-and-forth, good communication will make
the achievement of more satisfactory results.
The officer's communication in this case the DPJP to the patient
has been running according to the SOP. DPJP informs the patient that his
condition is stable, fills in the patient's status and writes a prescription
for medicine to be taken home, and explains it to the patient. After leaving
the patient's polyclinic Specialist doctors in FKTL have the authority to start
the service stage, determine stable patients, educate patients and write
prescriptions for Referback participants. The
patient's belief in the words of the specialist doctor is very influential on
the acceptance of the situation and must be referred back. Likewise, additional
explanations from officers will make patients feel happier and want to be
referred back (Dianita, 2017).
Knowledge
The higher the officer's understanding of the Referral Back program and understanding of the DRR Guidelines, the more concerned officers/DPJP will be with patients. patients with a diagnosis of 9 PRB criteria. Increased knowledge of officers / DPJP will make officers / DPJP feel more comfortable and do not hesitate to refer patients back to FKTP. Meanwhile, the perception of specialist doctors towards primary care physicians influences the DPJP's decision in referring back patients. If the DPJP knows that the patient can return to the hospital if it is not stable, or under certain circumstances, then the DPJP does not feel burdened by referring the patient back to the FKTP (Dianita, 2017).
The high knowledge of DPJP will make DPJP more consistent in making decisions. In addition, DPJP is also more sensitive to notification of DRR patients so that it will reduce notification of status of potential DRR patients in the Vclaim program at FKRTL which tends to be neglected (Jajat, 2020).
Patient knowledge of DRR at Naili DBS Hospital in Padang is still low, this is because there has been no socialization of the PRB team to patients since the pandemic. This is in accordance with the lack of socialization to the community, this is because there is no special evaluation method from BPJS in the process of monitoring or periodic evaluation (Kemenkes, 2020). In addition, there is no forum to increase public knowledge about the Referral Back Program from BPJS (Oktavy, 2020) if the patient orientation towards specialist services is better. Patients feel that access to specialist doctors is often limited due to referrals made by doctors from health facilities 1 (Ginting, 2016) Implementation of the Referback Program for Health Services at the Health Service Plus Health Center stated that the procedures for implementing DRR and the process of implementing DRR have not been implemented properly, because the community does not understand the benefits DRR. People tend to feel disadvantaged if they are referred back to the FKTP (Ministry of Health, 2020).
In this study, the researchers suggested that Naili DBS Padang Hospital could provide more knowledge to
patients/potential DRR participants with active, periodic socialization and
also through promotional means such as leaflets, banners, grooves that were affixed/placed
in places that were easily seen by patients and hospital visitors. or through
educational videos that are shown on the TV waiting room at Naili
DBS Hospital in Padang.
In
addition, the researcher suggests that there should be a forum for
communication between officers and DPJP to increase the knowledge of officers
and DPJP. Communication can be through zoom meetings, video calls, special
groups or regular meetings to increase the knowledge of officers and DPJP. So
that officers and DPJP understand and are aware that the patient must be
referred back if it meets the PRB criteria.
Leadership
Monitoring is carried out by the director in the whatsapp
group and appreciation is given in the form of thanks to DPJP for referring
back patients. This marks the main task of the leadership is not optimal, where
the head of an agency has the main task of coordinating, supervising and
evaluating all activities and personnel in the agency (Raymanel, 2012).
Leaders need a leadership style that is visible or invisible to
subordinates (Rivai, 2014). The leadership style requires 3 basic
patterns, namely the importance of carrying out tasks, the importance of
cooperative relationships, and the importance of the results achieved.24
Effective leaders also apply various forms and sources of power that are
suitable for the same followers (Thoha, 2014). While the ideal leadership style is
determined by the type of employees themselves (Ambarwaty, 2015).
The leader, in this case the director of Naili
DBS Hospital in Padang, has a role as a supervisor for the implementation of
DRR, tiered follow-up from the director to the DRR team and the DRR team also
reports to the director. The results of in-depth interviews about leadership
showed that the monitoring and evaluation of the leaders had not been
maximized.
C. Output
The output of this research is the implementation of the Referral
Program at Naili DBS Hospital in Padang has not
reached the target of BPJS so that an evaluation is needed because the DRR
target has not been achieved at Naili DBS Padang.
Conclusions
The results of the research on the implementation of the Referback Program at Naili
Hospital DBS Padang were less than optimal, especially the input and process
components, causing the output to not reach the target set by BPJS. Human
resources are not optimal in the implementation of the Referback
Program at the Naili DBS Hospital in Padang. The
Hospital's Policy on Referral Programs has not been updated. The SOP for Referback at Naili Hospital DBS
Padang already exists, in accordance with BPJS rules. Referral patient flow has
not been updated since 2019. There is no specific flow for potential re-control
patients for PRB. The PRB corner is available at Naili
DBS Hospital in Padang. The process is good communication between DPJP and
officers to patients. The patient's knowledge is still lacking about the Referback Program. Monitoring evaluation from the
leadership has not been optimal. So the Refer Back Program at Naili DBS has not reached the target set by BPJS.
Socialization of the DRR team to administrative officers to
find out the data input of potential DRR patients. The Director makes a policy
on periodic evaluation and monitoring that adapts to the current pandemic
conditions. You don't have to face to face in the room, but you can do zoom
meetings or group video calls. The hospital optimizes the function of the PRB
corner for patient education. Increased knowledge of doctors with periodic
socialization as well as reminding DPJP to pay more attention to patients with
potential for DRR. Reactivate periodic socialization to patients from staff.
Periodic monitoring and evaluation from the head of the Refer Back Program at Naili DBS. Activate risk management at Naili
DBS Hospital Padang.
BPJS provides an explanation/socialization about the
referral program, SOPs, targets and how to achieve targets in hospitals.
Socialization of Referback Program to FKTP. Provide a
means for registration officers to code for unstable patients so that they
cannot be read by potential. It is hoped that BPJS will carry out ongoing
socialization about the benefits of BPJS Health insurance in order to increase
JKN and DRR participation. It is necessary to form a Monitoring and Evaluation
Team to oversee the implementation of DRR.
