A Conceptual Model of Indonesia Hospital Accountability
In Hospital Reformation Era
Andi Indahwaty, Faculty of Public Health, [email protected]
Indrianty Sudirman*), Faculty of Economics and Business, [email protected]
Hasanuddin University, Makassar INDONESIA
Abstract :
The research aimed to develop a conceptual model of the hospital accountability in
Indonesia during the era of hospital reform. The research was conducted by using two stages,
namely: (1) developing the conceptual model by using the qualitative method based on
collected data from the hospital experts, academicians, managers, regulators, legislators, and
hospital owners, and (2) verifying the measurement model of Indonesian hospital
accountability in the health service in the hospital reformation era by using the confirmation
factor analysis with 360 samples by significant statistics on ≥ 0.3 using an accidental
sampling technique from 46 hospitals in Indonesia. The research result indicates that the
hospital accountability dimension comprises 2 (two dimensions) namely: responsibility and
transparency. The responsibility dimension is measured by 3 (three) variables namely: moral,
obligation, and rational decision; whereas the transparency is developed by 3 (three) variables
namely: visibility, understandability, utilization. This research is expected to significantly
contribute not only on the development of new conceptual model of accountability in the
field of hospital management, but also on the improvement of public health policy to be
endorsed by government in promoting more transparancy and accountablity of healthcare
sectors.
Key-words: Hospital, accountability, responsibility and transparency.
*) To whom correspondence should be addressed
1.
Introduction
Health care reform throughout the world have shifted the paradigm of academics,
researchers, and practitioners for health care system. In the 1980s, health sector has been
focused on quality and cost control, since the 1990s, accountability has become an important
issue due to the pressures of healthcare reform. This shifted was influenced by five factors.
The first factor is the existing of financing institutions in the healthcare reform era (Daniels
and Sabin 1998; Rowe 2006) . The second is the pressure of various hospital stakeholders to
provide health care more effectively, efficiently, safely, timely and equitable (Davidson
1999; Brinkerhoff 2001; Brinkerhoff 2003; Brinkerhoff 2004). Third, the movement of
sociodemographic (Charles, Gafni et al. 1999; Frosch and Kaplan 1999; Shiloh, Gerad et al.
2006). The fourth is the growth of hospital industry cause high competition . For that reason,
health care should be more transparent and accountable (Daniels and Sabin 1998; Brinkerhoff
2003; Allsop, Jones et al., 2004; Willging 2005; David.Hyman and Cannon 2009) Stewart
cite in et.al (Freeman, McWilliam et al. 2009). Fifth, the growing pressure on public
institutions to implement the principles of good governance (Eeckloo, Van Herck et.al, 2004).
Previous studies have developed the concept of accountability for hospital (Gamm
1996; 1996a; Emanuel 1996b; Pawlson and O'Kane 2002; Pawlson and OÂ'Kane 2002;
Lanier, Roland et al. 2003; Timmermans 2005; Willging 2005; Rowe 2006). Nevertheless,
there is still a gap between the concept of hospital accountability based on reformation era
with the concept of accountability has been studied previously. This leads to three gaps. The
first gap is differences in understanding, conceptualization, and dimensions of accountability
(Schedler 1999; Mulgan 2000; Bovens.M 2005). The next gap is related to theoretic and
empiric aspects. It is about the appropriateness of dimension and conceptualization of
accountability in the hospital context . The third is the comprehensiveness of accountability
concept and measurement of hospital. At this time, the development of accountability
concept in hospital is mainly focus on the accountability of the medical profession (Gamm
1996; Pawlson and O'Kane 2002; Lanier, Roland et al. 2003; Timmermans 2005; Rowe 2006;
Freeman, McWilliam et al. 2009). After formulating these ideas, it is concluded that there are
three important aspects of accountability ie what, to whom, and how accountability should
be implemented.
Empirical conditions showed that in Indonesia, it does not have the concept of
hospital accountability and measurement adaptively for healthcare reform era. The
definition of accountability is still related to public organizations generally. However, it is
needed the clear definition of hospital accountability. It is due to hospital has uniqe
characteristics comparing to other public organization. In addition, it has not,yet been
developed the mechanisms and dimensional hospital accountability comprehensively to
satisfy multiple stakeholders. Therefore, this research aim is to develop a conceptual model
and measurement of hospital accountability in Indonesia at the hospital reform era.
2.
Literature Review
The development of accountability theory followed the shifting of Public
Administration science paradigm from Old public management (1900 – 1970) to the New
Public Management (1980-2000 ). Today, the era of New Public Governance, which is begin
in the early 2000s (Osborne 2010). Accountability study began to be studied systematically
in the era of Old Public Administration (OPA) in 1940. The definitions and dimensions of
accountability were varied and there is no agreement about it (Schedler, A. 1999, Mulgan, R.
2000, Bovens.M 2005). The table below describes about the difference of accountability
definition based on the era of Administration, Old Public Administration, New Public
Management and New Public Service.
Table 1. The Difference of Accountability Definition
Old Public Administration
New Public Management
New Public Service
Responsibility to political
1. The
role
of
1. External control
party
entrepreneurship
2. Profession standard
2. Efficiency
3. Citizens preference
3. Cost Effectiveness
4. Moral issues
4. Market
pressure
5. Public law
Response
6. Public interest
Source : Denhardt and Denhardt, 2007
1.1 Accountability measurement
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To measure accountability, there are three important points that should be maintained,
they are what, to whom, and how the accountability process. All three of these questions are
so complex , it makes the accountability measurement is unlikely to to be implemented
easily (Bovens, M. 2007, Biela, J. and Y. Papadopoulos 2010).
Accountability measurements has been developed by two expert. First, wrote in 2007
Global Accountability Report (Lloyd, R., J. Oatham, et al. 2009). This report is the annual
report of thirty organizations about their accountability capacity to civil society based on
four dimensions such as transparency, participation, evaluation, and the mechanism of
complain and response.
1.2 Important issues of health care reform
Health care reform has some agendas, such as decentralization, providing services
efficiently, effectively, timely, safely, timely and equitably; cost containment, universal
coverage. These agenda influence hospital management. The government response to this
situation by establishing regulation that hospital organization must be organized as a Public
Service Agency (BLU), it is explained in section 7 of Constitution No. 44 in 2009 about
hospital and in section 51 stated that the revenue of public hospital organized by government
are directly used entirely for operational cost of hospital and it can not be used as a state or
local government revenue (2009) . Another regulation is the implementation of universal
coverage insurance system. This regulation has effect on hospital management even
professional behavior due to implementation remuneration, referral system and payment
method through Indonesia Case Base Groups.
This implies that hospital has greater responsibility and authorization to manage
resources, therefore hospital should be managed with the principles of Good Governance, one
of that principle is accountability (Taylor, D. W. 2000).
1.3 Accountability in the health sector
Nowadays, health sector has been reformed since 1990s era and the focus has been
shifted from cost containment and quality to accountability . One of health reformation
agenda is to promote public organizations including health care to provide services
efficiently, effectively, safety, timely and equitable. Accountability is one of aspect that can
influence or even a control tool for health care organizations to provide a qualified service
(WHO 2012). Beside that, accountability is used as a tool to improve the performance and
interpret mistakes as a lessoned learn (Brinkerhoff, D. W. 2004, Biela, J. and Y.
Papadopoulos 2010, Boeker, W. and R. Wiltbank 2005, Shortell, S. M. and L. P. Casalino.
2008).
1.4 Accountability measurement challenges in Indonesia
There are two main challenges in accountability measurement. The main technical
barrier is the hardness in measuring the impact of health care, but it is also because of the
data related to medical record data (Roper, W. L. and C. M. Cutler 1998). The second
challenge is the low development of health information system so that health care
information is difficult to access. Then, The existence of professional ethics and health care
ethics influence whether the information in hospital can be published.
3.
Research Methods
This study used a hybrid method consisted of two stages: the first stage is a
qualitative method and the second stage is a quantitative method. The qualitative method
applying an explorative study to develop a conceptual model and dimensional measurement
of hospital accountability in Indonesia at reformation era. While the quantitative stage used
hypothetical deductive by confirmatory factor analysis to measure the validity and reliability
of measurements of the dimensions of hospital accountability models in Indonesia.
3|Page
The qualitative stage of this research carried out three methods, in-depth interviews,
brainstorming, and a literature review. In-depth interviews were conducted on several key
informants are experts in the field of hospital management, such as hospital management
lecturers, public administration lecturer, management science lecturer, Professional
Association, Hospital Practitioner, the Hospital Board Supervisory, Regulator: (Former
Director General of the Indonesian Ministry of Health), legislator (Member of the House of
Representatives regarding health affairs), Director of Private Hospitals. These informants
were interviewed to explore their idea about 1 ) what is Accountability?, 2) what elements
should be accountable in the hospital at health reform area, 3) who should be accountable in
the hospital at health reform area,, 4) to whom the hospital should be accountable at health
reform area, 5) How to measure hospital accountability, 6) what mechanisms should be done
to assure accountability process. Based on in depth interview and literature review, it was
developed indicators of each variable. At the quantitative stage, these indicators was analyzed
through confirmatory factor analysis . The number of respondents are 360 who are the
management staff at the hospital in eastern Indonesia.
4. Results And Discussion
4.1 Stage I
All the transcript of in-depth interview was analyzed through the text of proxy of
experience ) counting words that mentioned by informant (Denzin, N. K. and Y. S. Lincoln
2011). The summary of the result showed by the following matrix :
Table 2 : The matrix of the text of proxy of experience
NO
Key Question
Definisi
1
Frekuensi
Unsur
2
3
4
5
Frekuensi
Siapa
Frekuensi
Kepada Siapa
Frekuensi
Mekanisme
Frekuensi
Answer
TGJW
9x
PRLAY
2x
TRP
5x
PRTSPS
1x
LYADM LYKEU
4x
4x
CHNBLETIKA RESP
1x
1x
2x
1X
1x
1x
LYDOKLYOBT LYPER LYAPO MULYKL
3x
3x
3x
DOKTER PRWT APOTK MNJR PSTDD PDDK
5X
5X
5X
5X
1X
1X
MASYK PEMLK PEMRTH PSTDD PDDK CINTL
6X
3X
6X
1X
1X
4X
LAPORAN XBANNER
FORUM
5X
ANSWERBLMWORT LIABLE STDR
3x
1x
1x
1x
PGSDM PGSAR PGKEU RENJA KBJKN SOP
1x
1x
1x
1x
1x
1x
CLPRV PROS AKR
ORTALA
1x
1x
1x
PEMLK SUPPL
1X
1X
PROFESI
1X
2X
Source : Primary Data, 2013
This matrix shows that the definition of accountability consists of responsibility and
transparency. Aspects that have to be accountable are administrative, financial, medical
services, and pharmacy. Furthermore, the subjects have to be accountable are doctors, nurses,
pharmacists and hospital management. Hospitals should be accountable to the society, the
owners and the government. The results of this matrix can be described as follows
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Transparency
Administrative
Doctor
Community
Financial
Nurse
Government
Accountable
Pharmasict
Pharmasict
Owner
Managerial
Medical
Service
Responsibility
Figure 1. Hospital Accountability
Responsibility is a number of tasks or functions lawfully performed by a worker,
professional organizations, courts or other organizations (Bivins, T. H. 2006). In addition,
responsibility is defined as a task given to someone related to the person's duties and
functions within an organization. So there are obligation, moral in the responsibility ( Shaw,
W. H., et al. (2010). Responsibilities in health can be divided into Professional
Responsibility, clinical responsibility, Medical responsibility, responsibility of the nurse and
managerial responsibility (Health, D. o. 2010).
In terms of transparency, transparency is the opennes of information and can be
accessed (Bauhr, M. and M. Grimes, 2012). Other important points that the visibility of
data and the reliability of data and the data can be used to evaluate an organization
(Garsten, C. and M. L. De Montoya ,2008).
Actors who should be accountable in the hospital are doctors, nurses, pharmacists and
managers. The four actors needs to perform tasks responsibly and do the transparency to the
public / patient, owners and government. Furthermore, the aspects has to be accountable is
the administrative, financial, pharmaceutical and medical services. These four aspects must
be done responsibly and transparent to the public / patients, owners and government.
The results of literature review concluded that the concept of responsibility is built by
three variables, its are moral, obligation, and bounded rational decision and the dimensions
of transparency composed by 3 (three) variables: visibility, understandable and utility. So the
conceptual model of accountability has been developed as follows:
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Moral
Obligation
RESPONSIBILITY
Bounded Rational
decision
ACCOUNTABILITY
Visibility
Understandable
TRANSPARENCY
Utility
Figure 2. Conceptual Model of Accountability
4.2 Stage 2
Then, indicators for each variable were developed based on the information of key
informants and literature review. There some aspects considering when developing these
indicators, ie implementation of social health insurance, accreditation, hospital regulation and
Hippocrates oath. The number of indicators for each variable as follow: moral (27
indicators), obligation (29 indicators), bounded rational decision (6 indicators), visibility (7
indicators), understandable (3 indicators), utilities (11 indicators). The validity and reliability
of this model are assured by applying confirmatory factor analysis. The loading factor of
each indicator was evaluated . The statistical significance is ≥ 0.30 for 360 samples (Tatham,
R. L. and W. C. Black 1998).
As for moral variables, there are 27 (81.1%) indicators measuring moral variable
significantly at the hospital. Moral is the standard of behavior that has a serious impact on
humanity (Shaw, W. H., et al. 2010). Sources of moral: justification, religious, ethical
relativism. (people’s habits). The implementation of moral in the hospital refers to principles
of bioethics: Respect for a person, beneficence, non maleficience, Justice and equity and the
economic beneficence (Beauchamp, T. L. and J. F. Childress 2001).
The second variable is obligations. There are 29 (87.9% of the developed indicators)
indicators that were significantly measuring bond variable at the hospital. Obligation is an
action which is done by someone who is bound morally and legally, a task or commitment.
The basic concept of Hobbes that basic obligation is to obey the laws of nature, all of the
obligations are from this concept (Nagel, T. 1959). Hospital obligation in Indonesia is
regulated by constitution 44 of 2009. Besides that, hospitals also have ethical and moral
obligations that must be considered while providing health services to the community. Some
literature examines the legal obligations of nurses ,physicians have moral obligation to
involve patient in decision making (Segall, M. 2003, Wang, X. 2002).
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The next variable is bounded rational decision , there are six indicators (50% of the
developed indicators) that were significantly measuring variable of Bounded Rational
Decision at the hospital. Decision making is an important element in the implementation
responsibilities. There was a theoretical model of bounded rationality (Simon, H. A. 1972).
This theory also considered the rational choice and recognizes the cognitive limitations of
the decision maker. Hospital has a rule of thumb when making decision patient prioritizing,
considering the principles of bioethics in health care.
As for visibility variable, there are 7 indicators (100% of the developed indicators)
measuring significantly visibility at the hospital. These indicators shows that hospital should
have website publishing up to date data. Transparency in the organization is connected to
visibility and the information presentation (transparency) (Garsten, C. and M. L. De
Montoya. 2008). Development web site has been done by some hospitals, in order to
facilitate employees so they can communicate with customers to provide a complete and
comprehensive information (Garsten, C. and M. L. De Montoya 2008, CHANG, C.-C.
2007).
There are 3 indicator (100% of the developed indicators) that were significantly
measuring variable of understandable at the hospital. These indicators show that hospital
should publish understandable data including information about quality of hospital..
Transparency is a form of organizational communication with stakeholders so that the
published information should be understood (Lee, S. M. 2003).
There are 11 indicators (100% of the developed indicators) that were significantly
measuring the variable of utilization at the hospital. The information provided to the public is
not just an information, but it is expected to be used to evaluate institutions. This study found
that, the aspects should be published are management, morale, quality, ethics, finance,
human resource competencies, educating the public about the duties of the hospital. These
findings added aspects of
published information in hospital because prior research
revealed that information published tended to focus on tariff (Gooch, A. 2008, Cutler, D.
and L. Dafny 2011, Sinaiko, A. D. and M. B. Rosenthal, 2011). Although in United States,
information about the performance of doctors have been published, but it is still debatable
(Millar, M. and D. McKevitt ,2000).
7|Page
Figure 3. Measurement Model of Accountability
5.
Conclusion
The concept of hospital accountability consisting of two dimensions, ie
responsibility and transparency. The dimension of responsibility is measured by moral (27
indicators), obligation (29 indicators), and bounded rational decision (6 indicators ). While
the dimension of transparency is measured by visibility (7 indicators), understandable (3
indicators) and utilization (11 indicators). All these indicators are connected to the
implementation of universal coverage and quality assurance in hospital. This study has
several weaknesses i.e : 1) the result of in-depth interview should be used as an object for
brainstorming; 2) there are some proposed indicators that are unlikely to be understandable
by the respondents so that the respondents did not give correct answers. It is proposed that
further research should be carried out to examine the implementation of this model.
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