Analysis on Implementation of Clinical

Performance Standard Tool in Delivery Room

Panyabungan District General Hospital of
Mandailing Natal District North Sumatera Province
1 2 3
Liza Mouliza , Khairuman Yahya , Fatni Sulani
1,2
Public Health Faculty,3EMAS Program North Sumatera, 1,2Sumatera Utara University.
Medan North Sumatera, Indonesia
Correspondence should be addressed to:liza.mouliza@gmail.com and khairum4n@gmail.com

Abstract─ Maternal deaths in the world including in Indonesia is

still quite high, in Indonesia, many death cases occur in emergency
conditions during labor or postpartum both in the time of pre-
referral or in the hospital. The Health Ministry of Indonesia has
already issued Guidelines of Emergency Obstetric and Neonatal
Comprehensive Services (PONEK) 24 hours in the hospital to
standardize the service on maternal emergency and the newborn.
However, some PONEK hospitals still have not implemented this
standard well because there is no standard system of monitoring
and evaluation for the implementation. Since 2015 Panyabungan
District Hospital is already implementing a self-assessment system
using Clinical Performance Monitoring Tool (APKK/Alat Pantau
Kinerja Klinis) to assess the PONEK standards in the delivery
room. APKK is a tool that initiated by a cooperation program by
the Ministry of Health of Indonesia through EMAS (Expanding
Maternal and Neonatal Survival) Program funded by USAID.
The purpose of this research is to analyze the effectiveness of
implementation of APKK to improve the quality of maternal
emergency services and the newborn in the delivery room. This
research was conducted with qualitative approaches through the
in-depth interview and observational design. Informants in this
study were 10 midwives on duty in the delivery room with
triangulation informants were the Head of units: Delivery,
Emergency, Perinatology, Operating Room, Deputy Director of
Health Services and the Director of RSUD Panyabungan. The
result of this research; there is no legal policy of APKK team;
there is a special team responsible for conducting the self-
assessment routinely per three months in delivery room; the self-
assessment results become the basis for decision making by the
hospital management to complete needs of medicines, medical
equipment and supporting facilities needed to improve the service
in the delivery room. The APKK helps the hospital to identify the
needs of supporting facilities, human resource, and other needs to
improve service quality of PONEK hospital. Policy from the
hospital management to support the sustainability of the APKK
implementation in RSUD Panyabungan is still required.
Keywords─Self-Assessment, Clinical Performance Monitoring
Tools, Monitoring & Evaluation
I. INTRODUCTION
Maternal mortality in the world is still quite high,
according to a study released by The Lancet on 8
October 2016, the number of maternal deaths on
worldwide in 1990 amounted to 390,185, in 2015
maternal death is 275,288 (down to 29%). In
Indonesia, in 1990 the number of maternal deaths is
18,715 and then in 2015 maternal death is 8,937
(down to 52%). However, maternal mortality rate in
Indonesia is still quite high compared to the MDGs
target by 2015 (102/100,000 live births) and the
SDGs target on 2030 (70/100,000 live births).
Maternal deaths often occur in prereferral, referral
and in health facilities. The Ministry of Health has
issued numbers of policies to reduce maternal
deaths, like Integration of Obstetrics and Neonatal
Basic Emergency Services (PONED) in first level
health facilities and Obstetrics and Neonatal
Emergency Comprehensive Services (PONEK) in
referral health facilities for 24 hours and 7 days a
week.[2] At referral hospitals, to carry out the policy
the government has issued the PONEK guideline,
trained the health workers and prepared the
infrastructure and medicines for obstetric and
neonatal care.
In the implementation some hospitals that have
been designated as PONEK hospitals still have not
implemented all the PONEK indicators, this is
happening because there is no monitoring and
evaluation system for PONEK hospitals. In 2012 the
Ministry of Health launched the Expanding Maternal
and Neonatal Survival (EMAS) Program which is
funded by USAID and implemented in 6 provinces
that contributed the largest number on maternal and
neonatal deaths in Indonesia i.e.: North Sumatra,
Banten, West Java, Central Java, East Java and
South Sulawesi. The approach taken in this program
are: 1) Improvement in Clinical Emergency Services
in health facilities; 2) Increase the Efficiency and the
Effectiveness of the Referral System and 3)
Accountability Strengthening to improve policies
and resources. EMAS Program develop one
standard evaluation tool for clinical emergency
services in health facilities called Clinical
Performance Monitoring Tool (Alat Pantau Kinerja
Klinis/APKK) to evaluate quality improvement of
services in order to standardize and develop the
professionalism of health workers in hospitals to
accelerate the reduction of maternal mortality rate
(MMR) and infant mortality rate (IMR).
Quality improvement process aims to change
"actual practices" to "best practices" through the
quality improvement cycle called Plan-Do-Check-
Action (PDCA). There are some important keys that
can make this quality improvement process ongoing,
i.e.:
 The involvement and ownership of all officers /
staff.
 Patients Oriented
 Focusing on systems and processes
 Be aware of costs and efficiency.
 Continuous learning, development and capacity
building
 Sustainability of the quality improvement
Meet those keys, the process of quality improvement
can be run following the cycle as shown in Figure 1.
Make a follow-up
Assesment and
plan (Plan)
Analysis (Action)
Current
Best
Practice
Practice
Monitoring and
Evaluation (Check)
Implementation of
the follow-up plan
(Do)
Figure 1. Quality Improvement Cycle
This cycle begins with data collection and analysis.
The purpose of the data collection and analysis is to
identify gaps between existing conditions with the
desirable conditions/standards in maternal and
neonatal emergency services. The activities carried
out together with the team and the actors in the
health facility which consists of head/deputy head of
the related units, the head of related departments,
including the committees, the assessment baseline
form conducted with participatory assessment
system, so that officers at all levels involved from
the beginning within efforts that related to quality
improvement on framework for implementation of
good clinical governance.[1]
The APKK is a tool to build managerial capacity,
the performance capabilities of health personnel,
standard medicines, medical equipment, facilities
and infrastructure needed to provide obstetric and
newborn emergency care in a hospital. There are 4
APKK clinical indicators for a hospital: maternal
indicators, neonatal indicators, governance
indicators and infection prevention indicators that
are used to push the entire structural and functional
components to improve maternal and neonatal
emergency services.
The method of APKK implementation is
independently by the person who responsible in the
delivery room and within discussion every three
months to evaluate the progress and make plans to
achieve performance indicators consist in APKK.
The application of the tool is to identify performance
gaps that should be minimized or eliminated.
Managers and officers can analyze the causes of the
gaps and implement appropriate interventions to
improve it - for example; The emergency trolleys are
not ready, emergency medicines and equipment are
not always available, maternal and neonatal death
and or near miss cases study are not done, lack of
knowledge and skill of the midwives and others.
Managers are encouraged to make action priority
and start with a simple intervention in order to
achieve an early tangible result so as to create a
momentum for change and acquire update skill and
knowledge on the management of maternal and
neonatal emergency cases.
Panyabungan District Hospital of Mandailing
Natal is one of the model hospitals to be among five
other hospitals in North Sumatra province that were
intervened by EMAS Program. The APKK used as a II. RESEARCH METHODOLOGY
tool in concept to help facility to improve and at the
same time can be used as an evaluation tool for1. 1. Research Subject
PONEK hospital standard. The subjects of this study were taken purposively
Based on results of baseline data at the time the to get information in line with the purpose of
program intervention started in Panyabungan research. Based on predetermined criteria that are
hospital in September 2015, obtained the result: served in Panyabungan hospital with working period
maternal indicators 28%, neonatal indicators 20%, > 1 year, was not on leave or are continuing their
governance, and infection prevention indicators education.
were 0%.
From the results of the assessment using APKK 2. Research Method
found: Primary data were collected by in-depth
1. Maternal and neonatal indicators: no emergency interview with 10 midwives in the delivery room as
team, medicines, equipment, standard key informants and interview with triangulation
procedures (SOP), knowledge and skill on informants, i.e. the Head of the delivery room, head
maternal and neonatal emergency management. of Perinatology room, head of the emergency room,
2. Governance indicators: the dashboard and and head of Operating room, Deputy Director of
death/near miss cases review have not been Health Services and Director Panyabungan Hospital.
implemented; no Standard Chartered services Furthermore, the observation and analysis of the
and patient satisfaction mechanism yet. Performance achievement standards in line with
3. Infection Prevention/IP indicators: no standard APKK.
infection prevention equipment, standard
procedures (SOP), no team and guidelines of 3. Data Analysis
PPIRS (Hospital Infection Prevention and Data was processed in line with the
Control) yet. characteristics of content analysis: data processing
and data reduction by making the coding and
Based on the pre-survey results conducted in early categories, data presenting and make a conclusion.
January 2016 together with Management Team and
Head of Delivery Room Unit Panyabungan III. STUDY RESULT
Hospital, found that APKK is very helpful in
identifying the needs of completeness emergency Implementation of APKK in the delivery room was
service standards in the delivery room to improve the not run optimally. There is already a team responsible
quality of maternal and neonatal services. for the implementation of APKK but there is no
Therefore, researchers wanted to see more about the legality / decree (Surat Keputusan/SK) of APKK
effectiveness of APKK as a tool to evaluate PONEK team. APKK assist management in identifying the
policy implementation in the delivery room of resource needs of a hospital to run the service i.e.
Panyabungan Hospital. medicines, medical equipment, human resources and
For a policy can be implemented effectively, it must infrastructure necessary to improve the quality of care
meet the "four right", i.e.: 1). Policies Right; 2) in PONEK hospitals.
Implementing Right; 3).Target Right; and 4)
Environment Right.[3] 1. Team Legality
In the delivery room, there is a team of three
midwives who perform independent assessments
using APKK, 5 out of 10 key informants stated that
there is no legality/decree (SK) issued by the
hospital management related to the implementation
team. Another 3 informants stated they did not
know about legality / SK for APKK team . 2
informants did not even know about APKK team.
This is related to the statements from informants in
Box 1.
Box 1.
"APKK team? What is it kak? ... "(I6)
"... Who made a checklist right? yes there are
midwives who do the checklist, about the SK I do not
know for sure... "(I10)
"... yes ... there is a team of three midwives, but we
do not have the SK, we just do the check list then we
report ..." (I2)
"... There is still no SK ...we wanted to make one ...
but somehow it still on process..." (IT1)
"the SK is yet to be made but there are midwives
appointed for the APKK implementation" (IT5)
The depth interview can conclude that the team for
implementation of APKK is already designed in the
delivery room, but not their legality /no official
decree issued by the hospital management.
The absence of an official decree on the APKK team
cause less responsibility of the team member for the
implementation of APKK. To complete a
responsibility, a Decree (SK) need to be issued by
the hospital management which contains the official
designation to certain people as the implementation
team including their duties and responsibilities. This
is reflected in the statements in Box 2.
Box 2.
"... Usually, they made it every three months,
sometimes they made it some time they did not..."
(I3)
"actually it should be made every three months...
sometimes if you have not been asked by the head of
the unit we just forget ..." (I1)
APKK need to be used routinely to assess the quality
of service in the delivery room. APKK need to serve
as a policy which makes the midwives in the
delivery room identify the needs in the room and
then report it to the management to improve the
quality of maternal and neonatal services. So to
ensure the implementation of APKK, legality in the
form of SK Team is necessary.
2. Implementation of APKK
In APKK there are four indicators considered:
maternal indicators, neonatal indicators,
governance indicators and infection prevention
indicators. A thorough assessment of the four
indicators is carried out routinely every 3 months to
identify the needs of medicines, emergency
equipment, and infrastructure needs for maternal
and neonatal emergency services. The assessment
carried out independently by the APKK team in the
delivery room. The assessment results reported to
the hospital management to meet the needs of
medicine, equipment, facilities and infrastructure
that is needed for the services.
All key informants stated the assessment result
by APKK is helpful in identifying the needs of the
delivery room as seen on the statement in Box 3.
Box 3
"...After we do the checklist, it will appear
medicines what is lacking, what tools we have not
had, how many of our human resources are lacking,
which SOP we do not have yet ..." (IT1)
"... We do the checklist in ER because for early
admission the patient management performed in the
ER ... and then the patients were taken to the
delivery room" (IT3)
APKK usage not only perceived benefits in the
delivery room. This is also done in 3 other rooms,
Perinatology room, emergency room/ER and
obstetric operating room because of these three
rooms are closely related to the handling of cases of
maternal and neonatal emergencies. This is
consistent with the statements of three triangulation
informants ie head of perinatology unit, Emergency
unit, and obstetric operating room.
3. APKK Activities
Maternal indicators assessment identified needs
fulfillment in terms of:
a. Emergency response
Related needs of equipment, drugs, human
resources, SOPs, job aids / algorithms.
b. The third stage active management (MAK3) of
labor, postpartum hemorrhage, severe pre-
eclampsia/eclampsia, sepsis and obstructed
labor.
c. Increase midwives competency in the delivery
room through training / emergency cases drill
and clinical skills assessment of midwives for
the maternal emergency cases management.
Neonatal indicators assessment obtained:
a. Emergency response on neonatal emergency
cases including equipment needs, medications,
SOPs, human resource, job aids / algorithm.
b. Sepsis case management, complications of
premature, early breastfeeding initiation,
exclusive breastfeeding, and kangaroo care
method.
c. Increase midwives competency through training
/emergency cases drill and clinical skills
assessment of midwives on neonatal emergency
cases management.
The governance indicators assessment obtained:
a. Monitoring of clinical performance by making
the delivery room dashboard to monitor and
evaluate trends of activity and quality of the
service.
b. Study on maternal and neonatal death and or
near miss cases for learning in order to improve
the quality of services.
c. Assessment of patient satisfaction through the
provision of media for delivering advice and
complaints.
Infection prevention/IP indicators appraised:
a. Guidelines, hospital infection prevention team,
completeness SOPs of Infection Prevention.
b. Direct assessment and observation on IP
practices in the delivery room.
c. Preparation and implementation of
decontamination and sterilization.
d. Medical waste management.
Once the assessment is done using the APKK the
team will discuss the findings before reported to the
hospital management for the fulfillment of their
needs.
According to three key informants and one
triangulation informant the reporting results will be
followed up by hospital management, but in the
process, it is not as smooth as expected, sometimes
the fulfillment was easily obtained, but sometimes
they also have to wait for budget adjustments. This
is in line with the statement of the triangulation
informant 5 and 6 which stated that the procurement
of medical equipment and medicines should follow
the rules as stated in Box 4.
Box 4.
"... The medicines are sometimes available but
sometimes runs out ... it takes time and we need to
wait for the medicines procurement... sometimes we
need to ask the patients to buy the meds first" (I5)
"It is hard to ask for tools, our incubator had broken
for a long time but not replaced instead ..." (I2)
"For the tools/medical equipment, we need to follow
the e-catalog procedure ... we have to wait the new
budget period to buy new tools" (IT6)
4. Communication
Two out of 16 informants stated that
communication is not well established, they said that
APKK that have been prepared are not well
socialized to all midwives. One informant stated
good communication already established with other
midwives. As shown in Box 5.
Box 5.
"... The APKK was not well described so I think
the communication was not so good ..." (I5)
"It does not seem well ... for example no
dissemination of the contents of APKK, what is
our responsibility, we work according to a routine
shift, we read the information on the board and
ward notebook, and we discuss the cases. If there
is a problem in our room we consult to our
supervisor ... "(I3)
"..We used to fill the APKK matrix with a checklist
and analyze it on a computer, some other indicator
results were explained to the staff." (I2)
Three informants stated communication with the head
of the unit is good. It can be seen from the actions
taken such as providing warning and conduct joint
discussions if there are problems in implementing the
tasks, as contained in Box 6.
Box 6
"The head of the maternity ward is quite good, if there
is a mistake we will be warned, but there are some
midwives who work carelessly, patient information,
midwifery notes is not filled properly. If there is no
settlement we consult it to the hospital director "(I4)
It is not in line with two triangulation informants
stated that socialization of APKK has not given in
detail because of the head of the unit was too busy.
As shown in Box 7.
Box 7
"It has been socialized e.g. about emergency
team in the delivery room as I have already
explained....I have explained about APKK but not to
all of them, I do not have much time...I also have
many other things to do ..."(IT1)
Program socialization needs more improvement
and needs more effort to achieve strong
internalization values from the staff. Because of
vague understanding of the policy makes the
implementation not working well as expected.
Existing forums such as monthly meeting should be
used optimally to confirm the purposes and benefits
of implementation of APKK to the midwives in the
delivery room.
Head of the delivery room has been trying to
communicate all problems that occur in the service
and try to find the resolve together. Communication
is the source of program information, carried out by
all midwives and other staff in the delivery room. So
the communication problem can be overcome and the
policy can implement easily, smoothly and precisely.
5. Resources
a. Fund/Budget
Five informants did not know the source and the
amount of the funds/budget in each program e.g.
APKK. As disclosed in Box 8.
Box 8
"We do not know about the funds and the problem
connected to the funds"(I8)
But there are two informants declared that the
source of the funds was from EMAS Program, but
they do not know the amount of the funds
provided. As mentioned in Box 9.
Box 9
"We did not receive any funds, all the activities are
still supported by EMAS, and it all manage by the
hospital management."(I2)
This is in line with the statement of three
triangulation informants that the funding comes from
EMAS. As shown in Box 10.
Box 10
"Sources of funding for the APKK training, the visit to
a model facility in Deli Serdang district and the
mentoring activities are supported by EMAS."(IT6)
Resources within the Program implementation of
APKK is a major factor in the success of the program.
Therefore we need a reliable resource. Not only
limited to human resources, but also other resources
such as financial and material. Insufficient funds are
one factor that contributes to the implementation of
APKK. Instead, an immediate or timely incentive is
going to be one of the motivating factors for the
employees to work well and continuously.
b. Human Resources
There is one informant who claimed that there
was a training on APKK implementation program
once in 2015, the personnel in charge of APKK
implementation already pointed but there is still no
legal decree. As disclosed in box 11.
Box 11
"To support APKK implementation there was a
training once. APKK benefits are in terms of
recording and reporting when we proceed it if there is
a case we have notable evidence. APKK is good for us
to improve the midwives performance, but not very
actively used because of less routine training on how
to use it, but yes we do not have the decree from the
hospital director... "(I1)
This is in line with the statement of two triangulation
informants, the training for the midwives obtained
during the visit and mentoring by EMAS Program
mentors. As shown in box 12.
Box 12
"The human resource is still lacking, especially for
running APKK program, so far only a few people are
given the responsibility to fill the APKK in the delivery
room."(IT6)
Generally, all midwives in the delivery room know
about APKK when they were visited and assisted by
the EMAS Program mentors. The midwives in the
delivery room feel overload in the workforce, they
have difficulties in carrying out the tasks due to the
midwives are in charge for several programs at once
including patient services, administrative tasks such
as preparing reports, and many other routine tasks
di delivery room.
c. Medicines, Medical equipment,
Infrastructures
Out of seven, four key informants stated
medicines, medical equipment and infrastructures
provided to the fulfillment of the indicators in APKK
as disclosed in box 13.
Box 13
"In terms of medicines, medical equipment, and
infrastructure I think we are getting better now,
emergency medicine was more complete, we use the
standard in clinical monitoring tool ..." (I4)
Without it, the tasks cannot be performed and
the goals cannot be completed as intended. The
availability of infrastructure is an important
determinant of performance policy. The
implementor must receive the resources needed
to keep the program running smoothly.
Although the policy has clear objectives and
targets, in the absence of adequate resources,
the policy only stay at the paper documents.
Actually, infrastructure (equipment / facilities)
of a program are the type, quantity, adequacy,
appropriateness and feasibility of the physical
facilities owned by a hospital. [6,7]
APKK is one effective method to evaluate PONEK
standards in hospitals. With the simple filling
method and can be referenced in discussions
ranging from the executive level in the delivery
room to management level, to see the achievement
and the target indicators of the standard expected.
Based on the results of APKK that have been
implemented in Panyabungan hospital since
September 2015 until September 2016, visible
achievement of clinical standards of ongoing
improvement, as seen in Figure 2-5. This proves
effectivity of APKK used in quality improvement
cycle of service with the concept of Plan-Do-check-
Action.

"Protective equipment are still less, sometimes we do

not wear gloves, some were torn so it is not good
anymore...we want to wear it but we do not have the
good gloves..." (I6)

It is not compatible with the information

expressed by three triangulation informants that
infrastructure is already available as evaluation Figure 2. Trend of Clinical Indicator Performance Standard Achievements on
results of the APKK assessment. Indicators of RSUD Panyabungan (Sept 2015 until Sept 2016)
medicines compliance, medical equipment,
facilities and infrastructure already following
standard indicators for PONEK hospital.
Achieving PONEK goals policy should be
supported by the availability of medicines,
medical equipment, and infrastructure needed.

Figure 3. Trend of Clinical Hospital Performance Standard Achievements on
RSUD Panyabungan (Sept 2015 - Sept 2016)
Figure 4. Trend of Fulfillment on Maternal Emergency Trolley
Figure 5. Trend of Maternal Death and Near miss Cases Review
IV. CONCLUSION
Implementation of Clinical Performance
Monitoring Tool (APKK) in the Delivery Room of
Panyabungan hospitals Mandailing Natal effectively
assist in the evaluation of the PONEK hospital, even
though its implementation in delivery room of
Panyabungan hospital is not running optimally
because not all health workers/midwives in delivery
room involved, there is no legality / SK for APKK
team. The implementation of APKK in
Panyabungan hospital as evidenced by the following
results:
1. There is no legality for APKK team yet, it makes
the member of team or person in charge has not
met responsibility for routine assessment.
2. Implementation of self-assessment within APKK
perceived advantage for team member and
hospital management in terms of identifying the
needs of human resources, medicines, medical
equipment, facilities, and infrastructure needs to
improve the quality of care in the delivery room.
3. Activities undertaken to improve the quality of
hospital services in line with the indicators of
APKK, such as: meet the needs of equipment and
medicine, additional health personnel, training of
handling emergency cases of maternal and
neonatal, clinical skills assessment for each
officer to improve the competency in delivery
room, update skill and knowledge by obstetrician
and pediatrician, death and or near miss cases
review to learning for health professionals and
hospital management.
4. Communication in APKK implementation is still
not running well because there is still the lack of
socialization of APKK to all health workers in the
delivery room, APKK task load is only delegated
to only limited people in charge in the delivery
room.
5. APKK resources which consist of the fund,
human resource, medicine, medical equipment
and infrastructure in the hospital. Since the
implementation of APKK from September 2015
until September 2016, the fund is fully
supported by the EMAS Program unless the
fulfillment of human resources and the need for
 medicines, medical equipment, facilities and
infrastructure already provide by hospital
resources (district budget)
6. From the results of the initial assessment
(baseline) to the last assessment in September
2016, the trend of clinical performance standard
are increased quite significant. This proves that
the assessment method routinely and
continuously through APKK will give an idea
how far the achievement and positive impact on
the standard of service improvement in the
delivery room in particularly and hospitals in
generally.

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