Development Management Model of Specialist and Sub-specialist

Doctor in the Context of UU-JKN at RSUP-HAM Medan

Zulfendri

, Juanita

, A. M. Lubis

Fakultas Kesehatan Masyarakat, Univeritas Sumatera Utara

Keywords: Specialist and Sub-specialist Doctor Management, National Health Insurance, General Hospital, Medan

Abstract: In Indonesia has not adopted clinical governance system in clinic to improve clinical quality. One important

factor is the fact that doctors have a place of practice in private hospitals and private practice areas. The

purpose of this study is to develop a model of management of specialist doctors and sub-specialists in the

context of the National Health Insurance Law (UU-JKN) in every SMF Haji Adam Malik General Hospital

Medan (RSUP -HAM). This research is qualitative research. Data obtained from interviews and FGDs.

From the result, the Human Resource Management system of Specialist and Sub-Specialist Doctors has

been implemented in accordance with the hospital's internal regulations based on the regulation of Hospital

Bylaws and Staff of Medical Bylaws owned by RSUP HAM. Therefore, it is necessary to improve the

system that has been built through regulation Bylaws Hospital and Medical Staff Bylaws develop according

to the development of science and technology of health services in hospitals.

1 INTRODUCTION

Since January 1, 2014, Indonesia has undergone a

transformation of the health financing system by

the enactment of the National Health Insurance

(JKN) held by the Social Security Insurance

Provider (BPJS) which is mandated by Law no. 40

of 2004 (UU RI) on the National Social Security

System. The benefits of JKN can provide

comprehensive benefits with affordable premiums

and apply the principles of cost and quality

control. That means participants can get adequate

quality service at a reasonable cost and under

control, not "up to the doctor" or up to "hospital".

In addition, it also ensures sustainability (certainty

of sustainable health financing) and has

portability, so it can be used in all parts of

Indonesia. In the 2019 JKN target it is expected

that at least 85% of participants will be satisfied,

either in service at BPJS or in service at health

facilities contracted by BPJS.

Clinical Governance and Tradition

management system of specialists and sub-

specialists in government hospitals. One of the

key factors in the development of hospital

services is how to improve the quality of clinical

services. Hospitals are institutions that provide

clinical services so that clinical quality is an

important indicator for the good of the hospital.

Good and bad clinical service process is

influenced by the appearance of specialist doctors

work at the hospital. As with the governance

system in hospital management, a current

governance system is developed at the clinic. This

development was pioneered by the British in the

decade of the 90s by using the term clinical

governance

The basic principle in the development of

clinical governance management is how to

develop systems to improve clinical quality. The

quality improvement is done by combining

management, organizational and clinical

approaches together (Trisnantoro, 2017). Clinical

governance is in charge of ensuring that there is a

system for monitoring the quality of well-

functioning clinical practice; clinical practice is

always evaluated and the results of its evaluation

are used to make improvements;

and clinical

practice is in accordance with the standards,

issued by the national professional regulatory

body.

In detail, systems implemented in clinical

governance include activities such as clinical

audit, effective management of poorly performing

Zulfendri, ., Juanita, . and Lubis, A.

Development Management Model of Specialist and Sub-specialist Doctor in the Context of UU-JKN at RSUP-HAM Medan.

DOI: 10.5220/0010078405610567

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

561-567

ISBN: 978-989-758-449-7

561

clinical colleagues, risk management, evidence-

based clinical practice, clinical effectiveness

evidence implementation, leadership skills

development for clinicians, education sustainable

for all clinical staff, until consumer feedback

audits

Knowledge and leadership skills among clinical

staff. In this case there must be a clinician who

becomes the leader of the clinician Clinical

governance framework is composed of four things:

evidence based medicine, good information, clinical

work assessment, and the relationship between

clinicians and management. Large implications arise

with this framework. First, the organization conducts

evidence-based practice.

Implementation of evidence based is severe.

Second, the improvement of clinical information

infrastructure. Third, a mechanism is developed to

assess the performance of clinics integrated with

management performance. Fourth, development

needs to be done.

Traditionally, clinical management systems in

Indonesia have not adopted these activities. One

important factor is the fact that physicians have a

place of practice in private hospitals and private

practice areas. Due to the difficulty of doctors

dividing time in government hospitals, clinical

management is still not applicable. This will lead to

conflict. The Medical Practice Law about the

practice of doctors is a rule that has the meaning of

changing the culture of doctors. It is conceivable that

there is a possibility of conflict between the

traditions and work culture of a specialist with the

intent of the Medical Practice Law.

2 THE PROBLEM RESEARCH

How does the human resources management system

of specialist physicians and sub-physicians include

recruitment, training, working time, compensation,

and retirement in the in-patient wards of Haji Adam

Malik General Hospital (RSUP-HAM) Medan?

How the specialist physician's management

system and the sub-specialist doctors in the

implementation of clinical governance include

activities such as clinical audit, effective

management of poorly performing clinical

colleagues, risk management, evidence-based

clinical practice, evidence of clinical effectiveness in

inpatient wards Haji Adam Malik General Hospital

(RSUP-HAM) Medan?

2.1 Research Objectives

Describes the human resources management system

of specialist physicians and subclinical doctors

including recruitment, training, working time,

compensation, and retirement at the Adam Malik

Hospital General Hospital (RSUP-HAM) Medan.

Describe the implementation of specialist

doctors and sub-specialist management systems in

the implementation of clinical governance covering

various activities such as clinical audit, effective

management for clinical colleagues, risk

management, evidence-based clinical practice,

clinical effectiveness evidence implementation in

inpatient wards of the General Hospital Haji Adam

Malik Center (RSUP-HAM) Medan.

Develop a model of management of specialist

doctors and sub-specialists in the context of the

National Health Insurance Law (UU-JKN) in every

SMF Haji Adam Malik General Hospital Medan.

2.2 The Benefits of Research

This research is useful as a source of information

about: Human resources management system of

specialist physicians and physicians sub spesilis in

the context of National Health Insurance Act (UU-

JKN) in every SMF in Medan-Medan General

Hospital. Implementation of specialist doctors

management system and sub specialist in the

implementation of clinical governance in RSUP-

HAM Medan

2.3 Study of Literature Clinical

Governance

Clinical governance is a term applied to collect all

activities that promote, review, measure and monitor

the quality of patient care into a coherent whole. In

Western Australia, it has been defined as a

systematic and integrated approach to guarantees

and reviews of clinical responsibility and

accountability that improve quality and safety so

patients optimize outcomes (Department of health,

2001).

Clinical governance as "the framework within

which the organization's NHS is responsible for

continuously improving the quality of their services

and maintaining high standards of care by creating

an environment where clinical care excellence will

flourish” (Kane, 2005). It further mentioned that

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

562

from the results of literature study and expert

opinion there are 6 elements of clinical governance

namely clinical effectiveness, quality assurance,

providing development and education, clinical audit,

risk management, development and research.

Clinical governance is the main framework used

by hospitals and should be responsible for protecting

the highest standards of health care (including

dealing with poor professional performance), to

continuously improve the quality of their services,

and to create and maintain an environment where

clinical excellence can develop (Department of

Health, 2001). The introduction of clinical

governance is therefore aimed at improving the

quality of clinical care at all levels of the

organization by consolidating, codifying, and

standardizing.

2.4 Hospital Bylaws

One of the obligations of the hospital is to prepare

and implement internal hospital regulations or

Hospital By Law (Article 29 of Hospital Law

Number 44 of 2009 on Hospital). Hospital By Laws

(HBL) is an internal regulation of hospitals

designated by the owner of a hospital or a

representative of which governs the organization of

the owner or who represents, the roles, duties and

authorities of the owner or who represent, the roles,

duties and authorities of the director of the hospital,

organization of medical staff, as well as the roles,

duties, and authorities of medical staff (KMKRI,

2002).

A rule or management discipline poured into

HBL must be adhered to, so HBL can

also serve as a

guide in running the wheels of hospital management

well and orderly. All of this depends on the

willingness and compliance of the whole range and

related parties in the hospital, from the highest to the

lowest. HBL rules must be obeyed and if violated

there will be sanctions

Designing a "Basic Hospital Rules (PDRS)",

must be created something new that is in accordance

with the social culture of the Indonesian nation.

Looking at the different hospitals in Indonesia today

that have different history of establishment, religion,

vision, and mission, purpose and purpose, PDRS can

not be made uniformly for PDRS for all hospitals

(Guwandi, 2004).

2.5 UU BPJS with Explanation

According to the Law of the Republic of

Indonesia Number 24 Year 2011 on the Social

Security Administration Agency in Article 1

mention the Social Security Implementing Agency

hereinafter abbreviated as BPJS is a Legal Entity

formed to organize the social security program. This

law forms two BPJS namely BPJS Health and BPJS

Employment. BPJS Health organizes a health

insurance program and BPJS Employment program

provides work accident insurance, pension, pension

and death insurance. The formation of two BPJS is

expected to gradually expand the coverage of social

security programs.

2.6 The Perception of the Specialist

Doctor and Sub-specialist Doctor

UU BPJS

Perception is an observation that is a combination of

sight, smell, hearing and past experience. Perception

is expressed as a process of interpreting sensations

and giving meaning to stimuli. Perception is the

interpretation of reality and each person views

reality from a different perspective angle

(Notoadmodjo, 2003). The factors that affect the

perception that is, the level of knowledge and

education of a person, factors on perception / party

perception, the object or target is perceived, the

situation where the perception is done

After the enactment of Law No. 24 of 2011 on

BPJS ynag is a direct command of law number 40

About SJSN, has brought good news for all levels of

Indonesian society, including those who crave health

services with social justice. According to both laws,

from January 2014, all Indonesian citizens (not to

mention doctors) are obliged to become participants

of national social security (health). As a result, they

are required to pay health insurance contributions to

BPJS. With ketetntua, capable residents will pay for

themselves, while for those who can not afford, the

fee paid by the state therefore the payment of health

services / honorarium doctor has been done by BPJS

health. Health providers are not arbitrary because he

must work with BPJS through a contract

accompanied by certain requirements that must be

fulfilled.

Facing the two great powers above, maybe

doctors and health professionals, are in a very weak

position. Doctors and health professionals who have

been reported to be very strong because they can

Development Management Model of Specialist and Sub-specialist Doctor in the Context of UU-JKN at RSUP-HAM Medan

563

determine various things in the provision of health

services will certainly change. Hospitals controlled

by business principles would always hope to make a

big profit by taking advantage of doctors and health

professionals as their money seekers

The critical review is whether the primary care

physician included in Law no. 20 of 2013 is a

solution of national health problems, especially the

financial deficit BPJS. According to this Law the

Primary Services Doctor (DLP) is a general

practitioner who must undertake specialist

equivalent education in order to provide first-rate

health facilities such as puskesmas, outpatient clinics

and others. Doctors who do not participate in

primary care physicians should not serve BPJS

patients even though they have been declared

graduated as a doctor through a national competency

exam. It is naïve that the struggle of medical

students of 6 years of study plus national and

internship competence exams in remote areas has

not convinced the government of their competence.

On the one hand the government is behaving for the

business of competence and quality of the

government to expect high-standard doctors

equivalent to foreign doctors but at the same time

the government's appreciation of doctors is still

minimal compared to responsibilities and lawsuits

when carrying out his profession

That greatness hegemony BPJS not only can

monopolize health insurance but can change the

system of health education services radically. All

will be submissive and forced to obey the rules of

BPJS although the system is not necessarily good

and benefit the community. The first health services

in the community should be improved, but the way

of improvement is not by imposing DLP but creating

a holistic and sustainable integrated system, by

collaborating a well-established system, listening to

all aspirations of field practitioners rather than

partial ways like the DLP.

Law No. 20 of 2013 which passed was too fast

and without adequate academic studies and only

imitate a health system of other countries. As a result

DLP was rejected by doctors all over Indonesia who

are members of the Indonesian Doctors Association

and have done legal efforts with material tests to the

Court has been done even though defeated.

2.7 National Health Insurance

Many new parties realize that JKN has triggered

various reforms in health services. With the Single

Payer design for the entire population, BPJS and the

government have strong controls to improve service

quality and service efficiency. Doctors are

particularly most directly affected by the prospective

change of retrospective to prospective payment. The

head of the hospital changes its business strategy and

services to ensure sufficient funds are received. In

the long term, JKN is designed to balance the public

interest and private interests (employers and private

healthcare facilities) (Thabrany, 2015).

The National Health Insurance (JKN) developed

in Indonesia is part of the National Social Security

System (SJSN). The National Social Security

System is organized through a mandatory Social

Insurance mechanism based on Law No.40 of 2004

on the National Social Security System. The aim is

that all Indonesians are protected in the insurance

system, so that they can meet basic public health

needs.

2.8 The Principle of National Health

Insurance

The National Health Insurance refers to the

following principles of the National Social Security

System (SJSN):

1. Principle of mutual cooperation

In SJSN, the principle of gotong royong means

participants who are able to help disadvantaged

participants, healthy participants help the sick or at

high risk, and healthy participants help the sick. This

is realized because SJSN membership is mandatory

for the entire population, indiscriminately. Thus,

through the principle of mutual social assistance

mutual aid can foster social justice for all Indonesian

people.

2. Nonprofit principle

Fund management is mandated by BPJS is a non-

profit not for profit (profit-oriented). Instead, the

main objective is to meet the maximum interest of

the participants. Funds collected from the public are

trust funds, so that the results of development, will

be utilized as much as possible for the benefit of

participants

3. Principles of openness, prudence, accountability,

efficiency, and effectiveness

These management principles underlie all fund

management activities derived from participant

contributions and development outcomes.

4. The principle of portability

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The principle of social security portability is

intended to provide continuous guarantee to the

participants even if they move jobs or residence

within the territory of NKRI.

5. The principle of participation is mandatory

Membership shall be intended for all citizens to

be participants so as to be protected. Although

membership is mandatory for all people its

application is still adjusted to the economic capacity

of the people and government and the feasibility of

program implementation.

6. The principle of trust fund

Funds collected from participant contributions

are deposited funds to the organizing bodies to be

managed as well as possible in order to optimize the

funds for the welfare of the participants.

7. Principles of management of the Social Security

Fund

Utilized entirely for program development and

for the greatest interest of the participants

3 RESEARCH METHODS

The type of this research is qualitative research to

develop the management model of specialist doctors

and sub-specialist of Adam Malik Center General

Hospital (RSUP-HAM) Medan. The study was

conducted at Adam Malik Center General Hospital

(RSUP-HAM) Medan and the study was take 6 (six)

months (June - November 2017).

The study population is all of SMF is 16 SMF,

all specialist and sub-specialist, Director, Human

Resources Director of General Hospital of Adam

Malik Haji Center (RSUP-HAM) Medan. Samples

for SMF were taken throughout the existing SMF, as

did the hospital director and director of the hospital

tbsp. While the samples for specialists and sub-

specialists, determined according to the needs,

purposive, ie 3 specialist doctors / sub specialists

from SMF surgery and 3 specialist doctors / sub

specialists from non-surgical SMF

3.1 Methods of Data Collection

The method used to collect research data is done by

in-depth interview. The in-depth interview method

was done to the informants of the SMF chairman,

the Director of the Hospital, the Director of Human

Resources, and the surgeon and non-surgical

physicians, respectively, 3 guides to instruments

with unstructured answers (open answers) that have

been prepared in advance. To complete the interview

result data, the researcher also collects the secondary

data that is the data that already exist and according

to the research needs

3.2 Data Analysis

Based on the type of data that has been collected, the

data analysis is done using interactive model

analysis (Miles, 2005). The interactive model

analysis consists of three paths, namely data

reduction, data presentation and conclusion /

verification. These three paths are a type of analysis

activity and the data collection activities themselves

are cyclical and interactive processes

4 RESEARCH RESULTS

From the interview result, Human Resource

Management system of Specialist Doctor and Sub-

Specialist staff has been implemented in accordance

with the hospital's internal regulation which is

guided by regulation of Hospital Bylaws and Staff of

Medical Bylaws owned by RSUP HAM.

a. Recruitment and selection: After going through a

recruitment process and obtaining a clinical

assignment letter (SPK) and having a SIP at the

HAM Hospital, doctors work at the SMF in

accordance with the clinical authority they have.

b. Training: doctors always take part in educational

and training activities both conducted internally

and external by SMF to improve competencies in

order to be able to work professionally. The

education and training activities are generally

funded by the doctor concerned or in

collaboration with pharmacy.

c. Working time: 7.45-16.15 WIB (Monday-Friday)

d. Compensation: payment of medical services

(remuneration) based on individual performance

indicators (IKI), the better the doctor's

performance, the more medical services he

receives. Payment of medical services directly

deposited by the finance department to the

account of each doctor. Most doctors’ payment

system medical services respond well because it

is in accordance with the results of the

performance.

e. Retirement: There is no retirement process in

SMF. If anyone wants to resign, the specialist

and sub-specialist must provide a letter of

Development Management Model of Specialist and Sub-specialist Doctor in the Context of UU-JKN at RSUP-HAM Medan

565

resignation to the Director of Medan Hospital or

in accordance with ASN rules.

f. Permission to practice: Every 5 years the doctor

is obliged to extend his SIP and attendance has

been using finger print which is connected to

doctor's data on the central computer network, so

that he cannot receive remuneration because he is

considered not working if he not to extend his

SIP.

g. Quality Assurance: Evaluation of performance

every 6 months, and time of service to maintain

the quality of service provided to patients. To

improve the quality of services, specialist doctors

and sub-specialists must also improve their

education.

Implementation of specialist doctors and sub-

specialist management systems in the

implementation of clinical governance is in

accordance with the regulation of Medic Bylaws

staff covering various activities.

a. Clinical audit: RSUP HAM has carried out a

medical audit, but its implementation still tends

to be incidental when a medical case occurs.

b. Effective management of clinical colleagues:

communication between specialist doctors and

sub-sepsis to the clinical section is considered

important in the SMF clinical pathology,

anatomical, radiological, skin and genital

pathology, and teeth.

c. Risk management: all SMFs have implemented

clinical risk management in a planned and

systematic manner in an effort to anticipate

unexpected possibilities in clinical services.

d. Evidence-based clinical practice: all SMFs have

carried out evidence-based clinical practices such

as the use of medicines, if there is a need for

drugs outside the national formulary; evidence

based on them is required.

e. Evidence of clinical effectiveness: all SMFs have

applied clinical effectiveness evidence that every

doctor who carries out medical care to patients

always uses evidence-based standard operating

procedures (SPO) and clinical practice.

f. Leadership development for clinicians: RSUP

HAM has implemented clinical leadership

through the appointment of a Doctor of Patient

Responsibility (DPJP) by the SMF in every

medical service for patients participating in the

medical service managerial process

Development of the Specialist Doctor and Doctor

Sub-Specialist management model by developing

clinical leadership for each specialist and Sub-

Specialist Doctor through 4 stages of leadership

development process that is the personal / team

internal stage, the stages of the whole service / cross

team, the cross-stages of the service / organization

broader and broader stages of the organization /

healthcare system.

5 CONCLUSIONS

The Human Resource Management system of

Specialist and Sub-Specialist Doctors has been

implemented in accordance with the hospital's

internal regulation which is guided by the regulation

of Hospital Bylaws and Medical Staff Bylaws

owned by RSUP HAM

It is necessary to maintain and improve the

Human Resource Management system of Specialist

Doctors and Sub-Specialists by referring to the

system that has been built through the regulation of

Hospital Bylaws and Medical Staff Bylaws to

develop in accordance with the development of

science and technology of health services in the

hospital.

ACKNOWLEDGEMENT

Thanks to the University of Sumatera Utara

Research Institute which has funded this Applied

research through Non-PNBP funds for the fiscal year

2017.

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