Central Java, Indonesia—At Margono Hospital in Indonesia, doctors, midwives and nurses embrace a philosophy that every mother and every newborn should be treated as family and receive the kind of quality care that staff would demand for a wife, sister, daughter or son.
Dr. Hendro Boedhi Hartono, a senior obstetrician and gynecologist, cites this family-first philosophy as an example of the transformation under way at this 101-bed hospital in Central Java (population 30 million) to improve the quality of health services and reduce maternal and newborn deaths. The hospital, where 5,000 women give birth annually, is among 150 hospitals and 300 puskesmas, or community health centers, participating in the U.S. Agency for International Development’s Expanding Maternal and Neonatal Survival (EMAS) program, which is led by Jhpiego. Through a systematic review of hospital procedures and policies, health care providers are engaged in a process of identifying problem areas, setting standards for care, devising solutions to correct deficiencies and benefiting from the changes that occur—all with the goal of saving the lives of mothers and newborns.
“Change is not an easy thing,” says Dr. Hendro, “but change is very possible if we start with small steps that build on what we already have. It all depends on your willingness and working from deep inside your heart.
“I never feel we are doing enough when it comes to reducing maternal and neonatal mortality,” he adds. “If we intend to achieve a good quality service, we must treat every patient as if we were sisters, brothers by blood.”
The transformation began 18 months ago, when Margono Hospital began receiving support through peer-to-peer mentoring under the auspices of EMAS. The expectation was that the facility would be mentored to improve the quality of emergency obstetric and newborn care, and would subsequently begin to mentor other hospitals. Hospital staff members were skeptical about the types of changes EMAS promoted. But Margono lacked the most basic health and safety measures and was in need of improvement.
For example, hand soap wasn’t readily available in each room and infection prevention measures were few. The emergency trolley lacked essential supplies and equipment such as magnesium sulfate (MgSO4), which is used to treat a pregnant woman suffering from pre-eclampsia/eclampsia. The on-duty nurse sat at a desk with her back to the maternity wards. This seating arrangement made it difficult for her to observe and monitor clients, and it sent a message to families that she was unavailable. The hospital had not established a uniform approach for receiving emergency cases. In addition, because the hospital did not conduct emergency drills, employees were ill-prepared to handle unexpected complications. Furthermore, relationships and communication between doctors, nurses and midwives were spotty and left open the possibility that critical consultations were not occurring.
But through mentoring in the use of performance standards, dashboards—a collection of data reflecting health indicators specific to a health facility—and other clinical governance approaches, teams of health care providers at Margono began to identify their problems and work together to find solutions. Handwashing became a routine activity with handwashing stations and soap established in each room. Working collaboratively to institute emergency drills and review facility data led to better relations between providers and underscored the need for all to communicate openly with each other. Attitudes toward patients improved significantly; staff greeted women and families warmly and “armed” them with knowledge and important information at discharge so mother and baby would be well cared for.
“EMAS has taught us one thing: to honor mothers,” says Midwife Siti Nur Chasanah, who works in the postpartum unit. “Patient safety and comfort is Number One. We need to pay attention to our maternal and perinatology units. We began to build compartments to separate one patient from another (for privacy).”
With EMAS interventions, staffing levels also improved. Additional doctors were assigned to each unit, and a new maternal emergency unit was constituted with a team of four or five nurses and midwives and one specialist doctor.
“I feel very happy that I can dedicate myself to and serve patients much better,” Midwife Chasanah says. “My knowledge has improved . . . and I am happy that every doctor supports EMAS.”
Chasanah and others attribute the substantial improvements at the hospital to Drs. Hendro and Daliman, who uses only one name in the tradition of many Indonesians. “They are the motors of Margono’s successes,” adds Dr. Fahrul Arbi, the Newborn Clinical Advisor for EMAS.
Through mentoring, Margono Hospital put in place designated teams capable of responding quickly to emergencies. And the hospital prioritized routine emergency drills to prepare staff for the most common obstetric and newborn complications. Processes were modified to improve the ability to respond during emergencies. For example, emergency trolleys with the essential equipment, supplies and a checklist for postpartum care were installed. Other, simple changes were made. For example, basic practices to stop the spread of infection were instituted. Over the course of a year, the hospital transformed itself from a facility achieving far less than 50 percent of clinical and management standards to one that achieved 100 percent of standards across almost all measures.
“After EMAS, their skill has been intensified, and they have become more expert dealing with emergency cases,” says Dr. Dyah Retnani Basuki, EMAS Clinical Coordinator for Banyumas District in Central Java. “They wanted to be better, they wanted to change.”
Now Margono has achieved 80 to 90 percent of the maternal, newborn, infection prevention and clinical governance performance standards. And to fulfill a key aspect of the EMAS initiative—that is, to establish a sustainable model of quality control and improvement among health facilities—Margono has begun mentoring another hospital. A team of five health specialists have begun their work with Cilacap Hospital, observing Cilacap’s maternal and neonatal emergency services, conducting interviews and focus group discussions, and offering constructive feedback on emergency drills and clinical simulations, near-miss audits and death audits.
Dr. Hendro credits his mentoring team with motivating their colleagues at Cilacap Hospital, noting that they work as a family under the values of honesty, dedication, professionalism, fellowship and credibility. He says the staff at Cilacap have become very motivated in making changes in infrastructure and attitudes at the hospital.
“The most important thing is that they now are finding a way to put a big emphasis on patient safety. They want to treat their patients in the right way . . . I could see their effort to change on the second day of our visit,” says Dr. Dyah.