rnational International Journal of Workplace Health Management

Journal Measuring Hospital Accountability

Journal: International Journal of Workplace Health Management

Manuscript ID Draft

Manuscript Type: Research Paper

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Accountability, Institutional Aspect, Liability, Financial, Accessibility,
Keywords:
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2
3 MEASURING HOSPITAL ACCOUNTABILITY
4
5 Abstract
6
7 Purpose: The main objective of this research is to analyse the validity and reliability of hospital
8 accountability measurement in Indonesia environment. This research is a continuation of previous
910 research which found the specific dimensions, variables, and indicators of accountability
11 applicable to hospitals in Indonesia using qualitative method.
12
13 Methodology: The variables proposed to measure accountability consists of eight variables
14 identified i.e. institutional aspect, healthcare delivery process, liability, financial, quality assurance
15 and patient safety, accessibility, clarity of information, and use of information. The data obtained
16 data obtained from questionnaires distributed to the top and middle managers of hospitals,
17
18 including public and private hospitals. The analysis is performed using confirmatory factor
19 analysis, using.
20
21 Findings: The result shows the eight variables are valid in measuring accountability. However,
22 healthcare delivery is proven not reliable. This fact reflects that the health care delivery process
23 differs depending on the environment, including regulation applied.
24
25 Originality: The measurement model was design by author based on the result of previous study.
26
27 Research limitations/implication: This finding contributes to future research by providing
28 measurement model on hospital accountability construct.
29
30
Keywords: accountability; institutional; liability; financial; accessibility; information
31
32 Introduction
33
34 Although the principle of accountability around the world across organizations is similar, its
35 implementations differ from one country to another country, as well among different industries
36
37 such as hospitals. The importance of measuring hospital accountability is undebatable. An
38 unaccountable functional and operational system in hospital management affects inefficiency in
39 financial, human resources, time, and the decrease of stakeholders’ satisfaction. (Sudirman &
40 Sidin, 2014). In addition, accountable hospital management is proven able to control healthy
41
42
competition among hospitals (Sudirman, 2012). As an example, the data obtained from Indonesia
43 Corruption Watch (ICW) shows that there are 220 cases of corruption in the health sector during
44 2010 – 2018 with the amount of state budget losses around IDR 822 billion (Kontan.co.id, 2018).
45 According to ICW, the two potential areas leading to corruption sources, i.e., procurement of
46
47
health infrastructure and the executing of programs such as disease prevention programs. The
48 correlation among these two aspects with hospital accountability is on executing such activities.
49 Regarding health infrastructure procurement, the vulnerable crucial things are medical equipment,
50 drugs, consumable medical material procurement for hospitals. Therefore, accountability should
51
52
be implemented starting from planning to the process of procurement itself. While in the
executing
53 program, some examples such as double counting or uncounted costing or absence of reporting
54 can lead to corruption.
55
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3 Such findings are in line with the opinions of some authors emphasizing on the importance
45 of accountability in hospital management in order to achieve the strategic goals of health care
6 delivery in high competition and rapid changes in health sector environment, regulation changes,
7 and the increasing demand of community to high-quality health services (Gamm 1996; Emanuel
8 & Emanuel 1996a; Daniels & Sabin 1998; Lanier & Roland et al. 2003; Brinkerhoff 2004;
910 Timmermans 2005). Until recently, most literature reviews on hospital accountability still use
11 traditional approach since they just focus on vertical accountability and financial aspect. These
12 aspects are considered insufficiently effective in evaluating the comprehensiveness of
13 accountability of hospitals to fulfil high demands on New Public Management (Jessop 1998;
14 Erkkila 2007).
15
16 Previous research has explored the practices of accountability of public and private
17 hospitals in Indonesia (Indrianty et.al., 2018). The result shows that, in general, the practices of
18 accountability of public hospitals differ from private hospitals. The public hospitals tend to be
19 more rigid and bureaucracy, while private hospitals are more flexible in the administration
20
process.
21 The distinct of public hospitals is in their answerability and transparency, while private hospitals
22 distinction is they are more efficient due to flexibility. This indicating that both styles have their
23 advantages and disadvantages (Sudirman, et al.; 2018). This finding is consistent with Mulgan
24 (2000), who stated that private sector (for-profit) companies are more accountable in terms of
their
25
26 'bottom line,' accountability requirements in the public sector are generally more stringent,
27 particularly with regard to process and general policy.
28 Despites, previous research in Makassar Indonesia found that, institutional aspect,
29 healthcare delivery process, liability, financial, quality assurance and patient safety, accessibility,
30
31 clarity of information, and use of information can be used to measure hospital accountability, the
32 validity and reliability have not examined yet. That is the reason why it is important to further
33 analyse the validity and reliability of the variables and indicators explored from previous research.
34 The result of the analysis can be used to develop an instrument to measure hospital accountability
35
36
practices.
37 Literature review
38
39 The way to improve the quality and safety of care, the control of costs, or the health of the
40 population itself are among goals raised the issue of accountability (Denis, 2014). That is why
41 accountability should take into consideration the shared goals of the authority of the governing
42 bodies and providers to measure the achievement or the fulfilment of accountability principles. It
43
44 is not necessary that the relationship between the governing bodies and hospitals in hierarchical
45 order. It can be a dialogue between hospitals and governing bodies about their shared pre-defined
46 goals (Saltman & Ferroussier-Davis 2000).
47 Some of research in accountability have explained what dimensions should be accountable
48
49 to improve governance effectively as well as efficiency in achieving goals. Some of authors have
50 the same opinions concerning dimensions of accountability, such as organizational,
administrative,
51 professional, and financial performances (Daniels & Sabin, 1998; Brinkerhoff, 2001; Brinkerhoff,
52 2004; Bovens.M, 2007; Koppell, 2005; Blagescu & Lloyd, 2009). In the same tone, Emanuel &
53
54 Emanuel (1996) stated that the domain of accountability consists of professional competence,
55 management practices in accordance with the regulation and ethics applied, financial
performance,
56 accessibility, public health promotion, and the benefit of the community. This is consistent with
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3 authors' findings in previous research that the measurement variables of hospital accountability
45 consisting of institutional aspect, healthcare delivery process, liability, quality assurance and
6 patient safety, financial, accessibility, the clarity of information, and the usefulness of
information.
7
8 Institutional Aspect
9 Institutional plays an important role in hospital accountability. Therefore, it is important to
identify
10 the strategic level in hospital organization. According to Saltman et al. (2011), hospital
governance
11 is divided into three levels of governance. At the macro-level, hospital governance is the part of
12
13 traditional national, regional and/or supranational policy-making that establishes the structural,
14 organizational, and operational architecture of the hospital sector. At intermediate level, hospital
15 governance is focused on decision making at the overall institutional level of the hospital. Lastly,
16 the micro-level of hospital governance focuses on the day-to-day operational management of staff
17
18 and services inside the organization. This level is, in fact, what is known as hospital management
19 and incorporates such subsets as personnel management, clinical quality assurance, financial
20 management, patient services, other cleaning services such as cleaning and catering services, etc.
21 (Saltman et al.; 2011). (Mikhaylov et al., 2014).
22
23
Concerning human resources management, the contingency approach to strategic human
24 resource management on firm performance is conditioned by an organization's strategic posture
25 (Youndt, et al. 1996). Especially as a public sector, recruitment and hiring were planned strictly
26 by local government. When facing the adjustment of organizational structure, initiative and
27
28
flexibility were limited (Yang & Chen; 2015). Arthur (1992, 1994) found that human resources
29 practices focused on enhancing employee commitment (e.g., decentralized decision making,
30 comprehensive training, salaried compensation, employee participation) were related to higher
31 performance.
32
33
According to Engelbrecht et al. (2002), financial management in public hospital is an
34 integral part of district health management. The financial planning made up in cyclical way
35 through a series of stages. The processes start from assessing the current financial position, linking
36 financial to programs, and determining a budget. Based on the first process, financial allocated
37 across district services. Service and district managers receive support from their finance sections
38
39 to manage the finances. During the disbursement, managers keep ensuring that funds are spent and
40 revenue collected according to the financial plan and according to the norms and standards set by
41 the treasury or authorized bodies. They apply suitable internal control measures and monitor the
42 process. At the end, they draw up an annual report.
43
44 Healthcare Delivery Process
45
46 According to Ferlie and Shortell (2001), there are four levels of health care system i.e. the
47 individual patient; the care team (clinicians, pharmacists, and others), the patient, and family
48 members; the hospital that supports the development and work of care teams by providing
49 infrastructure and complementary resources; and the political and economic environment (e.g.,
50
51
regulatory, financial, payment regimes, and markets). The last is the conditions under which
52 organizations, care teams, individual patients, and individual care providers operate.
 Journal of Workplace Health Management
53 Further, Ferlie and Shortell (2001) added that the recent changes in health care policy
54 reflect an emphasis on consumer-driven. The increasing expectation of the patients’ demand
55 among them are the availability of information and the establishment of private health care
1
2
3 spending accounts. This shifting has driven the changes in the system for improved quality,
45 efficiency, and effectiveness. In conclusion, there is a shifting role of patients from a passive
6 recipient of care to a more active participant in care delivery. The article published by The Royal
7 College of Radiologists (2012) emphasizes the importance of the involvement of patients in
shared
8 decision making process and agrees with the outcome.
910 The overall purpose of health care delivery is to provide holistic, patient-centered,
11 respectful, timely, safe, high quality, efficient, and effective services to the patients addressing
12 their individual health care needs in a safe environment (Alam & Alabdulaali, 2016).
13
14 Liability
15 Adopting from Random House Dictionary of the English Language, Harris & Spanier, (1976)
16 proposed the definition of liability related to accountability as a liable person is "subject, exposed,
17
18 or open to something possible or likely, especially something undesirable." In other words,
liability
19 refers to people's obligations. Here, the obligation does not mean that the people will be subjected
20 to sanction. It rather means the people are open to be sanctioned if their performance is
21 unsatisfactory. According to Mahlmeister (1999), based on the principle of vicarious liability, the
22
23 hospitals are liable for the negligent acts of its employees. However, the reverse has occurred in
24 many settings in the name of cost containment.
25 We have the same understanding with Sage (1997) that one of the purposes of managing
26 care is to control costs. It can be understood if both patients and physicians are concerned with the
27
28
cost of health services. At the patient's side, they are afraid the cost they paid is correlated with the
29 quality of care they received. While at the physician side, they are in a dilemma between arbitrary
30 contracting policies and administrative requirements and legal responsibility to optimize clinical
31 outcomes. The implementation of hospital liability for medical malpractice may reduce conflict,
32
33
curb abuses, and protect patients in managing care. Further, Kinney (1995) stated the challenge of
34 hospital liability is how to promote fair compensation, clinical quality improvement, and
35 administrative efficiency.
36
37 Quality Assurance and Patient Safety
38 Patient safety has been becoming the most priority in health care systems. The topic of patient
39 safety is a subject that should be taken up by all personnel working in health services (Dursun,
40
41 et.al., 2010). One of the works on the idea of the importance of patient safety was released in the
42 report entitled "To Err is Human: Building a Safer Health System" in 1999 by the Institute of
43 Medicine (IOM). According to this report, almost 98,000 die in United States (US) hospitals every
44 year as a result of preventable medical errors. Consequently, the occurrence of medical errors was
45
46 highly considered by health policy-makers and stakeholders worldwide (Al-Ahmadi, 2009).
47 However, Yaprak (2016) stated that medical errors cause by health workers is impossible to be
48 annihilated. It might be possible to reduce at the minimum level by implementing patient safety
49 culture in hospitals including employees.
50
51 Financial
52 In both public and private hospitals, director medical services play a key role in providing in
53
54 translating the pressures of cost efficiency into reality pressures upon acute units into operational
55 reality (Jones, 1999). For example, a study of attitudes in a large acute hospital (Jones and
Dewing,
1
2
3 1997) showed that the implementation of financial accountability for the director of a medical
45 service focuses more on quality and quantity of care. While unit managers put financial
6 accountability as their top priority. In addition, poor quality of management accounting reporting
7 and under-developed costing only provides little information to pursue cost efficiency at the
8 operational level.
910 That is why having clinical pathways are very important in the context of case tariff fees
11 as a part of the International Statistical Classification of Diseases and Related Health Problems
12 (ICD) for inpatient hospital services. Many authors agree that clinical pathways has significant
13 contribution to reduce the period of hospitalization (Hommel et al., 2008; Ishiguro et al., 2008),
14 reducing costs (Verdú et al., 2009; Barbieri et al., 2009; Rook, 1998) and increasing the quality of
15
16 the services provided (Schwarzbach et al., 2010; Andriessen et al., 2009; Feuth & Claes, 2008)
17 and cost as well. From the hospital management point of view, the clinical pathway can be used
18 as a strategic management instrument for controlling cost continually, and also considered as a
19 part of transparency health services. That is why very important to acquire relevant knowledge to
20
21 quality and supply planning. Such that, the range of services, can be standardized without
22 neglecting the individual requirements of the patients (Romeyke & Stummer, 2012).
23
24 Accessibility
25 According to Pearson et al. (1999), equal access to information is very important to design,
26 develop, and implementation of consumer health information systems, regardless of location and
27
28
cost. Further, Bental et al., (1999), the consumer satisfaction and the willingness to use the
29 information can also be affected by the complexity of the interface and content. It is recommended
30 to develop customized information systems to provide more appropriate interfaces and content,
31 such as able to provide equal access to information.
32
33
The study conducted by Milne et al. (2008) illustrates how important is the accessibility.
34 Further, they concluded that the unavailability information in order to obtain support and advice
35 from healthcare professionals when people being home might cause anxiety and uncertainty.
36 Patients feel convenient when being able to access hospitals and healthcare when they are at home
37 easily.
38
39 Clarity of Information
40
41 According to Ranallo et al. (2016), the use of health information technology (IT) has a significant
42 contribution to facilitating the delivery of safe, high-quality, and cost-effective health services.
43 Asymmetry of information between patients and health professionals can be minimized by
44 providing internet and customer hotline. It is very important to provide clear information in
45
46 accordance with the level of knowledge maturity of each patient; such patients can understand
47 (The Royal College of Radiologists, 2012).
48 The complaint center also plays an important role in providing the clarity of information
49 and handling the patient's complaint. The response of the complaint center affects patient's
50
51
satisfaction. As a matter of fact, many patients dissatisfied with the response of the complaint
52 center (Friele et al., 2008; Daniel et al., 1999; Doig, 2004). That is why very important to find
such
53 ways to handle complaints in meaningful ways for patients. Such ways should be more than just a
54 common thing to do (Eaves-Leanos & Dunn, 2012; Duclos, 2005). De Feijter et al., (2012)
55 emphasized that improving complaints handling may reduce many some crucial things, such as
1
2
3 the numbers of financial claims, prolonged legal disputes between patients and their physicians.
45 Even, it can be used as a feedback information for quality improvement (De Feijter et al., 2012) as
6 well as improving patient safety (Eaves-Leanos & Dunn, 2012; Haw et al., 2010).
7
8 Usefulness of Information
9 The recent issues on accountability in health care systems show several concerns. Firstly,
concerns
10 are related to the unsatisfactory level of health care systems performance. There are different
issues
11 between industrialized countries and developing countries. In industrialized countries, the main
12
13 concerns are on cost issues, quality assurance, and access. While in developing countries, in
14 addition to the same issues in industrialized countries, the issues are more complex, including the
15 availability and equitable distribution of basic services, abuses of power, financial
mismanagement
16 and corruption, and lack of responsiveness. Secondly, the requirement of specialized knowledge,
17
18 complexity of the size, and scope of health care bureaucracies in both the public and private
sectors
19 lead to significant demand for the improvement of hospital accountability since it can affect
20 people's lives and well-being. Thirdly, health care constitutes a major budgetary expenditure in all
21 countries, and proper accounting for the use of these funds is a high priority (Brinkerhoff, 2003).
22
23 According to WHO (2016), health professionals have an obligation to inform the
individual
24 (or, where appropriate, their care) of the risks and benefits of the examination and, in doing so,
25 explain the risks of not having the imaging examination in a form understandable to the patient.
26 Patients should become a part of the decision making process concerning their care by providing
27
28
clear information to enable their participation and being involved in the actual decisions (The
29 Royal College of Radiologists, 2012).
30
31 Methodology
32 The data used in this research was obtained from 60 top and middle managers of public and
33 private
34 hospitals in Makassar, Indonesia, who have a good understanding of hospital management
35 practices. The questionnaires are prepared, referring to previous research that used in-depth
36 interviews and literature review, as presented in appendix 1. There are eight variables proposed
37
38
to measure hospital accountability consisting of institutional aspect, healthcare delivery process,
39 liability, quality assurance and patient safety, financial, accessibility, the clarity of information,
40 and the usefulness of information. The technique of analysis using confirmatory factor analysis
41 (CFA).
42
43 Findings
44
45 Based on statistical analysis, the eight variables are valid to measure accountability. However, the
46 healthcare delivery process is not reliable in measuring hospital accountability. This result reflects
47
48 that despites the same principles; the health care delivery process differs from one to another
49 environment. This finding is consistent with the findings of Ferly and Shortell (2001), who wrote
50 that the healthcare delivery process is also affected by the environment in which hospitals as an
51 organization, physicians, and other care teams, as well as the patients, taken in place. The validity
52
53
of each indicator to measure each variable is described as follows.
54
55 Institutional Aspect
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3 There are 28 indicators proposed to measure institutional aspect as described in appendix 1.
45 Among 28 indicators, there are two indicators that are not valid to measure the institutional aspect.
6 The t-statistic value for both indicators is less than 1.96, which is the threshold in assessing
7 validity, as could be seen in appendix 2. Those indicators consist of corporate social
responsibility
8 and performance contract signed between hospitals and staff. Based on the interview, the program
910 of corporate social responsibility does not reflect the accountability since the services provided by
11 hospitals have been considered as the implementation of social responsibility itself. The second
12 invalid indicator is either not suitable for measuring hospitals accountability. This is consistent
13 with Han et al. (2011), who stated the nature of health services in hospitals is unpredictable and
14 uncertain. The number of patients and the level of severity are difficult to predict. As a
15
16 consequence, the resources needed and performance is also difficult to determine. That is why it
17 is difficult to predetermine the performance of staff.
18
19 Healthcare Delivery Process
20 Conversely, the reliability test for healthcare delivery process shows the Cronbach alpha value is
21 0.3162, as could be seen in appendix 3. While to assess the reliability, the value should larger
than
22
23 0.60. However, the five indicators measuring the healthcare delivery process are valid since all t-
24 statistic values are larger than 1,96. This circumstance reflecting that even though all indicators
25 are significant to measure the healthcare delivery process, but the demand or standards using to
26 deliver health services are different from one context to another context. This research is
conducted
27
28
in Makassar, Indonesia, which the demand of healthcare delivery process may be different from
29 the standard used in another city or country. This finding is also consistent with the statement of
30 Ferlie and Shortel (2001), who stated that regulatory bodies, regulation, financial aspects, payment
31 regimes, and markets could affect the healthcare delivery process. In Makassar, Indonesia, the
32
33
healthcare delivery process is different for out of pocket patients and patients who covered by
34 social insurance. This is in line with Sparrow et al. (2013) research, which assesses the targeting
35 and impact of subsidized social health insurance for the informal sector and the poor in Indonesia.
36 It is obvious that in the beginning, the social insurance program is indeed targeted to the poor and
37 those most vulnerable to catastrophic out of pocket health spending. Nowadays, the increasing
38
39 health expenditure has slightly widened the access to health care the increasing utilization of
40 outpatient care among the poor.
41
42 Liability
43 Among seven indicators measuring liability, none is eliminated. All indicators are considered
valid
44 since the t-statistic value is larger than 1,96, as could be seen in appendix 2. The indicators are
45
46 mostly concerning about answerability, which accepted as the main dimension of accountability
47 since five decades ago. According to Harris and Spanier (1976), a person who is liable is 'subject,
48 exposed, or open to something possible or likely, esp. something undesirable. They believe
49 accountability attaches liabilities to people's obligations, not in the sense that they necessarily will
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51
be subjected to sanction, but rather in the sense that they are open to sanction if their accounts are
52 unsatisfactory.
53
54 Quality Assurance and Patient Safety
1
2
3 The same result with quality assurance and patient safety; all indicators analysed are valid in
45 measuring the variable, as could be seen in appendix 2. The seven indicators measuring the
6 variable of quality and patient safety derived from quality and patient safety standards required to
7 be implemented by any hospitals around the world. This is confirmed by the Institute of Medicine
8 (IOM), which considers patient safety "indistinguishable from the delivery of quality health care."
910 (Erickson, et al., 2003). Such a statement is quoted from Mitchell (2008), who concluded that
11 patient safety is the cornerstone of high-quality health care. Further, Mitchell (2008) explain that
12 there are workgroups, who have attempted to define the quality of health care in terms of
standards.
13 Initially, quality is defined as the degree to which health services for individuals and populations
14 increase the likelihood of desired health outcomes and are consistent with current professional
15
16 knowledge. This led to a definition of quality in a list of indicators, which are known as standards.
17 Financial
18 The financial variable is measured by three indicators, which all are valid, as could be seen in
19
20 appendix 2. Those three indicators are related to the implementation of clinical pathways to
21 control the quality and cost, the importance of calculating unit cost for cost containment, and
22
23
informed consent concerning the tariff of health services. The two first indicators are consistent
24 with Engelbrecht (2002), who points out that the budget reflects the service priorities. Budgeting
25 is an important framework for spending money and for assessing financial performance. The last
26 indicator is might not directly related to the financial aspect, but it reflects the implementation of
27
28
accountability as required by new federal law in health care.
29
30 Accessibility
31 The variable of accessibility has eleven indicators measuring it, which all are valid, as could be
32 seen in appendix 2. Millman (1993) defines hospital access as the degree to which individuals
and
33 groups are able to obtain services needed from the hospitals. The terminology of access is
referring
34 to the equitability to access hospitals with insurance coverage, having enough doctors, and the
35
36 location of hospitals nearby living area. Nevertheless, having insurance or living nearby hospitals
37 does not mean people who need health services are able to access the hospital. Conversely, many
38 people who lack of insurance coverage or living in areas with limited healthcare facilities, but still
39 able to access the services (Millman, 1993). In this research, accessibility is not limited measured
40
41 by distance or wealth, but more by the equitability in getting clear and asymmetric information.
42
43 Clarity of Information
44 There are six indicators analysed to check their significance in measuring the variable of the
clarity
45 of information. All indicators are valid, as presented in appendix 2. This variable is closely
related
46 to the variable of accessibility. The clarity of information obtained by people will improve their
47
48
ability to access hospitals. The clarity of information in this research covers of understandability
49 of information, lack of information gap between hospitals and patients, and patients’ education.
50 A clear example of the clarity of information is federal healthcare law started to be
51 implemented on 1st January 2019. The new federal law required all hospitals to post prices online
52 for services they provide. This change in policy aims to help consumers in search of the most
53
54 suitable healthcare services for them. Previously, these patients could request the information
from
55 the hospital, but the process was seldom smooth or easy. As a result of the new law, nowadays,
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3 patients are able to compare the tariff of one hospital to another hospital regardless of the hospital
45 is near or far, and of all sizes. This changing behaviour is reflecting more transparency to the
6 consumer than ever before (NC Coalition for Fiscal Health, 2019).
7
8 Usefulness of Information
9 The ten indicators measuring the variable of the usefulness of information are valid, as could be
10 seen in appendix 2. This finding is relevant since the essential aspect of hospital management
11 quality is the availability of information about the processes of healthcare delivery, as this
provides
12
13 input for improvement strategies. External accountability has become increasingly important over
14 the last few years. As a result, hospitals are under increasing pressure to share indicator-based
15 performance information with the government, regulatory bodies, health insurers, and the general
16 public. Hospital performance indicators facilitate patient’s choice and hospital-insurer contracts
17
18 and promote public accountability.
19 The information provided by hospital covers management, quality, ethics, financial, staff
20 competence, and patient’s education on hospital health services. From time to time, this coverage
21 has changed from just providing information to principal in the form of performance reports.
Then,
22
23 regulatory bodies of healthcare services emphasize the importance of providing information on
24 tariff. In overall, information should be provided to multi-stakeholders such they could make use
25 of such information.
26
27 Conclusion
28
29 The result of this research shows that the institutional aspect, healthcare delivery process, liability,
30 financial, quality assurance and patient safety, accessibility, clarity of information, the usefulness
31 of information are valid in measuring accountability. However, the healthcare delivery process is
32
33 not reliable in measuring accountability. This result reflects that the health delivery process differs
34 from one country to another country or even among districts. It depends on the environment in
35 which the health services operated. Furthermore, the indicators to measuring those eight variables
36 mostly valid except two variables measuring the variable of institutional aspect i.e. the obligation
37
38
of the hospital to have a corporate social responsibility program and the performance contracted
39 between hospitals and medical staff.
40
41 Agenda for Future Research
42 The results found this research can be used as a basis to develop instrument to measure hospital
43 accountability especially in developing countries. It also can be used to develop operational
44
45 guidelines to improve accountability in hospital management. Such guidelines should reflect the
46 fulfilment of accountability dimensions in each functional management, such as monitoring and
47
48 performance evaluation system, remuneration systems, employee career systems, and other related
49 functions.
50
51 Appendices
52 Appendix 1. Indicators for Measured Variable
53
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54
Questions of indicators related to institutional aspect:
 1
2
3 IA1 The hospital provides an WWTP
4
5 IA2 The hospital developed a CSR program
6 IA3 Hospitals provided prayer room
7 IA4 Hospital develop cost containment
8
9 IA5 The hospital makes contract documents with staff
10 IA6 Restructuring logistics management
11 IA7 Hospitals have remuneration
12
13 IA8 Hospital has human resource strategy planning
14 IA9 Optimizing the roles of medical professions at hospital
15 IA10 Development of hospital performance indicators in a more comprehensive manner
16
17
IA11 Hospital perform planning for human resource recruitment
18 IA12 Employee recruitment system
19 IA13 The scheme of compensation system
20
IA14 Hospitals should have employee performance system
21
22 IA15 The hospital formed an ethics committee
23 IA16 The hospital facilitates staff rights and obligations
24 IA17 Hospitals have financial planning
25
26 IA18 Hospitals conduct marketing
27 IA19 Hospitals prepare list of scale priorities in the budget disbursement
28 IA20 Hospitals implement marketing strategy
29
30 IA21 Unit cost determination for budget controlling
31 IA22 Hospitals develop policies to protect the privacy of doctor, patients, and other hospital
32 staff
33 IA23 Hospitals develop policies to implements the principle of beneficence
34
35 IA24 The hospital formed an ethics committee
36 IA25 Hospital has credential committee
37 IA26 The hospital formed a rational therapy committee
38
39
IA27 Empowerment of the roles of credential committee at hospital
40 IA28 Hospitals has board of advisory in accordance with hospital acts issued by Indonesian
41 government
42
43
44 Questions of indicators related to Healthcare Delivery Process:
45
46 HD1 Hospitals provide clergyman
47
HD2 Optimized the role of patients in decision making
48
49 HD3 Hospitals provide room for patients with special needs
50 HD4 Hospital implement policies to assure equitability in delivering services
51 HD5 Hot line 24 hours
52
53
Questions of indicators related to Liability:
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1
2
3 L1 Reporting and publication should able to fulfill the interests of vertical requirements,
4
5 accreditations, and community needs
6 L2 Recording and reporting on plague or particular diseases should in accordance with
7 hospital acts issued by Indonesian Government
8 L3 Destroying or deleting any files should be in accordance with hospital acts issued by
9
10 Indonesia Government
11 L4 The hospital is legally responsible for all losses incurred due to negligence of health
12 workers
13 L5 Hospital reporting financial status
14
15
L6 Hospital perform internal audit
16 L7 Guidance and supervision are carried out under good administration
17
18 Questions of indicators related to quality assurance and patient safety:
19
20 QA1 Application of clinical pathway to provide information on duration of treatment
21
22
QA2 Hospital determine quality standard of patient safety
23 QA3 Hospital implement, develop, and apply quality assurance system
24 QA4 Cost and quality control
25 QA5 Hospitals implement standard pf patient safety
26
27
QA6 Hospitals develop the concept of patient safety
28 QA7 Hospitals focus on developing sustainable quality assurance system
29
30 Questions of indicators related to financial:
31
32 F1 Hospital implement clinical pathway to estimate the expenditures
33
34
F2 Unit cost determination for budget controlling
35 F3 Hospital gives inform consent related to the cost
36
37 Question of indicators related to accessibility:
38
39 A1 Everybody can access information on hospital's services 24/7
40
41
A2 Everybody can access information on the hospital's services from anywhere
42 A3 Information always provided actual
43 A4 Information provided should be clear even without further explanation
44
A5 If there is unclear information, everybody can contact hospital staff easily at any time
45
46 any time place
47 A6 Information on quality should transparent
48
A7 Hospitals provides information center either virtual or on site
49
50 A8 Hospitals applied customer driven standard and all general information transparent to
51 public
52 A9 Hospital website development
53
54
A10 Hospital information system developed to support decision support system
A11 Hospital determine the official tariff for services
1
2
3
Question of indicators related to clarity of information:
4
5 CI1 Everyone can easily understand the contents of the information presented by the
6
7
hospital
8 CI2 Information provided by hospitals can be utilized by stakeholders to ensure that
9 hospitals perform functions
10 CI3 Community can understand the information provided by hospitals to be able to
11
12 understand the quality of hospitals
13 CI4 Patients education
14 CI5 Hospital provide complaint center
15
16
CI6 Hospital enhance the way to communicate to the patients
17
18 Question of indicators related to usefulness of information:
19
20 UI1 Information provided by hospitals should be able to use for accountability reporting
21
22
23 UI2 Information provided by hospitals should include sufficient performance evaluation
24 and indicated free corruption practices
25 UI3 Information provided by hospitals should able to use by community to evaluate the
26
27
quality of hospital with focus on patient safety
28 UI4 Information provided by hospitals should be able to use the implementation of good
29 governance and free from corruption and collusion
30
31
UI5 Information provided by hospitals should able to use by community to evaluate the
32 quality of health services delivery by hospital in accordance with international
33 standard
34 UI6 Information provided by hospitals should be able to use by stakeholders to evaluate
35
36
the implementation of hospital task and responsibility
37 UI7 Information provided by hospitals should be able to gives assurance for patients and
38 visitors when they are in hospital
39
40
UI8 Information provided by hospitals should be able to be used by stakeholders to
41 evaluate the hospitals performances
42 UI9 Information provided by hospitals should be able to help community in choosing the
43 right hospitals
44
45 UI10 Information provided by hospitals should use to monitor the utilization of public
46 resources to assure economic enhancement
47
48
49
Appendix 2. Validity Analyses
Original Standard Standard
Sample T Statistics
Sample Deviation Error
Mean (M) (|O/STERR|)
(O) (STDEV) (STERR)
A1 <- A 0.5578 0.5499 0.0968 0.0968 5.762
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1
2
3 A10 <- A 0.4481 0.4403 0.0893 0.0893 5.0199
4
A11 <- A 0.5467 0.5462 0.0772 0.0772 7.0812
5
A2 <- A 0.6546 0.6507 0.0798 0.0798 8.199
6
7 A3 <- A 0.4811 0.4792 0.0918 0.0918 5.2383
8 A4 <- A 0.5827 0.577 0.0907 0.0907 6.4257
9 A5 <- A 0.5198 0.5291 0.0882 0.0882 5.8947
10 A6 <- A 0.8203 0.8214 0.0264 0.0264 31.0586
11 A7 <- A 0.774 0.7775 0.0324 0.0324 23.8787
12 A8 <- A 0.7471 0.7464 0.0529 0.0529 14.1209
13 A9 <- A 0.6089 0.6091 0.0682 0.0682 8.9285
14
15
CI1 <- CI 0.3933 0.4023 0.1063 0.1063 3.699
16 CI2 <- CI 0.5655 0.5552 0.0935 0.0935 6.0467
17 CI3 <- CI 0.8899 0.8863 0.0253 0.0253 35.2003
18 CI4 <- CI 0.8837 0.8811 0.0248 0.0248 35.5959
19 CI5 <- CI 0.8855 0.8805 0.0276 0.0276 32.0464
20 CI6 <- CI 0.8947 0.896 0.0191 0.0191 46.8882
21 IA1 <- IA 0.3468 0.3356 0.0576 0.0576 6.0187
22
IA10 <- IA 0.8842 0.8847 0.0176 0.0176 50.279
23
24 IA11 <- IA 0.9282 0.9286 0.0162 0.0162 57.1974
25 IA12 <- IA 0.3676 0.358 0.056 0.056 6.5613
26 IA13 <- IA 0.7615 0.764 0.0448 0.0448 17.0112
27 IA14 <- IA 0.8589 0.852 0.0337 0.0337 25.4558
28 IA15 <- IA 0.925 0.9231 0.0157 0.0157 59.0749
29 IA16 <- IA 0.1882 0.1787 0.0563 0.0563 3.3431
30 IA17 <- IA 0.8657 0.8676 0.0292 0.0292 29.6867
31 IA18 <- IA 0.9012 0.9041 0.0254 0.0254 35.453
32
33
IA19 <- IA 0.9178 0.9165 0.0176 0.0176 52.1232
34 IA2 <- IA -0.1302 -0.1422 0.114 0.114 1.1419
35 IA20 <- IA 0.879 0.8815 0.0247 0.0247 35.5807
36 IA21 <- IA 0.6794 0.6836 0.0442 0.0442 15.374
37 IA22 <- IA 0.5574 0.5565 0.0598 0.0598 9.3217
38 IA23 <- IA 0.8097 0.8181 0.0346 0.0346 23.4264
39 IA24 <- IA 0.9004 0.8989 0.0186 0.0186 48.305
40 IA25 <- IA 0.8195 0.8187 0.0245 0.0245 33.4596
41
42
IA26 <- IA 0.9354 0.9358 0.0116 0.0116 80.8472
43
IA27 <- IA 0.8406 0.8363 0.0233 0.0233 36.0311
44 IA28 <- IA 0.9377 0.9366 0.0137 0.0137 68.4234
45 IA3 <- IA -0.1866 -0.1842 0.0593 0.0593 3.1472
46 IA4 <- IA 0.4981 0.4928 0.0718 0.0718 6.9378
47 IA5 <- IA 0.18 0.1878 0.1095 0.1095 1.6442
48 IA6 <- IA 0.9168 0.9158 0.0157 0.0157 58.5591
49
IA7 <- IA 0.8588 0.8593 0.0244 0.0244 35.2059
50
IA8 <- IA 0.9722 0.972 0.0066 0.0066 148.1665
51
52 IA9 <- IA 0.7313 0.7349 0.0427 0.0427 17.1199
53 UI1 <- UI 0.8407 0.8351 0.0352 0.0352 23.8494
 1
2
3 UI10 <- UI 0.5435 0.5361 0.0853 0.0853 6.3709
4
UI2 <- UI 0.8388 0.8384 0.033 0.033 25.399
5
6 UI3 <- UI 0.863 0.8608 0.0359 0.0359 24.0486
7 UI4 <- UI 0.8388 0.8384 0.033 0.033 25.399
8 UI5 <- UI 0.8679 0.8661 0.029 0.029 29.9476
9 UI6 <- UI 0.8595 0.8567 0.0298 0.0298 28.8128
10 UI7 <- UI 0.8906 0.8899 0.0277 0.0277 32.1602
11 UI8 <- UI 0.8984 0.8993 0.0218 0.0218 41.2643
12
13
UI9 <- UI 0.4657 0.4675 0.0836 0.0836 5.5723
14 F1 <- F 0.856 0.8558 0.0179 0.0179 47.79
15 F2 <- F 0.9045 0.9038 0.0175 0.0175 51.5591
16 F3 <- F 0.8191 0.8172 0.0313 0.0313 26.1856
17 L1 <- L 0.9582 0.9593 0.0069 0.0069 138.6883
18 L2 <- L 0.966 0.9667 0.0057 0.0057 168.5217
19 L3 <- L 0.9235 0.925 0.0116 0.0116 79.3565
20
21
L4 <- L 0.8213 0.8233 0.031 0.031 26.5127
22 L5 <- L 0.7645 0.7668 0.0407 0.0407 18.7691
23 L6 <- L 0.8987 0.9016 0.0172 0.0172 52.2524
24 L7 <- L 0.8547 0.8575 0.027 0.027 31.6579
25 QA1 <- QA 0.795 0.7933 0.0349 0.0349 22.8012
26 QA2 <- QA 0.9134 0.9138 0.0144 0.0144 63.4847
27
QA3 <- QA 0.9268 0.9265 0.0117 0.0117 78.9093
28
29 QA4 <- QA 0.9403 0.9424 0.0095 0.0095 99.2931
30 QA5 <- QA 0.8583 0.855 0.0281 0.0281 30.5825
31 QA6 <- QA 0.9094 0.909 0.0164 0.0164 55.4207
32 QA7 <- QA 0.8825 0.8792 0.019 0.019 46.3976
33 HD1 <- HD 0.4367 0.4395 0.0927 0.0927 4.7123
34 HD2 <- HD 0.614 0.6157 0.0897 0.0897 6.8417
35
HD3 <- HD -0.5646 -0.5583 0.0914 0.0914 6.1755
36
37 HD4 <- HD 0.895 0.8958 0.0196 0.0196 45.6524
38 HD5 <- HD 0.8473 0.8473 0.0363 0.0363 23.3571
39
40
41
42 Appendix 3. Reliability Analyses
43
44 Composite Cronbach
45 AVE R Square Communality Redundancy
Reliability Alpha
46
ACT 1 1 0.9991 1 1 0.1928
47
48 A 0.3892 0.8712 0 0.8399 0.3892 0
49 CI 0.6053 0.8958 0 0.8558 0.6053 0
IA 0.573 0.9684 0 0.9591 0.573 0
UI 0.6463 0.9465 0 0.9353 0.6463 0
F 0.7407 0.8953 0 0.8248 0.7407 0
L 0.7859 0.9623 0 0.9535 0.7859 0
QA 0.7931 0.964 0 0.9561 0.7931 0
HD 0.4811 0.6568 0 0.3162 0.4811 0
0 Journal of Workplace Health Management

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