WHO had identified the risk of adverse event in health services which are serious and threaten the safety of patients globally? [1]. Risks detected since the report of the Institute of Medicine (IOM), reported adverse events on the hospital in Utah and Colorado by 2.9% which 6.6% of them died, and the New York Hospital by 3.7% with the mortality rate is 13.6% of them [2-5]. The report of adverse event in Indonesia from the Ministry of Health is quite high. Until February 2016, it is reached 289 reports. The type of adverse event consists of 69 events of near miss (43.67%) in the form of medication errors (29.2%), patient falls (23.4%), canceled operations (14.3%), diagnosis errors (11%), incorrect laboratory tests (8.4%) and incorrect roentgen (5.2%) [6].

Since the implementation of JKN in 2012, PT BPJS as the executor of JKN adjust a procedure starting from the first level of health care. To reduce maternal and infants mortality rate in Indonesia was done by the availability of BEOC-CHC in each district as a gate keeper for the safety of mothers and children. BEOC-CHC will improve access to maternal and neonatal to cope with obstetric and neonatal emergency cases which is the largest contributor to maternal and child mortality rate [7]. The aspects of patient safety in the primary health centers appears as the part of the Regulation of Ministry of Health number 75 of 2014, but still no clear guidelines for its implementation [8,9].

There isn’t much information about adverse event in primary care [10]. Based on some research, it is in the form of missed or delayed diagnosis and medication management, medication and diagnosis errors, failures communication between the human resources [11,12]. Teamwork, management support, communication, staff and the value of patient safety the lack of guidance, ineffective communication, lack of knowledge and lack of quality assurance mechanisms [13-15].

To provide a high quality health services and be able to compete in the global marketplace, it can be used the Malcolm Baldrige Criteria for Performance Healthcare (MBHCP). The advantages of MBHCP are its ability to provide a comprehensive and integrated assessment. MBHCP is used because of its ability to identify the strengths and opportunities for improvements, provide a framework to improve performance advantages by giving liberties to the management to implement its management strategies. An integrated management framework includes every factor that defines the organization, operational processes and a clear and measurable work, increases the process speed and quality of work, building a high work system, translating the vision and mission into strategy and builds the loyalty of patients. The purpose of this study is to determine the implementation of the seven standards of patient safety as the basic of patient safety model development based on Malcolm Baldrige in BEOC-CHC of Padang as the implementation of maternal and child safety [16].

This study uses a descriptive exploratory study with a qualitative design. The study was held in Department of Health of West Sumatera as the policies holder, Department of Health of Padang as the direct supervisor and BEOC-CHC. The study was conducted from January to August 2016.

The number of informants is 25 which are the Head of Health Registry Section, Accreditation and Sertification of Department of Health of West Sumatera, the Head of Health Services of Department of Health of Padang, the Head of Lubuk Buaya and Seberang Padang BEOC-CHC. All informants got in-depth interview. Six health personnel from Lubuk Buaya BEOC-CHC, nine health personnel Seberang Padang BEOC-CHC, and also 12 patients got focus group discussion (FGD). Informants get asked about the implementation of the seven standards of patient safety based on a system approach in terms of input, process and output using the guidelines which are derived from the hospital patient safety guidelines which were modified and adjusted based on research purposes.

The result of in-depth interviews and FGD will be written in the field notes, personal documents, official documents, drawings and photographs. Furthermore, the result would be read and analyzed. The analyzed was done by interpret and dechiper the data that has been acquired into a substantive theory. The data that had been required were analyzed descriptively, summarized and presented.

Based on the 25 informants in this study, the average age of the respondents is 39 years old, with the youngest is 25 and the oldest is 52 years old. The average length of work is 13 years, the longest is 22 years and the shortest is 2 years. For almost all patients were housewives.

Based on the results, the adverse event was found last year in BEOCCHC is medication errors and patient falls out of the bed. This adverse event was completed amicably between health centers and patient's family. Incidents didn’t report in writing to the Department of Health of Padang because there are no guidelines and reporting format for adverse events. Until now there are still no guidelines for patient safety from Department of Health of West Sumatra, Department of Health of Padang and BEOC-CHC in Padang about the implementation of patient safety in the BEOC-CHC (Figure 1).

Figure 1: Thinking flow of the implementation of patient safety standard in BEOC health centers.

Patient rights

There are no guidelines to fulfill the patient rights on BEOCCHC yet. The doctor in charge of service making plans of service and done assessment of patients. Medical records and informant consent as the document of services planning and implementations. In the implementation process, information provide and explanations to the patients and their families about plans and results are not always given, but for every services performed is always preceded by the signing of informed consent. Patients or family explained about the services that will be given but without being informed about the result of services, the further services plans and the likelihood of adverse events. The output has not been running well. Patients have not been informed about the results of the services given and the possibility of adverse events.

Educate patients and their families

There are no specific plans to educate the patients and their families about patient safety at BEOC-CHC. The health guidance and promotion about the maternal and child safety limitary given only to the mother through maternal classes every month, without educate the patient's family. The implementation of giving right information, transparent and honest to patients was not done yet but patients have already know their obligations and responsibilities, patients understand and accept the consequences of services, also patients and families fulfill their financial obligations. The output has not been accomplished too.

Patient safety and continual care

Planning of the patient flow from registered until finish was conduct through the workshops in BEOC-CHC every month. Every health personnel in charge from patients register until the medication and patient go home. Standard Operational Procedures (SOP) for each supporting facilities and the flowchart of patient services flows has been displayed on the walls of health centers. The coordination of services started from the patient registered until going home accordingly to the patient needs, but sometimes constrained due to the limitations of doctors, sometimes patients were examined and given a prescription not by doctor. The improvements of communications and transfer communication among health personnel running well. The output already performing well.

The use of improvement methods of performances to evaluate and improve patient safety

Planning in the input by conducted performance assessment for health personnel is carried through the accreditation process of BEOCCHC. All heath personnel of BEOC-CHC will empowered all health personnel. Lubuk Buaya BEOC-CHC is one of the best CHC in Padang which already have an ISO 9001 certificate. Implementation of patient safety not done yet. There is no designing plan of improvement with the 7 standards patient safety, accumulation of data, such as incident reports, risk management and audit quality of health services. Likewise, there has been no intensive evaluation of adverse events and proactively evaluate the high-risk cases, because there are no result of data analysis, thus the change of system have not been implemented. The output has not accomplished.

The role of leadership to improve patient safety

For input, the planning has not specifically for patient safety. The head of BEOC-CHC has not appointed a specialized team. There are no guidelines and documents about patient safety in the health center yet because the patient safety issue is still a new issue for the health center. The implementation is also has not been done yet, no interdisciplinary team, no risk identification, no mechanism of work, no responsive procedure towards incidents, no internal and external reporting mechanisms, no mechanism to handle incidents, no open collaboration and communication between units, no resource and information system, no measurable targets. The output has not been accomplished too.

Educate the personnels about patient safety

Plans for training and orientation process about patient safety which adjusted based on the decision from the Department of Health of Padang as the direct supervisor of BEOC-CHC. There are no guidelines and documents about patient safety. There are no integrating patient safety topics in every in-service training activities and also providing a clear guidance about reporting incidents yet, but there are trainings about teamwork to support interdisciplinary approach and collaboration in serving patients. Based on the output, education and training programs and orientation about patient safety for new health personnels in accordance with their respective duties has not yet accomplished.

Comunication is the key to the personnels to achieve a patient safety

There is no specific planning about comunicating about patient safety. There are no guidelines and documents about patient safety in BEOC-CHC yet because the patient safety issue is still a new issue. For process, no budget available to plan and design data processing to obtain data and information that is related to patient safety. For the output the implementation of data transmission still is not clear and the information still is not timely and accurate yet.

Based on the research, it is obtained that the adverse event occurred at BEOC-CHC at the last year. The implementation of patient safety in BEOC-CHC had been varied because no specific guidelines available yet [4].

In Indonesia, the regulation about the accreditation of primary health centers just had been declared recently on Permenkes number 75 of 2014, the implication in the health centers is not clear yet [8]. The risk management which is the core of the implementation of patient safety in the BEOC-CHC has not been running yet. And the adverse event still is the fault of the individual because ‘blaming culture’ still is applied [17,18].

The implementations of the 7 standards of patient safety at BEOCCHC are reviewed with the system approach of input, process and output. Almost at all standards about patient safety (input, process and output) is not accomplished yet. Only the third standard about patient safety and continual care are systematically goes well. Changes happen in health care providers, now patient is an important aspect of the design of the health care and improving the quality of health services (patient centered care) [19]. Patients have an important role in helping to achieve an accurate diagnosis, in deciding on the appropriate treatment, in choosing an experienced and secured provider, in ensuring that the right treatment is given, monitored and adhered to, and in identifying the side effects and take appropriate action [19- 21]. Therefore, it is important to fulfill patients' rights and educating patients and families. Communication between health personnel in the unit are good but between units still worse. Worse communication can lead to adverse event. Good communication between heath personnel and with patient and family it’s important for patient safety [22,23].

Performance assessment in BEOC-CHC all this time based on health personnel attendances. Planning performance assessments in BEOC-CHC can be carried through the accreditation process of CHC. Good health personnel performance can improve patient safety through fix inadequate work space, fulfil incomplete equipment, given adequate information from the health personnel, and fix busy and disorganized working environment is busy and disorganized [24]. Such as strong, unwavering leadership and open communication and action can improve patient safety with encourage and ensure the implementation of the patient safety program through the implementation of “7 Steps to the Hospital Patient Safety” [25].

Health personnel as the practitioner must understand about patient safety. Educate the health personnel about patient safety was the sixth standard of patient safety, done by planning training and orientation process about patient safety [16-18]. Since training of health personnel is determined by the Department of Health of Padang as the direct supervisor of BEOC-CHC, it is necessary to planning about training health all personnel about patient safety in BEOC-CHC. Comunication was the key to the health personnel to achieve a patient safety. Good communication between health personnel, between health personnel and patients can reduce adverse event. Open communication is necesarry too, open communication would make good patient safety culture. To make good patient safety culture it is necessary to developt a model thats fit to patient safety in BEOC-CHC which can be developt bases malcom baldridge performance.

In general it can be seen that out of the 7 standards of patient safety based on patient safety guidelines by KPPRS, only the third standard about patient safety and continuous care that has been running systematically, started from input, process until its output, while the patient safety standard number 1, 2, 4, 5, 6 and 7 had not been accomplished yet. It is required a patient safety system that matches the conditions of the BEOC-CHC based on Malcolm Baldridge performance as the standard of the performance of the organization which is applied on the patient safety performance.

This Research is a part of Competitive Professor Grant Andalas University number 81/UN.16/HKRGB/LPPM/2016. Researchers would like to thanks to dr. Adang Bachtiar DSc, Prof. Dr. Herkutanto SpF SH LLM FACLM, Prof. Dr. Nur Indrawati Liputo SpGK PhD, Nilda Tri Putri ST, MT PhD. BEOC-CHC Seberang Padang and Lubuk Buaya, Department of Health Sumatera Barat and Padang, and Andalas University.

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