POLICY OF PATIENT SAFETY GOVERNANCE FOR HOSPITALIZED PATIENT AT THE KOJA PUBLIC HOSPITAL IN 2019 *Tiara

Clinical governance is a structured organizational framework to improve the quality and safety of patients in the hospital which made by the NHS into seven pillars and adjusted to RI Law No. 44 of 2009. The evaluation results from the quality and patient safety team of Koja Public Regional Hospital in 2018, showed that there is Fall Patient incidents (6 events), KTD and KNC (13 events) which is not following the 0 % of the target from Patient Safety Goals by the Ministry of Health. The study was conducted to analyze patient safety governance for hospitalized patients at the Koja Public Regional Hospital in 2019 based on 4 of the Clinical Governance theories, which are clinical leadership, clinical audit, clinical effectiveness (guidelines); and education, training, and development of conservation profession. This study is using in-depth interview methods through the Purposive Sampling method and also reviewing documents conducted from May to June 2019. The results of the study found that the implementation of Clinical Leadership in Koja Public Hospital was running quite well but not yet optimal because the leadership system, which used the Line Organization to help to faster the decision-making process, is still weak in monitoring. From the Clinical Pathway (CP) evaluation, The medical audit was done well, but the monitoring and evaluation aspects are not yet optimal. The evaluation of clinical effectiveness showed that the compliance to fill the CP form was not optimal because of the lack of CP benefit socialization. Training and courses were done pretty well but have not been evaluated yet. The management team recommends monitoring, collaborating with the medical committee to evaluate the CP usage, providing training related to CP procurement to increase understanding, and also providing necessary training and its evaluation.

Adverse Event in Utah and Colorado is 2.9% with a 6.6% mortality rate. Whereas in the New York area, the number of adverse events reached 3.7% with a 13.6% mortality rate. The report also mentioned that more than 1 million patients are injured every year (KMK RI Number 496, 2005).
A study of 8 hospitals in Milton Keys, UK, stated that the lack of commitment in performing patient safety care was due to imperfect clinical governance so that clinical audit and risk management activities were not well executed (John Storey and David Buchanan, 2012). The significance of understanding patient safety in clinical practice in the UK is vital to create a patientfocused environment (Kirk, Parker, Claridge, Esmail, & Marshall, 2007).
Research at 30 hospitals in Central Java showed that only 58% implement clinical governance processes, and only 67% implement clinical governance. It means that the implementation of clinical governance in 30 hospitals was still not optimal (Hartati, 2014). Likewise with research conducted at RSUD in Jambi Province that uses the seven pillars of Clinical Governance, states that clinical governance in RSUD is still not optimal due to lack of efforts to improve competence, ethics and medical professional discipline to improve patient safety (Yennie, 2017).
Koja Regional Hospital is a Type B Non-Education Regional Hospital located in North Jakarta. Quality and safety evaluation results show that the complexity of the health care system causes the mortality rate is also high when viewed from a system of clinical governance that is not optimal as in research at Kanujoso Djatiwibowo hospital which states that only 10 of the 10 patient safety standards have been implemented, meaning that the application of patient safety is still not optimal due to the lack of policy and supervision factors from the quality and patient safety team so that unexpected events are expected to increase (Iskandar, 2015). This can also be seen in the following Koja Hospital quality data: The graph above shows that undesirable events, HAIs infection, and needling are not following the RI Ministry of Health's target of 0%. KTD above can occur because it is supported by the factors below:

INTRODUCTION
Hospitals are institutions that provide individual health services to the community. The implementation of the hospital is directly proportional to improving quality in providing optimal services. Government regulations state that hospitals must implement good governance and clinical governance (RI Institutional Law No. 44, 2009).
Clinical governance is an organizational framework to improve the quality of services and provides clinical care with high standards where the clinical care environment can also help create these standards (NHS, 1998 In 2000, a report issued by the Institute of Medicine titled "To Err Is Human" stated that 44,000-99,000/year of patients died due to Medical Errors in the United States, out of 33.6 million/year inpatients in all US hospitals. The "Err is Human" report revealed an The data above is the result of the evaluation of the quality and patient safety team of Koja Regional Hospital which is related to patient services that are not following the Patient Safety Goals, which are Identify patients correctly, Improve effective communication, Improve the safety of high-alert medications, Ensure safe surgery, Reduce the risk of healthcare-associated infections and Reduce the risk of patient harm resulting from falls (SNARS, 2018).
The failure to achieve Patient Safety Goals in hospitals occurs because the Clinical Governance implemented by Koja Hospital is still not right and is not following government regulations. Thus, if the implemented of clinical management is still not right, the result of patient safety will not be good either. Because clinical governance is based on the four pillar theory of the NHS-UK and Law number 44 of 2009, the four pillars consisting of clinical leadership, clinical audit, clinical effectiveness (Guideline), as well as education, training and continuing professional development will be used as the basis for conducting this research.

METHODS
This research uses qualitative methods with a phenomenological approach. Primary data were obtained by researchers through in-depth interviews, while secondary data were obtained through document review at Koja Regional Hospital, North Jakarta. The purpose of this method is to gather information about the description of patient safety governance (Patient Safety) in the inpatient ward in Koja District Hospital. Qualitative methods are used to investigate, discover, and explain the quality of social influences that cannot be explained through quantitative approaches (Salamah & Rustiana, 2016). Phenomenology focuses on how one or more individuals experience a phenomenon, in this case, the application of patient safety goals by paying attention and analyzing the focus on the phenomenon under study and paying attention to the subjective aspects of object behavior (Carr, Lhussier, Reynolds, & Hunter, 2009). This research was conducted at the Inpatient Ward at Koja Regional Hospital, from May 2019 to June 2019. The research informants were research subjects who would provide the necessary information based on suitability and adequacy. Research informants consisted of key informants, Main Informants, and Informants who did not interact directly in the study but could provide other relevant information. Research informants were determined using purposive sampling or judgment sampling that was determined by the researcher based on the depth of information needed. Ten informants consist of the Koja Regional Hospital Service Representative, the Medical Committee; the Patient Quality and Safety Committee; the PPI Committee; the Education and Training Center; the Kasatpel of the Inpatient Unit, Doctor and Nurse of the Inpatient Unit of the Koja Regional Hospital. Qualitative research was carried out by interviewing selected informants and examining hospital documents and policies after all the data has been collected, then creating the interview transcript and processing the data by making an In-depth Interview Matrix.

Clinical Leadership
Leadership is defined as an emphasis on processes that tend to shift in giving, distributing or sharing leadership roles (Carr et al., 2009). Based on the theory from Gillies (1994) that leadership behavior as an agent of change has three tasks namely in conducting direction (Direction), coordination (Coordination), and supervision (supervision) (Bardan, 2017).
Stephen P. Robins, in the book Organizational Behavior, said that meetings are a face to face communication medium by various organizations for decision making by deliberation and consensus (Novita, 2013).
Based on the results of unstructured in-depth interviews, only a few people attended the Morning Report (Morpot), which was held every day at Koja District Hospital. Another informant said that he had never attended a large Morpot while working in a hospital and 3 (three) of them attended the Morpot in the unit only before conducting service activities to patients. From the document review, no assignment letter or SOP was found stating that Morpot activities is obliged, but done merely based on an oral order issued by the director.
Directives are related to the role of the leader to do effective communication, motivating, delegating, and supervising service providers in providing care whose results have increased significantly (Murtiani, 2013). The directional function of a manager will be directly proportional to the results of the performance of the care executor. The results of the study showed that the service implementers (doctors and nurses) who have a wrong perception of the direction of a manager's function would tend to implement the care management poorly (Warsito, 2007).
The interview results showed that the coordination mechanism between units was done in a structured or stratified manner, starting from the lowest position in the hospital to the managerial level. Coordination between units and professionalism must occur to increase patient satisfaction. The results of unstructured interviews also found obstacles for service providers in providing input or advice to hospitals.
Coordination is the process of integrating the goals and activities of separate units (management or service) in order to achieve goals efficiently. Thus the coordination function of an organization should become a union (Salamah & Rustiana, 2016).
Most of the informants said that superiors did not conduct optimal oversight because of the lack of monitoring by superiors. The relationship between supervision and implementation of patient safety is very close. Supervision activity is a form of communication with subordinates such as consulting, giving direction, and providing guidance regarding actions implementing services that support patient safety (Rivai, Sidin, & Kartika, 2016).
The clinical leadership function is crucial in determining the direction of the organization to create good clinical governance. Direction, coordination, and supervision are actions taken to monitor the quality of service. The existence of clinical leadership will increase discipline and commitment to continue to develop. The results of previous research said good communication would create the proper practices. The organization will not run without a leader, moreover to create clinical governance.

Clinical Audit
Clinical audit is a series of activities that consist of planning, measuring the analysis of findings,providing recommendations for improvement, and making the improvement (KMK RI Number 496, 2005). The results of unstructured interviews showed that clinical audit activities on Clinical Pathway (CP) in Koja Regional Hospital were done by the Medical Committee Team based on Permenkes number 755 of 2011 regarding the organization of medical committees. The clinical audit mechanism started with submitting a proposal for a medical audit to the Deputy Director of Services. The Deputy for Services as a facilitator will coordinate with related parties such as the medical records unit, general practitioners and others. The Deputy Director of Services will explain the respective duties in the letter given later to all relevant parties, then a meeting will be held, and a clinical audit timeline will begin. Then the next activity would be processing data by the medical committee, and the results would be given to the Director to get feedback.
The document review showed that the implementation of CP was still not optimal due to the lack of doctor's compliance in filling out the CP form. Clinical audits have a role in running good clinical governance. Conducting medical audits is useful for carrying out medical improvements by patient needs and medical service standards. So that obstacles and difficulties during the service process can be identified quickly and thoroughly.
The added value obtained from clinical audits is to achieve the changes desired by hospitals in improving patient quality and safety. The clinical audit program serves as an educational tool for all professionals so that it will realize good teamwork in carrying out good governance (Setiadi & Paramartha, 2015).

Clinical Effetivity ( Guideline )
Clinical Pathway (CP) is used to implement clinical guidelines properly. The aim is to choose the best practice to use. A guideline is needed to run health services; thus, the hospital must make CP and PPK set the standard. Customer satisfaction in receiving services would set good clinical governance. Considerating high cost and high volume are needed in order to estimate how much the cost and the number of resources used against one disease so that patients can get treatment for a long time (Hanevi Djasri, dr, 2013).
Based on the results of unstructured interviews showed that doctors who treat patients directly did not fill in the CP since the implementation of CP in Koja Hospital was still minimal. CP should be the responsibility of the Doctor in Charge, but doctors who treat patients do not know the contents of the clinical pathway itself.
Then the findings also found that inpatients ward doctors had not received CP training while working at Koja District Hospital and only received training by a doctor's association. The absence of filling the CP form resulted in variations in treatment delivery since the doctors did not remember the steps that existed in CP.

The CP filling compliance chart below:
A good guideline is comparing data that is relevant to exist events. The comparation activities consist of evaluating services, clinical auditing, looking at clinical indicators to reduce variations by physicians (Center, 2006).

Pelatihan, Pendidikan dan Pengembangan Profesi
Yohanes (2005), as quoted by Nababan (2016) states that education is a conscious and planned effort to improve general knowledge and understanding of the overall work environment. While training is part of HR investment to improve work skills and competencies to improve employee performance (Nababan, Tawas, & Uhing, 2016) Based on the results of unstructured interviews, all informants said they had received training and primary education related to patient safety such as basic PPI, basic life assistance, and APAR training. The work training program regulated that every employee who works at Koja District Hospital is required to attend education and training organized by Koja District Hospital.
The interview results found that there was no monitoring and evaluation of the training or education provided, so training materials were sometimes not appropriately applied. Meanwhile, the employees felt that the training provided was still less specific, such as Basic ECG training for cardiology nurses or specialized training for therapists for medical rehab units. Thus, the delivery of health services not carried out optimally based on the evaluation data of the Koja Regional Hospital quality team, as shown below.
Simultaneous and partial education and training have a significant influence. There are two benefits of the organizational and employee side. The organization will get capable and productive employees so that there will be an increase in performance, and employees will get the opportunity for promotion and fulfillment of personal growth needs (Dartha, 2010).
Training and education activities are carried out by making annual plans made by the quality improvement unit, Infection Control Prevention (PPI) and Functional Medical Staff (SMF). The work program of the Quality Team and PPI will be proposed to the Training Team to conduct an assessment of the training.

CONCLUSION
Based on the results of research on patient safety governance in Koja District Hospital, the researchers concluded that: 1. The application of clinical leadership principles used by Koja Regional Hospital is running well but has not been optimal because of inproper direction and supervision. The leadership system used by the Koja Regional Public Hospital, which is a multilevel system (Line Organization), has a disadvantage that less effective in expressing opinions, especially at the level of implementation. However, for the management level, this system is beneficial in making quick decisions.
2. The Medical Committee has done medical audits as procedures. However, monitoring and evaluation of the medical audit are still not optimal. This result happens because the compliance of fulfilling the Clinical Pathway in Koja District Hospital is still quite low, indicating that the understanding of CP is still lacking.

Clinical effectiveness evaluation results
concluded that Clinical Pathway compliance in form filling is still not optimal. This result is due to the lack of understanding and socialization of the benefits of Clinical Pathway and PPK Despite being implemented well, training and education have not been optimal. There was still no evaluation after training for the employee. Hence the supervisors do not know the work application of employee's knowledge after receiving training.

Quality and Patient Safety Committee
Perform monitoring at least once a month for service providers to be able to observe the situation and conditions related to the patient safety.
Conduct an evaluation related to employee knowledge about patient safety either through training or asking the caregiver directly.

Prevention and Infection Control Committee
Evaluate and document the pre and post-test results after conducting education and training activities related to PPI.
Propose to repeat the education and training of basic patient safety training even though the certificate would be valid for three years. It aims always to renew employee knowledge.

Training Team
Evaluate the results of education and training as an indicator of the quality of human resources working in Koja District Hospital Facilitate education and training related to the specialization of each unit so that practice would be better.

Medical Committee
Collaborate with the Education and Training Team to conduct training and education related to the socialization of the judicious use of CP; and the benefits and development of new knowledge related to CP.
Evaluate the application of KDP and document the results of the evaluation

Doctors and nurses
Re-understand the importance of CP and the application of PPK Improve effective communication to patients and families of the patient.

For Further Researchers
Future research should find the correlation of patient safety governance followed by patient safety target criteria using patient safety target indicators to assess hospital quality Research on clinical governance can be further developed not only about medical audits but also on patient quality and safety.