MITIGATION OF INPATIENT STANDARD CLASS RISK AT HOSPITAL X

,


INTRODUCTION
The National Social Security System (SJSN) in Indonesia operates on the principles of social insurance and equity, which entail mutual assistance and equality (Law of the Republic of Indonesia No.40 of 2004 concerning the National Social Security System, 2004).Mutual assistance is realized by mandating insurance payments for those who can afford it and assisting those who are less capable, while equity/equality means receiving medical services according to medical needs http://eduvest.greenvest.co.id regardless of the premiums paid (Lubis, 2018;Septiono, 2023).The public legal entity responsible for organizing national health insurance for all Indonesian citizens is the Health Insurance Administration Agency (BPJS Kesehatan) (Law of the Republic of Indonesia No.However, this policy still faces challenges in achieving its goals (Banerjee et al., 2021;Septiono, 2023).
There are twelve criteria for the standard inpatient class outlined in Director General of Health Services Decree No. HK.02.02/I/1811/2022, including: building components lacking high porosity; minimum room air ventilation of 6x per hour and isolation 12x per hour; room lighting of 250 lux; complete bed facilities including power sockets, nurse call buttons, and other necessities; bedside lockers for each bed; room temperature of 20-26 degrees Celsius with air humidity less than or equal to 60%; ward divisions based on gender, age, disease, and combined ward space; ward spacing with a 1.5-meter edge-to-bed distance, maximum of four beds in an inpatient ward; minimum bed size of 200cm x 90cm x 50-80cm, and a minimum of 2 bed positions; curtains or partitions between beds spaced 30cm from the floor with a minimum curtain length of 200cm and non-porous curtain material; bathrooms within inpatient wards; bathrooms compliant with accessibility standards, and oxygen outlets for each bed (Decree of the Director General of Health Services Number HK.02.02/I/1811/2022 concerning Technical Guidelines for the Readiness of Hospital Infrastructure Facilities in the Application of Inpatient Classes of National Health Insurance Standards, 2022).
The Standard Inpatient Class policy regulates the proportion of the number of beds in standard inpatient services to be at least 60% of all government-owned beds, and 40% of all privately owned beds.The minimum number of intensive care beds is 10% of all beds, and isolation rooms are 10% that can be multifunctional into KRIS space proportions.Implementation must be completed by January 1, 2023.(Government Regulation of the Republic of Indonesia Number 47 of 2021 concerning the Implementation of the Hospital Sector, 2021).The implementation of the standard inpatient class is mandatory for hospitals serving BPJS Health patients and is subject to evaluation for the extension of cooperation between Health Service Facilities and BPJS Health.
The KRIS trial was conducted by the government in 2022-2023.The first stage of the trial was conducted in four hospitals, and the second stage was conducted in ten hospitals (Indonesia, 2023).The Ministry of Health of the Republic of Indonesia, in its presentation of the Implementation of KRIS JKN (National Health Insurance) held on May 10-12, 2023, stated that the trial results showed that KRIS JKN did not affect the decrease in public satisfaction and hospital revenue.The trial results also showed that reducing bed capacity had no significant impact on BOR (Bed Occupancy Rate) and hospital service access (Indonesia, 2023).Based on these findings, the government is increasingly determined to implement KRIS JKN in all hospitals cooperating with JKN, with a maximum timeframe until December 2024, so that by 2025 all hospitals in Indonesia have complied with KRIS JKN.(Indonesia, 2023; Government Regulation of the Republic of Indonesia Number 47 of 2021 concerning the Implementation of the Hospital Sector, 2021).
However, this comes as a surprise to hospitals as healthcare providers involved because they are obliged to comply with these regulations in a short period.To meet these regulations, hospitals need to make changes.(ASHMR, 2020;Wijaya et al., 2022).In every change, there are risks associated with implementation, so all stakeholders in the implementation of the Standard Inpatient Class need to prepare and identify risks and risk mitigation.(Cagliano et al., 2011;Radiansyah et al., 2023;Susilo et al., 2018).This research aims to provide an analysis and risk mitigation overview of the standard inpatient class implemented by Hospital X to serve as information for other hospitals facing the standard inpatient class.

Risk Management Theory
Risk is the effect of uncertainty on something, whether directly or impacting a target, either positively or negatively, or both.Risks can arise throughout an organization, including within hospitals (British Standards Institution., 2018;Ramli, 2011;Susilo et al., 2018).Risk management needs to be carried out continuously by implementing risk management.Risk management is a coordinated activity to direct and control risk management within an organization.A structured approach is needed to manage uncertainties that may arise.(British Standards Institution., 2018) An organization needs to have a risk management framework aimed at integrating risk management processes into all activities and functions of the hospital.According to ISO 31000:2018, the risk management framework focuses on leadership and commitment, which includes integrity, design/planning, implementation, evaluation, and continuous improvement.(British Standards Institution., 2018) Risk analysis in this study uses a 5x5 matrix analysis matrix according to the Decision of the Minister of Finance of the Republic of Indonesia Number 577/KMK.01/2019Regarding Risk Management in the Environment of the Ministry of Finance.The criteria for probability use the likelihood of non-lowtolerance events occurring in one analysis period and impact criteria based on financial burden.(Anak Agung Diah Parami Dewi, I Dewa Ketut Sudarsana, 2023; Manajemen Risiko Di Lingkungan Kementerian Keuangan, 2019).http://eduvest.greenvest.co.id

Risk Mitigation Theory
Risk mitigation should be implemented in cases with medium, high, and very high risk levels, while for very low and low risk levels, risk acceptance can be done.(Manajemen Risiko Di Lingkungan Kementerian Keuangan, 2019; Radiansyah et al., 2023) Risk mitigation can be carried out in various ways, including: (Manajemen Risiko Di Lingkungan Kementerian Keuangan, 2019) 1. Reducing the likelihood of risk occurrence: mitigating actions against the causes of risk to reduce the likelihood of risk occurrence.
2. Reducing the impact of risk: actions cannot be taken against the causes of risk, so treatment is given to minimize the impact.3. Sharing risk: transferring part or all of the risk to another party.4. Avoiding risk: risk mitigation by not engaging in or even discontinuing activities that cause risk to arise. 5. Accepting risk: taking no action against the risk.

Methodology
The study was conducted at a class B private hospital that has been established since 1969, serving 84% of inpatients with BPJS Health financing.A qualitative study with Focus Group Discussions (FGD) was conducted in November 2023 with the Director of the Hospital and Department Heads, totaling 7 informants, regarding the mitigation of standard inpatient class risks using risk analysis matrices.Triangulation was done through direct observation and interviews with other structural personnel related to the implementation of standard inpatient classes.

RESULT AND DISCUSSION
Through the results of the FGD (Focus Group Discussion), it was found that the risk level of implementing inpatient class policies at Hospital X is very high.Policy changes necessitate adjustments by the hospital as a partner of BPJS Health.The UHC (Universal Health Coverage) rate in the area of Hospital X exceeds 95%, so the majority of patients at Hospital X use BPJS Health funding, requiring the hospital to implement standard inpatient class policies.The risk analysis and mitigation results from the FGD are shown in the table below.Through the research findings, it was found that there are two criteria with a risk level of 25 (highest), namely the fulfillment of building component criteria and inpatient room density.Follow-up risk mitigation actions need to be carried out for each potential risk that arises, but during the FGD, information was obtained about the hospital's plans and designs to mitigate standard inpatient class http://eduvest.greenvest.co.id comprehensively.The risk mitigation measures differ for each risk factor depending on risk management in Hospital X.
Regarding the criterion of buildings not having high porosity, the informants agreed to reduce the risk impact by improving the mold-infested areas according to the relevant department's report.The hospital plans to mitigate by reducing the likelihood of risk by renovating the old building, but this is costly and potentially reduces hospital revenue due to the reduction in treatment space during the renovation process, so this step is included in the strategic planning but has not been implemented yet.
In terms of inpatient room density with the requirement within the treatment room of a distance of 1.5 meters from each bed edge, with a maximum of four beds in an inpatient room, reducing the number of beds to a maximum of four beds per treatment room potentially reduces hospital revenue.Therefore, the hospital is renovating additional treatment rooms to replace the lost beds due to the implementation of standard inpatient classes at Hospital X.Some inpatient rooms are slightly smaller the standard 10 square meters per bed, with actual measurements in the field only 9.8 square meters per bed.Currently, the hospital chooses to accept the risk and take no action against this potential risk.The hospital decides that if it becomes a finding in the evaluation by BPJS Health in the future, the hospital is willing to reduce the number of beds to match the area at that time.
The potential reduction in hospital revenue occurs at Hospital X.These research findings do not align with the government's trials stating that the implementation of KRIS JKN does not affect hospital revenue.(Indonesia, 2023) This risk has also been reported in previous studies (Afni & Bachtiar, 2021;Arisa et al., 2023;Hardwiko Defityanto, Samino, Lolita Sary, 2022;Qurnaini Mz et al., 2023) In other studies, it has indeed been stated that building changes and renovations will pose financial and time risks.(Anak Agung Diah Parami Dewi, I Dewa Ketut Sudarsana, 2023; Septiono, 2023)

CONCLUSION
There are two standard inpatient class criteria that pose a very high risk level, namely building components do not have high porosity and the density of inpatient rooms and the distance between beds.RS X carries out risk mitigation by taking action to reduce the impact of risk in the form of improvements according to related room reporting, risk mitigation risk reduction by planning inpatient building renovations, and risk mitigation of accepting risks by allowing the condition of the treatment room which covers an area of 9.8 square meters per bed.
40 of 2004 concerning the National Social Security System, 2004; Government Regulation of the Republic of Indonesia Number 47 of 2021 concerning the Implementation of the Hospital Sector, 2021; Decree of the Director General of Health Services Number HK.02.02/I/1811/2022 concerning Technical Guidelines for the Readiness of Hospital Infrastructure Facilities in the Application of Inpatient Classes of National Health Insurance Standards, 2022).One of the government's strategies to achieve equity principles is by issuing the Standard Inpatient Class (KRIS) policy, as stipulated in Government Regulation No. 47 of 2021 regarding the Implementation of the Hospital Sector.Technical guidelines for facility readiness were also established through Director General of Health Services Decree No. HK.02.02/I/1811/2022.The government hopes that the KRIS policy can standardize hospital facilities across Indonesia (Decree of the Director General of Health Services Number HK.02.02/I/1811/2022 concerning Technical Guidelines for the Readiness of Hospital Infrastructure Facilities in the Application of Inpatient Classes of National Health Insurance Standards, 2022).

Table 1 .
Risk Analysis Matrix Based on Risk Management in the Environment of the Ministry of Finance

Table 3 .
Characteristics of Informants

Table 4 .
Risk Analysis Matrix and Risk Mitigation for Standard Inpatient Class Policy.