Inhibiting Factors in the Application of Risk Management at Hospital X Jakarta

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INTRODUCTION
Word Health Organization (WHO) notes that 60% of 8 million people per year die due to poor quality health care services (WHO, 2015).Patient safety is closely related to the quality of health services provided (Lee et al., 2019).One way to improve patient safety is to conduct risk management.According to (Yoshimatsu &;Nakatani, 2022) Risk management is an individual or organization's effort to prevent incidents where incidents are events that cause or have the potential to cause unnecessary harm to patients.
Risk management requires the efforts of a complete interprofessional team from top managers to lower-level managers, both in terms of implementing policies and practices, implementing them in daily patient care, and even when dealing with medical errors that have occurred.A team approach should be coordinated where everyone is on the same team and constantly strives to disclose risks regardless of one's job title, and each member should be knowledgeable about their duties, offering the best opportunities for quality risk mitigation.This interprofessional approach leads to improved patient care and a reduction in unexpected events (McGowan et al., 2023).
The role of managers in a healthcare organization is needed in making decisions to determine the tools used for risk assessment and management based on the scope of risk analysis, data, resources and complexity of existing problems (Policy et al., 2020).Risk management involves the process of minimizing risks in an organization by developing a system to identify and analyze potential hazards to prevent accidents, injuries, and others (Hariyati et al, 2019).A Managers should strive to improve safety systems, motivate and educate staff on the need to detect potential risks, and report accidents or adverse events proactively (Shi et al., 2021).The success of nursing managers cannot be separated from the factors of maintaining the degree and quality of nursing services, professional quality and patient safety (Rini et al., 2022).
The results of a preliminary study at Vertical Hospital "X" in West Jakarta in May 2023, that risk management reporting in the unit has not been fully carried out by the Head nurse.It has not been carried out optimally, according to information obtained from the head of the inpatient unit, the monitoring and evaluation system for the implementation of risk management has not been well documented.Risk management does not yet have tools to monitor risk mitigation efforts.The results of questionnaires distributed to team leaders and implementing nurses about risk management found that 12.1% of staff did not understand about risk management and 14.6% did not know about risk management guidelines, and about 24.4% of nurses still did not know the flow of reporting patient safety incidents which are closely related to risk management.
Research on the implementation of risk management has been widely conducted abroad, but not much has been done in Indonesia, especially research with qualitative design.Based on this phenomenon, researchers want to explore the role that should be performed by a nurse manager.

METHOD
This qualitative research uses descriptive qualitative design.Participants consisted of 12 participants, namely: 4 Team Leaders, 7 Head nurses and one Head of Inpatient Sub-Installation.The selection of participants in this study used a purposive sampling method in accordance with the inclusion criteria, namely: 1) Nurse manager from Team Leader level to Head of Care Service Coordinator, 2) Have experience as a nurse manager for at least 2 years, 3) Willing offline.The data collection technique uses Focus Group Interview techniques with semi-structured interview guidelines and open-ended questions.The data collection process is carried out until it reaches data saturation and all questions have been answered by participants.Data collection will be carried out in October-November 2023.The Focus Group Interview was conducted in a mutually agreed place, conducive, and carried out in a relaxed atmosphere.
Data analysis uses thematic content analysis techniques that produce narrative descriptions and key patterns from the data.Thematic content analysis consists of several stages, namely: 1) recognizing the data, researchers listen to the interview results and then transcribe the interview recordings verbatim and read the description along with the notes obtained during the Focus Group Interview process repeatedly until the researcher gets a feel or taste for the data, 2) identify the thematic framework, The researcher writes notes in the margins of the text in the form of short phrases that are ideas or concepts that arise from each text and the researcher will begin to develop categories, 3) data coding, at this stage the researcher filters the data by highlighting and sorting out important quotes, 4) charting (organizing codes and themes) after all the data is coded, the researcher will see the data horizontally, namely on the theme in all cases, and 5) mapping and interpretation of data, researchers strive not only to understand individual quotes, but also researchers must be quite imaginative in analyzing in looking at the relationships between quotes, and the relationships between data as a whole.
Researchers conduct member checks as an effort to validate that the results of the analysis / transcript are in accordance with the experiences expressed by participants.Researchers conducted a member check by sending verbatim results via WhatsApp and showing them directly to participants.This research received ethical approval from the ethics committee at Hospital "X" Jakarta with number: DP.04.03/KEP185/EC091/2023.All participants filled out an informed consent form.Data collection was carried out after participants were informed of the purpose of the study.Participation explained that research is voluntary and participants can choose not to complete the interview without any consequences.Furthermore, participants are informed of anonymity and that the data provided will be kept confidential and participant names coded from P1-P12.

RESEARCH RESULTS
The results of the study consist of a description of the characteristics of participants which can be seen in table 1 and the results of thematic analysis can be seen in figure 1 of the thematic tree.

Team Leader
Table 1 illustrates, the number of participants who participated in this study was 12 people, consisting of 59% were Unit Heads, 33% were Team Leaders, and 8% were Sub Installation Heads.The age range of participants was from 48 to 59 years old.The majority of participants' gender was female as much as 83% (10 people), and the participants' working period was in the range of 22 to 38 years.The education level of the participants in this study was the majority of Nurse by 83%.The participants' work units also varied consisting of the Palliative Unit, Adult Surgery Intermediate Room, Adult Surgery ICU Room, Adult Medical Intermediate Room, Adult Inpatient Room, Sukaman Pavilion Inpatient Room and Child Care Room.

Thematic Content Data Analysis
The results of thematic content data analysis obtained the theme of busyness, lack of structure of monitoring-evaluation systems, and knowledge are inhibiting factors in the implementation of risk management.This theme consists of 3 categories, namely: 1) Nurse activity factors; 2) Lack of knowledge factor; and 3) Lack of structured monitoring and evaluation system.Here are some examples of participant statement quotes in category order.Data analysis can be seen in figure 1 of the thematic tree.Category 1 "Yes, maybe if from the unit, yes, back to me, yes... myself still like e.. missed because of other activities finally e.. forgot to remind my friends about this risk management..."(P6, Head of Nurse) "It's almost the same...The obstacles in the implementation of monitoring are also ours, what is it because of?There are also many nursing care activities, sometimes these things if not reminded are often missed, actually..." (P5, Head of Nurse) Category 2 "...The first one in my opinion about risk management is not yet the one that... Plek gets the right training on how to make a risk management that is really focused on understanding how to grade.Maybe when we make it it's still gini... Gini yes... still like to look around like that..."(P6, Head of Nurse) "...There may also be obstacles, lack of socialization, as well as problems in the room, so that each staff may not contribute directly to help solve the problem..." (P10, Head of Nurse) "Some don't tell, or because they don't know how to report or from friends whether this is something that should be reported or not, because of ignorance there are also those who don't report."(P12, Team Leader) "...But for risk management training itself, which is really training that is not just providing material, I think not all can do it...You see, I haven't been before, as far as I remember..." (P11, Team Leader) Category 3 "... How the solution that has been formulated is sometimes because there is no incident it becomes forgotten even though there is no e..The monitoring incident should still be carried out, it is the obstacle..."(P5, Head of Nurse) "...So often because it comes from top to bottom, now the ones below like to forget and maybe we also like to forget to remind that oh this is the form that must be in this monev, for example, starting from socialization, then later supervision, there will be some data supporting it at the time of risk management reporting.The role may have been done informally, but the reporting was not well structured."(P7, Head of Sub.Installation) "Not if I am.. because e.
. not yet detailed, one is not yet detailed, then the implementation for the monev is also we have not been structured properly..."(P7, Head of Sub Installation) "... there is also a lack of coordination and perhaps one of them could be an obstacle in the risk management process..."(P10, Head of Nurse) "...The process is from top to bottom so in the unit also less what is the name.. feel that the risk will really happen.maybe it was said by Mrs. P7 that we make risk management in each unit so that it is in accordance with the conditions and can be anticipated as well so it is true that the risk will be as if it will easily occur in our unit so that all e... nurse or officer in the unit e.. what to anticipate.. anticipate with a different taste compared to being chosen from above."(P5, Head of Nurse)

RESULTS AND DISCUSSION
This study found that there are three inhibiting factors in the implementation of risk management, namely: 1) Busyness, 2) Lack of knowledge, and 3) Lack of structured monitoringevaluation in the implementation of risk management.Participants revealed that several obstacles in the implementation of risk management.These obstacles include busyness and many nursing care activities which cause the implementation of risk management to be less consistent in its implementation.This is in accordance with research conducted by (Ofei & Paarima, 2021) which states that predictors such as experience as a nurse manager, unit workload, and length of work significantly affect coordination in the unit, so to anticipate this a nurse manager needs to have competence in managing time well.A qualitative study on dynamic self-regulation as an effective time management strategy for clinical nurses conducted by (Talebi et al., 2019) Revealing that timing can be done by a process of self-efficacy that involves workload estimation, foresight, work style and skill development, division of labor, and time discipline.A manager is required to be able to carry out all five management functions, one of which is the planning function.Carrying out a good planning function, the nurse manager can manage his time well, know about the priority scale, and can complete all his tasks and obligations properly and on time.
After carrying out a good planning function, then the second phase that must be done by a nurse manager is organizing.Based on the research data, several participants revealed that the head of the room involved the team leader in the implementation of risk management.Through this function, a manager can perform a division of duties, providing a framework for explaining managerial authority, responsibility, and responsibility (Marquis &; Huston, 2017).A Team Leader Process from top to bottom can involve staff in the safety incident reporting system and see the sources of risk in the unit, the Head of Room involves the Team Leader in monitoring and supervising the implementation of risk management, and so on with the Head of Sub Installation.So as to create a tiered reporting system and all are in a good range of control.
The inhibiting factor of this study is lack of knowledge.Participants revealed that this lack of knowledge occurred in the nurse manager himself who did not understand in detail how to implement risk management comprehensively or on staff.This lack of knowledge on staff can occur due to lack of socialization about risk management or on the way of reporting related to patient safety incidents.The need for a nurse manager to increase the level of knowledge both for himself and for staff because with good knowledge of the patient safety system material will improve the nurse's performance in the application of the patient safety system (Muhammad Iqbal et al., 2020).Updating information about patient safety during education increases nurses' confidence in caring for their patients and makes their work evidence-based that improves the quality of care provided (Biresaw et al., 2020).The importance of knowledge about risk management also greatly affects the performance of an organization.This is in line with research conducted by (Durst et al., 2019) which states that there is a positive influence of risk management knowledge on organizational success, sustainability, growth, innovation and organizational movement.
When viewed from the level of competence possessed by participants, when referring to Permenkes No. 40 of 2017 concerning career paths, all participants should have understood how to implement risk management in their respective units.Based on the results of focus group interviews, it turns out that some participants still do not understand very well about this risk management.Some participants stated that they had indeed received risk management training but only through zoom and some had never even received complete risk management training.In fact, one of the strategies for implementing good risk management according to Permenkes No. 25 of 2019 concerning the Implementation of Integrated Risk Management within the Ministry of Health is to prepare facilities and infrastructure which include human resources, infrastructure, and standard operational procedures.So that increasing knowledge about risk management is very important so that the implementation of risk management in hospitals can run well.This knowledge increase is not only through training but the most concrete is practice and direct input from top managers in the implementation of risk management in the field.
Another inhibiting factor in the implementation of risk management is the lack of structured monitoring and evaluation system.The success of quality risk management efforts depends on the implementation of controls.The implementation of control is carried out by risk review to ensure the risk management process is carried out in an up-to-date and effective manner (Suprin et al., 2019).Nurse managers need to create a monitoring and evaluation system for the implementation of risk management in a structured manner and follow the development of existing technology.A good and structured incident reporting system is needed to facilitate staff and team leaders in monitoring and evaluation.This means that the system is very applicable and easy to do by all staff, so that incident reporting or monitoring of the implementation of risk management plans in the unit can run well.This is in accordance with what is stated by (Hernawati et al, 2023) that to do monitoring a tool is needed To monitor the implementation of risk management while supervising new nurses in the implementation of patient safety.
Nurse managers ensure all staff implement patient safety, implement an open reporting culture by eliminating the term bliming culture, and provide feedback to staff (Gunawan &;Hariyati, 2019) Risk management review and monitoring can use several sources of information, including: incident reporting, clinical audits, patient tracers, patient safety rounds, patient complaints, patient health surveys, staff complaints, and patient medical records (Hariyati, 2019).Nurse managers need to foster staff self-awareness in monitoring and evaluating the implementation of risk management in the unit.Open communication, reporting of patient side effects, and support of hospital supervisory and management units for patient safety are significant predictors of a patient safety culture (Lee et al., 2023), so that monitoring and evaluation of the implementation of risk management can continue to be carried out properly.

CONCLUSION
This study found that there are three inhibiting factors in the implementation of risk management, namely busyness, lack of knowledge, and lack of structured monitoring-evaluation system.Nurse managers have great duties and responsibilities in accordance with their roles and functions as a manager.A structured and easy-to-apply monitoring system is very helpful to monitor the success of risk management implementation.Nurse managers need to have good time management and knowledge about risk management so that with the implementation of good risk management the quality of service can improve.