Patient safety incident reporting systems provide information on the occurrence of patient safety incidents to mitigate risk, improve the system, learn from the mistakes, and share learning [1
]. Incident reporting in hospitals is usually governed by a national reporting system. In Indonesia, a patient safety incident reporting system was introduced in hospitals in 2006. The government has published supporting regulations and guidelines such as the National Guidelines for Hospital Patient Safety [5
], the Guidelines for Patient Safety Incident Report [6
], and other regulations [7
]. Patient safety implementation, including incident reporting, was handled by the National Committee on Patient Safety, the Indonesian Hospital Association (IHA), and the Commission for Hospital Accreditation (CHA) [5
] which is also responsible for hospital accreditation and delivering patient safety training. Government organizations, such as the Ministry of Health and District Health Offices (DHO), also carried out roles at the provincial and district/city levels, including advocacy for the patient safety program to the hospitals and advocacy for budget-related patient safety to the government [5
] (please refer to Table 1
Notwithstanding the efforts of all levels of government, the under-reporting of patient safety incidents is evident, as only around 668 incidents were reported in 2016 [9
]. This number is very low compared to the number of accredited hospitals [10
], which are supposed to report incidents to the National Committee. In addition, the yearly national patient safety incident report was not published because of confidentiality issues. At the hospital level, problems such as incomplete or unwritten reports, validation problems and adverse events not being followed up by investigation were found, and no effective feedback of learning or corrective actions were implemented to prevent the same incidents recurring [11
Since the government plays a vital role in the implementation of a national system for improving patient safety, including tracking and monitoring patient safety incidents, this study focuses on how the Indonesian government has been undertaking its role in patient safety at the provincial and city/district levels. The focus of the study is on the implementation of patient safety incident reporting according to the National Guidelines for Hospital Patient Safety.
This study revealed several problems at the macro-, meso- and micro-level for the implementation of patient safety programs and patient safety incident reporting in Indonesia. At the macro-level, the Indonesian government’s tasks are to develop the policy, set standards and undertake public assurance through a monitoring and reporting process [15
]. However, monitoring and evaluation have not been a priority, as the performance of the roles listed in the reporting guidelines have never been evaluated. The patient safety policy development lacked adequate resources to implement the policy at all levels, which could have been detected and fixed earlier if the monitoring and evaluation functions were carried out at the national level. Despite its importance, the government lacked a coordinated mechanism to systematically assess, evaluate and follow up quality improvement measures [16
]. This finding was strongly supported by the Republic of Indonesia Health System Review that highlighted the problems related to the implementation, as well as monitoring and evaluation of the impact of the regulations on quality and safety [17
At the meso-level, despite the government’s efforts to increase attention to patient safety, the DHO and PHO have not carried out their roles related to patient safety detailed in the national guidelines, especially those requiring advocacy for patient safety programs to the hospital and patient safety budgeting. The advocacy program was carried out by the DHO and PHO by simply adding patient safety issues to existing programs or activities. Neither organization had a specific program or budget allocated for patient safety, which showed a lack of commitment to and priority of patient safety.
Advocacy for patient safety programs on the part of the DHO and PHO did not extend to all hospitals in the region. This was primarily due to a complex bureaucratic structure that did not allow the DHO or PHO to work with all hospitals in the regions. This indicated lack of systematic partnership and collaboration in patient safety and lack of integration of disparate activities on patient safety [18
]. These results support the need to establish a patient safety council and patient safety work-plans at the provincial and district levels, since the DHO and PHO do not have specific patient safety units [19
]. Enhancing cooperative government and intergovernmental relations would also support the DHO and PHO in performing their patient safety roles [20
The DHO and PHO have not been involved in patient safety incident reporting. This is in keeping with the national guidelines, since patient safety and incident reporting are managed by independent agencies without the involvement and coordination of the DHO and PHO. In Indonesia, lacked of transparency and openness in reporting and web-based dissemination of the reported incident data is in contrast with Taiwan and Malaysia, which have a patient safety dedicated website and systematic learning from incidents mechanisms in place [21
]. This resulted in a missing link in the implementation of incident reporting between the national level and the provincial and district or city level, as the information about the incidents reported was concentrated at the national level and there was no feedback provided to the sub-national level. In organizing patient safety, it is crucial to engage different levels to work together to implement the program [23
At the micro-level, the hospitals tried to allocate a budget for patient safety programs, however, this financial commitment varied among the hospitals. Some hospitals were able to fund their own programs, but others were not. According to the World Health Organization (WHO), the allocation of funds for patient safety programs and actions by the government demonstrate a commitment to improving the safety and quality of care in health care settings [24
]. Political support and commitment from the government is critical to improving patient safety [25
], however, this has not yet happened in Indonesia.
Governments play a major role in achieving better quality with value in health care and in the success or failure of healthcare reform and improvement [26
]. While regulation is formulated at the national level, implementation occurs mostly at the regional and district levels [27
], thus monitoring and evaluation at every system level is needed to check whether the program or action is implemented as planned and has achieved the anticipated results [28
]. This is essential to determine whether the program should be continued, modified or eliminated [29
]. Monitoring and evaluation are complementary activities and need to be integrated with implementation, not as a distinct activity [20
] and need to have clear key performance indicators. Within a local government context, carrying out monitoring and evaluation also demonstrates good governance and accountability [20
]. However, these have not yet been carried out by the national level or the DHO and PHO in relation to patient safety.
The Indonesian DHO and PHO have not optimally carried out their roles in implementing patient safety set out in the national guidelines. The lack of involvement of these organizations in managing incident reporting means that they are not aware of patient safety issues in the hospitals in their regions. Moreover, monitoring and evaluation were not undertaken. The lack of commitment to and priority of patient safety, the complexity of the bureaucratic structure, lack of systematic partnership and collaboration, and the lack of a framework to systematically assess, evaluate and follow up quality improvement measures are the problems that need to be addressed. The three levels of government need to work more closely by setting annual patient safety goals, performance indicators and performance agreements, and developing guidelines to be used by the regional or local level government organizations on how to achieve targets. Monitoring and providing feedback are also important for ensuring effective and efficient national outcomes. Lastly, all documents and the progress reports must be made publicly available as part of the organization’s accountability.