Transformative Journey with LAFKI: Accreditation of GPM Sumber Hidup Hospitals in Quality Improvement and Patient Safety (Case Study)

GPM Sumber Hidup Hospital has undergone an accreditation process that reaffirms its commitment to high-quality standards in healthcare services. This process demands compliance with established requirements for the provision of healthcare services. Accreditation from LAFKI (Lembaga Akreditasi Fasilitas Kesehatan Indonesia) is important as it signifies the hospital's alignment with established quality and patient safety standards. The aims of this article is to present findings from a case report study on the accreditation of GPM Sumber Hidup Hospital in the context of improving quality and patient safety. It is hoped that this article can make a significant contribution to the understanding of enhancing the quality and safety of patients within the context of hospital accreditation. By presenting comprehensive and relevant research findings, this article aims to provide valuable insights for healthcare practitioners and researchers in their efforts to improve healthcare service standards.

GPM Sumber Hidup Hospital has undergone an accreditation process that reaffirms its commitment to high-quality standards in healthcare services.This process demands compliance with established requirements for the provision of healthcare services.Accreditation from LAFKI (Lembaga Akreditasi Fasilitas Kesehatan Indonesia) is important as it signifies the hospital's alignment with established quality and patient safety standards.The aims of this article is to present findings from a case report study on the accreditation of GPM Sumber Hidup Hospital in the context of improving quality and patient safety.It is hoped that this article can make a significant contribution to the understanding of enhancing the quality and safety of patients within the context of hospital accreditation.By presenting comprehensive and relevant research findings, this article aims to provide valuable insights for healthcare practitioners and researchers in their efforts to improve healthcare service standards.

INTRODUCTION
Research on the improvement of quality and patient safety is crucial in the healthcare world, especially in hospital environments.The quality of healthcare services is a primary focus for healthcare institutions to ensure that patients receive the best possible care.Patient safety is also an undisputed priority, with ongoing efforts to prevent medical errors and incidents that may jeopardize patients.
GPM Sumber Hidup Hospital has undergone an accreditation process that reaffirms its commitment to high-quality standards in healthcare services.This process demands compliance with established requirements for the provision of healthcare services.Accreditation from LAFKI (Lembaga Akreditasi Fasilitas Kesehatan Indonesia) is important as it signifies the hospital's alignment with established quality and patient safety standards.
This article aims to present findings from a case report study on the accreditation of GPM Sumber Hidup Hospital in the context of improving quality and patient safety.Through in-depth analysis of research findings, this article will reveal factors that have contributed to the success or shortcomings in efforts to enhance quality and patient safety in this hospital.
A better understanding of factors influencing quality and patient safety is expected to provide valuable insights for healthcare practitioners in their efforts to deliver better care to their patients.This article can also serve as a guide for other hospitals striving to improve the quality and safety of their patients through the accreditation process.
By presenting findings from this case report study, this article has the potential to make a significant contribution to healthcare literature.The information presented can be a valuable source of knowledge for researchers and healthcare practitioners interested in the field of quality improvement and patient safety.
The research methodology used in this case report study provides certain advantages in understanding the complexity of efforts to improve quality and patient safety.By analyzing various aspects of the accreditation process and the implementation of quality improvement programs in depth, this research can provide broader and deeper insights for readers.
Through a better understanding of factors influencing quality and patient safety, it is hoped that this article can make a positive contribution to efforts to improve the quality of healthcare services in hospitals and other healthcare institutions.Thus, patients can receive safer and more effective care.
This article can also promote greater synergy between healthcare practitioners and researchers in efforts to improve quality and patient safety.By sharing research findings with healthcare practitioners, this article can help strengthen the relationship between research and ongoing healthcare practices.
By delineating the background and purpose of writing this article, it is hoped that this article can make a significant contribution to the understanding of enhancing the quality and safety of patients within the context of hospital accreditation.By presenting comprehensive and relevant research findings, this article aims to provide valuable insights for healthcare practitioners and researchers in their efforts to improve healthcare service standards.

THEORETICAL REVIEW
Based on the analysis results of the PMKP (patient quality and safety improvement) standards that have been conducted, there are several relevant theories that can provide a profound understanding of the aspects discussed in the standards.Here is a review of the theories that can be associated with the analysis results:

A. Total Quality Management -TQM
The theory of Total Quality Management (TQM) emphasizes the importance of engaging all stakeholders in efforts to improve the quality of products or services.In the context of hospitals, the implementation of TQM can be reflected in steps such as forming quality committees, developing quality improvement programs, and evaluating these programs.TQM principles such as systematic data collection, in-depth analysis, and regular reporting are also relevant in ensuring alignment with PMKP standards.

B. Patient Safety Culture
The theory of patient safety culture highlights the importance of creating a working environment that prioritizes patient safety.Measures such as conducting patient safety culture surveys and developing improvement strategies based on survey findings adhere to the principles of patient safety culture.Patient safety culture also encompasses learning from incidents and utilizing data to enhance clinical practices and decisions.

C. Risk Management
The theory of risk management is crucial for understanding how organizations identify, assess, and manage risks associated with healthcare services.Steps such as risk identification, risk assessment, risk management, and risk monitoring are concepts aligned with the principles of risk management.Implementing a risk management program in hospitals enables the reduction of negative incidents and enhances overall patient safety.

D. Health Data Management
When it comes to the collection, analysis, and reporting of health data, health data management theory provides insights into how health data can be gathered, managed, and utilized for effective decision-making.The principles of health data management encompass steps to ensure the accuracy, security, and integrity of data, as well as the utilization of data for evaluation and continuous improvement purposes.
By understanding and effectively applying these theories, hospitals can develop best practices and ensure high-quality and safe healthcare services for their patients.

METHODOLOGY
This research utilized instruments established by the Indonesian Ministry of Health as guidelines for evaluating the quality and safety of patients at Sumber Hidup GPM Hospital.The survey process was conducted through a combination of online and offline methods by accreditation surveyors from the Indonesian Health Facility Accreditation Institute (LAFKI).Data collection took place in October 2023.
The research instruments employed adhere to guidelines set by the Indonesian Ministry of Health for hospital accreditation evaluation.These instruments encompass document review, facility inspection, observation, interviews, as well as demonstrations or simulations of aspects deemed necessary for a comprehensive understanding of the implementation of patient safety and quality improvement programs.
The survey was carried out over a 3-day period by a team of surveyors comprising experts trained in hospital accreditation processes.The survey team combined online and offline methods, visiting the hospital premises for direct observation and interviews with relevant staff, and conducting online surveys to gather additional necessary data.
Data collection involved various methods, including document review to gather written data regarding policies, procedures, and patient medical records.Facility inspections were conducted to directly examine the hospital's infrastructure and facilities.Observations were made to witness direct healthcare practices.Interviews were conducted with hospital staff to gain deeper insights into the implementation of quality improvement and patient safety programs.Additionally, demonstrations or simulations were performed for a better understanding of relevant aspects.
This research methodology enabled comprehensive data collection and a profound understanding of efforts to improve patient safety and quality at Sumber Hidup GPM Hospital.Through a combination of online and offline surveys and the utilization of various data collection methods, this research can provide an accurate overview of the implementation of patient safety and quality improvement programs at the hospital.

RESULT
The findings of the Case Report Study on the Hospital Accreditation of GPM Sumber Hidup Hospital.This research was conducted to evaluate the implementation of Quality Improvement and Patient Safety (QIPS) at of GPM Sumber Hidup Hospital based on several predefined criteria.Here are the results of the study:

A. PMKP 1: Regulation and Risk Management
The hospital director has established regulations regarding the improvement of quality and patient safety as well as risk management.The Quality Governance Committee has been formed and manages QMPS activities in accordance with legislation.The QMPS program has been developed, periodically evaluated, and approved by the owner/board of supervisors.

B. PMKP 2: The selection of Quality Indicators and Coordination
The Quality Assurance Committee is involved in selecting quality indicators and coordinating and integrating measurement activities.However, additional evidence in the form of visual photos related to the supervision of service units is needed.

C. PMKP 3: Data Collection and Quality Indicator Profile Development
The hospital has conducted data collection and created profiles of quality indicators both for hospital-wide levels and for individual service units.

D. PMKP 4: Data Analysis and Recommendation
Data aggregation and analysis have been conducted using statistical methods.However, further evidence is still needed regarding reporting the analysis results to the Director and the owners/board of supervisors.

E. PMKP 4.1: Identification of Improvement Opportunities
There is currently insufficient identification of improvement opportunities; further analysis is needed regarding internal and external comparisons.

F. PMKP 5: Data Validation and Leadership Responsibility
Data validation has not been fully proven, and there needs to be an improvement in leadership responsibility towards the quality of data and published results.

G. PMKP 6: Improvement Plan and Trials
The hospital has developed an improvement plan and conducted trials, but further evidence is needed regarding the necessary changes.

H. PMKP 7: Clinical Pathway Evaluation
The evaluation of clinical pathways still needs improvement to demonstrate compliance improvements and reduce variations in the application of medical service standards.

I. PMKP 8: Reporting System and Sentinel Event Investigation
There is a need to explain the investigation process in more detail regarding sentinel events.

J. PMKP 9: Data Collection and Analysis
Further in-depth data analysis is needed to identify unexpected patterns or trends.

K. PMKP 10: Measurement of Patient Safety Culture
Recommendations from the measurement results of patient safety culture need to be supplemented to develop a patient safety culture improvement program.

L. PMKP 11: Risk Management Program
More regular monitoring and reporting regarding risk management plans are needed.
Overall, the results of this study indicate several areas where GPM Sumber Hidup Hospital can make improvements in the implementation of PMKP to enhance the quality and safety of patient care.Further steps are needed to meet established standards and ensure optimal healthcare services for patients.

A. PMKP 1: Regulation and Risk Management
Regulation and Risk Management, according to expert theory concepts, require the use of precise analytical tools to explore gaps, shortcomings, support, and counterarguments.One relevant concept is the Donabedian Model, which suggests that the quality of healthcare services can be assessed through three dimensions: structure, process, and outcome.
In this case, regulation and risk management are part of the structure that forms the basis for the implementation of Patient Safety and Quality Improvement (PSQI) in hospitals.Strong support from the hospital director in establishing regulations demonstrates a commitment to improving patient quality and safety.The establishment of a Quality Improvement Committee also reflects efforts to involve various stakeholders in PSQI management, in line with the principle of collaboration in risk management (Leape, 1994).
However, gaps may arise in the effective implementation of regulations and risk management activities.One possible shortcoming is a lack of adequate resources, whether financial, human resources, or infrastructure, which can hinder the smooth implementation of PSQI (Institute of Medicine, 2001).Additionally, there may be a potential gap between the regulations set and the actual conditions in the field.This could be due to discrepancies between regulatory expectations and the practical situations faced by hospital staff (Shortell et al., 1998).
To address these gaps, it is important to strengthen communication and cooperation among various stakeholders, including hospital directors, the Quality Improvement Committee, medical staff, and other relevant parties.Continuous evaluation is also necessary to identify changes or adjustments needed in regulations and risk management to meet actual needs in the field (Carroll et al., 2009).
Regarding support, a holistic and sustainable approach to regulation and risk management can create an environment conducive to improving patient quality and safety.By involving all stakeholders, including staff, patients, and families, hospitals can create a positive safety culture and ensure compliance with established regulations (Huang et al., 2007).
However, in seeking stronger support, potential counterarguments must also be addressed.For example, some parties may doubt the effectiveness of the regulations set or feel that risk management efforts consume a lot of time and resources without yielding significant results (Reason, 2000).Therefore, it is important to continue communicating and educating all relevant parties to build a strong understanding of the importance of regulation and risk management in improving patient quality and safety (Institute for Healthcare Improvement, 2020).
In conclusion, the results of PSQI 1 demonstrate a strong commitment from the hospital in establishing regulations and managing risks to improve patient quality and safety.However, challenges and gaps in implementation still need to be addressed through a holistic approach, continuous evaluation, and effective communication with all relevant parties.

B. PMKP 2: The selection of Quality Indicators and Coordination
In PMKP 2, the role of the Quality Committee in selecting quality indicators and coordinating measurement activities aligns with quality management theory.According to Juran (1988), choosing the right quality indicators is key to ensuring success in enhancing organizational quality.With the involvement of the Quality Committee in this process, it is expected that the selected indicators will be relevant and aligned with the goal of improving hospital quality.
However, there is a need for additional evidence in the form of visual photos related to supervision of service units, depicting a gap between planning and implementation.According to Implementation Theory by Grol and Wensing (2004), the implementation of new practices often faces obstacles and challenges in the field.In this case, although the Quality Committee has been involved in coordination and quality measurement, there are still shortcomings in ensuring that supervision of service units is carried out effectively.
This gap is consistent with the concept of Gap Analysis introduced by Parasuraman et al. (1985).The gap between what is planned and what is implemented may indicate the need to improve existing processes or systems.In this regard, the gap between the role of the Quality Committee in selecting quality indicators and the lack of visual evidence of supervision indicates potential areas for improvement in the hospital's quality management system.
To address this gap, additional steps are needed based on the concept of Continuous Quality Improvement (CQI).According to Deming (1986), CQI emphasizes the concept of continuous improvement through data collection, analysis, and continuous improvement actions.Therefore, the hospital can enhance the effectiveness of supervision by strengthening monitoring and reporting mechanisms and providing additional training to Quality Committee members related to supervision tasks.Thus, while the involvement of the Quality Committee in selecting quality indicators is a positive step in line with quality management theory, additional steps are needed to address the gap in supervising service units.This will ensure that quality improvement efforts proceed as planned and have a tangible impact on patient safety and well-being.

C. PMKP 3: Data Collection and Quality Indicator Profile Development
The analysis of the results from PMKP 3 indicates that the hospital has engaged in data collection and the establishment of quality indicator profiles through the lens of the Total Quality Management (TQM) theory.TQM is a management approach focused on comprehensive quality improvement through the involvement of all organizational members in the enhancement process.In this regard, the hospital has effectively applied the TQM concept by undertaking the crucial initial steps in quality improvement, namely data collection and quality indicator profiling.According to Deming (1986), a leading expert in TQM, data collection is an essential initial step in improving quality because data forms the basis for quality decision-making.In this aspect, the hospital has adhered well to this principle, demonstrating alignment with the theory.
However, there are some gaps and shortcomings that need attention.One of them is the need to ensure that data collection is consistently and systematically carried out in accordance with established standards.According to Juran (1988), another TQM expert, consistency in data collection is key to obtaining accurate and reliable results.Therefore, the hospital needs to ensure that there are clear and consistent procedures for data collection to minimize errors and biases that may occur.
Furthermore, the creation of quality indicator profiles should also be supported by the selection of relevant and representative indicators.According to Crosby (1979), an important aspect of TQM is the selection of appropriate indicators to monitor performance and outcomes.Therefore, the hospital needs to ensure that the selected indicators not only meet organizational needs but also provide an accurate picture of the quality of services provided.
Support for the steps taken by the hospital can be seen through the concept of Continuous Improvement (CI).According to Shewhart (1939) and Ishikawa (1985), CI is a fundamental concept underlying TQM, where organizations are expected to continuously improve in all operational aspects.By engaging in data collection and creating quality indicator profiles, the hospital has demonstrated its commitment to the CI principle, as these steps form the foundation for continuous improvement in healthcare service quality.
However, it should be noted that the creation of quality indicator profiles is only the initial step in the process of continuous quality improvement.To achieve optimal results, the hospital needs to continuously evaluate, analyze, and improve the established quality indicators.As expressed by Juran (1988), the quality improvement process never ends, and organizations need to continually strive to enhance their performance.
Thus, while the steps taken by the hospital in PMKP 3 demonstrate their commitment to quality improvement, further efforts are still needed to ensure that data collection and quality indicator profiling are consistently, relevantly, and sustainably carried out.This will enable the hospital to achieve optimal results in their efforts to enhance healthcare service quality.

D. PMKP 4: Data Analysis and Recommendation
PMKP 4 highlights the importance of data analysis and recommendation-making in improving the quality and safety of patient care in hospitals.According to David J. Hand, a leading statistician, data analysis is the process of transforming raw data into useful information for decision-making.Hand (2001) states that proper data analysis can help identify patterns, trends, and relationships that may be hidden in the data, thus enabling better decisionmaking.In the case of PMKP 4, although data analysis has been conducted using statistical methods, it is important for hospitals to report the results of these analyses to the Director and the owner/board of supervisors.
One crucial analytical tool in this regard is the "Importance of Reporting and Transparency."This concept emphasizes that reporting analysis results to the appropriate authorities is a critical step in effective decision-making processes.According to James E. Grunig and Todd Hunt (1984), transparency in organizational communication is key to trust and legitimacy.In the context of PMKP 4, when data analysis results are reported to the Director and the owner/board of supervisors, it not only enhances the hospital's accountability but also enables them to make decisions based on accurate and reliable information.
However, there is a gap between expectations and reality.Despite data analysis being conducted, reporting analysis results to the relevant authorities has not been fully met.This indicates a deficiency in internal communication processes within the hospital.According to Peter Senge (1990), failures in internal communication can hinder the formation of shared understanding and impede organizational progress.In this case, the gap between reporting analysis results and the expectations of the relevant authorities suggests the need for improvement in the hospital's internal communication system.
In supporting the need for reporting analysis results, David M. Levine and Timothy C. Krehbiel (2005) state that effective decision-making requires access to accurate and relevant information.Therefore, reporting data analysis results to the Director and the owner/board of supervisors provides them with an opportunity to understand the situation comprehensively and take appropriate actions according to the hospital's needs.The support from these experts reaffirms the importance of reporting analysis results as a step towards improving decision-making effectiveness.
However, objections to the necessity of reporting analysis results may arise regarding bureaucracy and organizational complexity.Richard L. Daft (2007) suggests that in large and complex organizations, decision-making processes often involve multiple layers of management and formal procedures.This can slow down the flow of information and make reporting more challenging to do efficiently.Therefore, hospitals may encounter practical constraints in reporting data analysis results to the relevant authorities in a timely manner.
Overall, PMKP 4 highlights the importance of reporting analysis results to the relevant authorities to enhance the quality and safety of patient care in hospitals.Although data analysis has been conducted, further steps are needed to ensure that relevant and accurate information is available to those responsible for making decisions.Therefore, improvements in internal communication systems and efforts to address bureaucratic barriers can help enhance the effectiveness of reporting analysis results in the context of PMKP 4.

E. PMKP 4.1: Identification of Improvement Opportunities
Research findings on Sumber Hidup GPM Hospital indicate a significant deficiency in the aspect of Identifying Improvement Opportunities (PMKP 4.1).Conceptual theories from management experts such as Peter F. Drucker, renowned for his concepts of change management and innovation, can provide relevant insights into analyzing this situation.Drucker emphasizes the importance of identifying improvement opportunities as the initial step in the organizational innovation process.According to Drucker (1954), effective organizations must continuously seek, identify, and exploit improvement opportunities to achieve competitive advantage and enhance overall performance.In the case of Sumber Hidup GPM Hospital, deficiencies in identifying improvement opportunities indicate a gap in the application of innovation management concepts.One suitable analytical tool to understand this issue is SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis.In this context, shortcomings in identifying improvement opportunities can be considered organizational weaknesses.Inadequate identification of improvement opportunities suggests that GPM Hospital has not fully capitalized on potential improvements within its internal and external environment.In this regard, these weaknesses hinder the achievement of quality improvement and patient safety goals.
Moreover, gaps in identifying improvement opportunities can also be viewed from the perspective of quality management theory.According to Deming (1986), the first step in continuous improvement is recognizing variations or deviations from the desired standard.In this context, adequate identification of improvement opportunities would enable Sumber Hidup GPM Hospital to identify areas where they are not meeting desired standards, both from internal results and in comparison with similar hospitals or best practices.
To address these deficiencies, a systematic and targeted approach to the process of identifying improvement opportunities is required.Sumber Hidup GPM Hospital can strengthen this process by involving all team members, using SWOT analysis, Pareto analysis, or other techniques to identify improvement priorities more effectively.Additionally, training and education for relevant staff are necessary to enhance awareness and capabilities in identifying and reporting improvement opportunities.
Support for these improvements can be obtained from quality management literature such as Juran (1992), who emphasizes the importance of involving all parties in identifying and addressing improvement opportunities.Juran states that identifying improvement opportunities is key to enhancing organizational quality and productivity.Therefore, by enhancing the organization's ability to identify improvement opportunities, Sumber Hidup GPM Hospital can improve their overall performance.
However, there are also reservations about this approach.Some experts may argue that a process overly focused on internal analysis in identifying improvement opportunities may overlook external factors that also influence organizational performance.In the case of hospitals, factors such as regulatory changes, advancements in medical technology, and patient expectations can be significant sources of improvement opportunities.Hence, a balanced approach between internal and external analysis is necessary to comprehensively identify improvement opportunities.
In this research, Drucker (1954), Deming (1986), and Juran (1992) are some experts who can provide crucial insights into the deficiencies in identifying improvement opportunities at Sumber Hidup GPM Hospital.By using the appropriate analytical tools and integrating various theoretical perspectives, the hospital can enhance the process of identifying improvement opportunities and ultimately improve the quality and safety of their patients.

F. PMKP 5: Data Validation and Leadership Responsibility
The research findings concerning Data Validation and Leadership Responsibility (PMKP 5) at the Sumber Hidup GPM Hospital highlight the importance of data validation as a foundation for making informed decisions in managing patient quality and safety.A relevant theoretical concept in this analysis is the concept of Total Quality Management as explained by Management Expert James Harrington, which emphasizes the importance of accurate and valid data in effective decision-making (Harrington, 1991).According to Harrington, Total Quality Management encompasses all operational aspects of an organization, including data validation and leadership responsibility in ensuring its quality.
In this context, the identified shortfall is the lack of comprehensive data validation at the Sumber Hidup GPM Hospital.This creates a gap between ideal practices and what actually happens in the field.Without adequate data validation, decisions made by hospital leadership and medical staff may be less accurate, potentially leading to misdiagnosis or inappropriate patient management.
This gap can be addressed by increasing awareness and commitment among leadership to their responsibility in ensuring data validity.One approach that can be utilized is involving leadership directly in the data validation process, as suggested by Richard Chang in the concept of "leadership involvement" in change management (Chang, 2016).Thus, leaders can directly understand the importance of data validation and take concrete steps to improve the validation process at the hospital.
However, a caveat to this approach is the possible constraints of time and limited resources in directly involving leadership in data validation.This may pose difficulties in implementing necessary changes within a short timeframe.Support from the entire management team and hospital staff is also needed to address this gap.
Therefore, to mitigate the shortcomings in data validation and enhance leadership responsibility, collaborative efforts between leadership, management, and hospital staff are necessary.Concrete steps such as increased training on the importance of data validation, assigning specialized teams for validation, and implementing periodic monitoring systems can help improve the data validation process sustainably (Chang, 2016).Thus, the Sumber Hidup GPM Hospital can significantly improve service quality and patient safety.
In this regard, research by Dallek (2005) also underscores the importance of leadership's role in ensuring data quality and the sustainability of Total Quality Management in healthcare organizations.Dallek emphasizes that leadership commitment is key to success in implementing changes towards better quality.
Through this approach, it is hoped that the Sumber Hidup GPM Hospital can achieve higher levels of data validation and enhance leadership responsibility for overall data quality and patient safety.

G. PMKP 6: Improvement Plan and Trials
Analysis of PMKP 6 at the Sumber Hidup GPM Hospital according to expert theory concepts regarding quality management and patient safety indicates several aspects that need consideration.One analytical tool that can be utilized is the Plan-Do-Check-Act (PDCA) theory by W. Edwards Deming.This theory emphasizes a continuous improvement cycle involving planning, doing, checking, and acting to achieve sustained quality improvement (Deming, 1986).
In the planning stage, the hospital has devised improvement plans; however, clarity in identifying necessary changes remains lacking.As expressed by Deming (1986), good planning should be specific and measurable to ensure clear objectives and desired outcomes are achieved.Therefore, there's a need for improvement in identifying required changes in detail and measurably.
Furthermore, in the implementation stage, the Sumber Hidup GPM Hospital has experimented with the devised improvement plans.However, the success of the implementation still requires further evidence regarding its effectiveness.According to Juran (1992), effective implementation necessitates good communication among all involved parties and careful monitoring of plan implementation.
In the checking stage, it's important to evaluate the results of the experimentation to assess its effectiveness.However, in this case, the need for further evidence regarding necessary changes remains a constraint.According to Crosby (1979), effective checking requires accurate data collection and indepth analysis to assess performance and identify problems that need fixing.
Lastly, in the acting stage, the evaluation results from the previous stages should serve as a basis for taking appropriate corrective actions.However, clarity regarding necessary changes still lacks in the implementation of PMKP 6 at the Sumber Hidup GPM Hospital.According to Shewhart (1939), actions taken should be based on clear evidence and a deep understanding of the issues at hand.
Therefore, the main gap in the implementation of PMKP 6 at the Sumber Hidup GPM Hospital lies in its lack of specific identification of necessary changes and its inadequacy in providing sufficient evidence regarding the effectiveness of plan implementation.The support needed involves the development of more detailed and measurable planning processes and more careful monitoring of plan implementation.Meanwhile, a caveat to this analysis is the possibility that sufficient evidence may exist but has not been welldocumented, thus requiring a review of existing documentation.
In this regard, the PDCA theory concept can serve as a strong foundation for the Sumber Hidup GPM Hospital to conduct comprehensive evaluations of PMKP 6 implementation and make necessary improvements to achieve sustained quality improvement and patient safety.

H. PMKP 7: Clinical Pathway Evaluation
Clinical pathway evaluation is crucial in ensuring quality and consistent healthcare services.However, research findings on the Sumber Hidup GPM Hospital indicate that this evaluation needs improvement.According to expert theories in healthcare management, enhancing clinical pathway evaluation can be achieved by applying the quality service concept analysis framework.
The appropriate analysis framework for this case is the "Plan-Do-Study-Act" (PDSA) approach proposed by Deming.PDSA is a continuous improvement cycle consisting of four stages: planning, implementation, observation, and action.In terms of clinical pathway evaluation, Sumber Hidup GPM Hospital can plan improvements in the planning stage, execute those plans, observe the results, and take corrective actions accordingly.
The main gap identified in the evaluation of clinical pathways at Sumber Hidup GPM Hospital is the lack of data demonstrating improvements in compliance and reduction of variation in the application of medical service standards.This can lead to uncertainty in service effectiveness and the hospital's inability to meet established quality standards.
One of the primary shortcomings in clinical pathway evaluation is the lack of focus on using data and evidence to support clinical decisions.Without strong data, it is difficult for hospitals to identify areas in need of improvement and implement appropriate actions.
To address these gaps and shortcomings, Sumber Hidup GPM Hospital needs to enhance the use of more structured and measurable evaluation methods.One solution is to use proven and effective evaluation tools, such as clinical audits or medical audits.Consequently, the hospital can more accurately identify needed improvements and measure progress towards clinical pathway evaluation goals.
Support for improving clinical pathway evaluation can be provided through training and education for hospital staff on the importance of data collection and analysis, as well as the implementation of best practices in clinical evaluation.Additionally, leadership support in providing adequate resources for evaluation implementation is also key to success.
However, objections to these improvement efforts may be related to resource limitations, whether in terms of time, personnel, or budget.The hospital may face challenges in implementing necessary changes due to these factors.
In supporting more effective clinical pathway evaluation, it is essential for Sumber Hidup GPM Hospital to strengthen its commitment to improving service quality.This can be achieved through the development of policies and procedures supporting comprehensive data collection and the implementation of appropriate corrective actions based on evaluation findings.Thus, the hospital can enhance overall service quality and patient safety

I. PMKP 8: Reporting System and Sentinel Event Investigation
The analysis of research findings on the reporting and investigation system of sentinel events in Sumber Hidup GPM Hospital requires a meticulous approach using relevant theoretical concepts.One theory that can be utilized is the risk management theory in healthcare services.According to David J. Ball, in his book titled "Risks and Decisions for Conservation and Environmental Management," risk management is a systematic approach to identifying, evaluating, and managing risks that may arise in an activity or operation.In healthcare, risk management is crucial to ensuring patient safety and optimal service quality.
Firstly, we need to scrutinize the analysis blade regarding the necessity to elucidate the process of investigating sentinel events in more detail.According to risk management theory, investigating sentinel events is a crucial step in identifying risk factors that may lead to similar events in the future.Therefore, ambiguity or inadequacy in explaining the investigation process can result in gaps in understanding and addressing risks within the hospital.
Furthermore, we need to highlight the gaps arising from deficiencies in the sentinel event investigation process.Without a clear understanding of the investigation process, hospitals may struggle to identify the underlying root causes of sentinel events.This can hinder efforts to implement effective improvements to prevent similar events in the future.
Moreover, deficiencies in explaining the investigation process can also impact the hospital's credibility in the eyes of patients and the general public.Patients and the public have the right to know that the hospital has a transparent and accountable system for handling sentinel events.Inadequacies in explaining the investigation process can raise doubts and distrust in the hospital's ability to provide safe and quality care.
However, on the other hand, we also need to support the hospital's efforts to improve the reporting and investigation system for sentinel events.For example, the hospital may have faced constraints in providing adequate resources for conducting detailed investigations.Support in terms of resource allocation and training for medical staff can help enhance the hospital's capacity to handle sentinel events more effectively.
In order to provide appropriate solutions to these deficiencies, it is crucial to involve various stakeholders, including hospital management, medical staff, and external parties such as accreditation bodies.With good cooperation and shared commitment, hospitals can identify and address weaknesses in the reporting and investigation system for sentinel events, thus enhancing patient safety and overall service quality.
In this regard, several studies support the importance of developing effective reporting and investigation systems for sentinel events in healthcare.For instance, research by Vincent et al. (2016) indicates that hospitals with strong reporting systems tend to have lower rates of sentinel events and better outcomes for patients.Therefore, investing in the development of reporting and investigation systems for sentinel events can yield long-term benefits for hospitals and their patients.

J. PMKP 9: Data Collection and Analysis
Research findings on the Sumber Hidup GPM Hospital, particularly regarding PMKP 9 highlighting data collection and analysis, indicate the need for a more in-depth approach to understanding unexpected patterns or trends.In this analysis, theoretical concepts from experts like Deming on the PDCA (Plan, Do, Check, Act) cycle could serve as a precise analytical tool.Deming emphasizes the importance of collecting quality data and careful analysis to identify improvements.In this regard, the PDCA approach becomes a powerful tool to ensure continuous iterations in enhancing patient quality and safety.
However, there is a gap in implementing this concept at the Sumber Hidup GPM Hospital.Despite efforts to collect data, deeper analysis is often overlooked.This may be due to resource limitations or a lack of training for relevant staff.Stronger support in terms of training and developing data analysis skills may be necessary steps to address this gap.
Moreover, deficiencies in accurate data collection can also hinder effective analysis.Without quality data, analyses tend to be irrelevant or unreliable.Therefore, special attention to the data collection process is necessary to ensure the accuracy and reliability of information used in analysis.
To support efforts for deeper data analysis, the Sumber Hidup GPM Hospital could consider implementing more sophisticated statistical methods or analytical technology to expedite and enhance the accuracy of analysis.Thus, the potential to identify unexpected patterns or trends can be increased, enabling the hospital to take more proactive actions in improving patient quality and safety.
However, it's also important to be aware that deeper data analysis may lead to increased costs and time.Therefore, reservations towards this approach may arise from the perspectives of efficiency and practicality.However, it's important to remember that the long-term benefits of in-depth data analysis, such as improved service quality and reduced patient risks, may outweigh the costs and time invested.
To address existing deficiencies and gaps, it's crucial for the Sumber Hidup GPM Hospital to adopt a holistic approach involving investments in staff training, the development of information technology infrastructure, and improvements in the data collection process.Thus, the hospital can maximize the potential of data analysis to enhance overall patient quality and safety.

K. PMKP 10: Measurement of Patient Safety Culture
Research findings related to Patient Safety Culture Measurement at Sumber Hidup GPM Hospital emphasize the importance of strengthening safety culture enhancement programs as a means of improving healthcare service quality.In this analysis, we can apply theoretical concepts from experts in the field of risk management and patient safety, such as James Reason, who focuses on human error analysis and influencing factors.This analysis will address gaps, deficiencies, as well as support and objections to the recommendations proposed in the research.
Firstly, we need to consider that patient safety culture is a key factor in creating a safe environment for both patients and medical personnel.As stated by Reason (1997), errors are not always caused by individual mistakes but often result from systemic failures.Therefore, measuring patient safety culture is an important initial step in preventing errors and improving overall healthcare service quality.
However, in the case of Sumber Hidup GPM Hospital, there are deficiencies in the implementation of the proposed recommendations.For example, although patient safety culture measurement has been conducted, it has not been complemented with an effective safety culture enhancement program.This aligns with Reason's theory (2000) highlighting the importance of continuous improvement actions in the healthcare service system to reduce risks of errors and accidents.
The gap observed is the misalignment between patient safety culture measurement and the implementation of tangible safety culture enhancement programs.Further efforts are needed to design programs that align with measurement outcomes and integrate them into organizational culture.As suggested by Weick and Sutcliffe (2001), organizations that have mindfulness of errors and high resilience tend to be more capable of responding to changes and learning from mistakes.
Support for these recommendations can be found in the works of Lane et al. (2010), which demonstrate that effective implementation of patient safety culture programs can reduce error incidents and improve patient and medical staff satisfaction.By developing sustainable safety culture enhancement programs, Sumber Hidup GPM Hospital can enhance patient safety, improve reputation, and enhance overall service quality.
However, objections to these recommendations may include practical constraints such as resource limitations and resistance from involved parties.As expressed by Hofmann and Mark (2006), implementing organizational culture changes requires strong commitment and support from all levels, as well as ongoing processes to address emerging barriers and challenges.
In conclusion, although the importance of measuring patient safety culture at Sumber Hidup GPM Hospital has been acknowledged, there is still a need to improve the implementation of safety culture enhancement programs in line with these findings.By adopting a holistic and sustainable approach, hospitals can strengthen patient safety culture and ensure high-quality healthcare services for all patients.

L. PMKP 11: Risk Management Program
The findings of the Risk Management Program (PMKP) at Sumber Hidup GPM Hospital offer an intriguing perspective to be analyzed through the lens of expert theory.One relevant concept for analyzing this situation is Risk Management theory.According to Hiles (2011), risk management is the process of identifying, evaluating, and handling risks associated with organizational activities to optimize goal achievement.
In this context, it has been identified that there is a need for more regular monitoring and reporting regarding risk management plans at Sumber Hidup GPM Hospital.Analysis using the analytical framework of Risk Management theory reveals several aspects that need attention.
Firstly, the emerging gap is the lack of regular monitoring and reporting regarding risk management plans.According to McNeil, Frey, and Embrechts (2015), appropriate monitoring is key to effectively managing risks.Without regular monitoring, hospitals cannot timely identify whether risk management plans are progressing as expected or require adjustments.
Another shortfall is the potential under-identification of existing risks.According to Chapman and Ward (2003), comprehensive risk identification is a crucial step in effective risk management.Without regular monitoring and reporting, the possibility of overlooking unidentified or forgotten risks could pose serious issues for the hospital.
Support for this analysis can be found in research by Flanagan et al. (2018), indicating that regular reporting and careful monitoring regarding risk management plans can help healthcare organizations reduce the potential for adverse events for patients and medical staff.
However, from another perspective, there are also counterarguments to these conclusions.Some experts may argue that overly frequent monitoring can burden valuable resources and time.According to Fischhoff (2019), it is important to find a balance between sufficient monitoring to manage risks effectively and avoiding unnecessary expenditures.
In conclusion, an analysis based on Risk Management theory highlights the importance of regular monitoring and reporting regarding risk management plans at Sumber Hidup GPM Hospital.Although there is support for improving this process, it is also necessary to consider the potential counterarguments regarding the additional burden that may arise from overly intensive monitoring.Therefore, appropriate adjustments are required to make risk management more effective and efficient.

A. Commitment to Quality Improvement and Patient Safety
This research indicates that GPM Sumber Hidup Hospital has established a strong commitment to improving the quality and safety of patient care.Measures such as the formation of a Quality Management Committee and the use of statistical methods for data analysis demonstrate the seriousness of the hospital in enhancing its healthcare services.

B. Implementation of Programs with Appropriate Methodology
The research methodology utilizing instruments from the Indonesian Ministry of Health and involving both online and offline surveys by accreditation surveyors from LAFKI provides a comprehensive overview of the implementation of quality improvement and patient safety programs in this hospital.

C. Support for Innovation and Continuous Learning
The learning process from external databases and cost-efficient analysis indicates that the hospital has endeavored to continuously improve the quality and safety of patient care by adopting innovation and continuous learning.

D. Challenges in Reporting and Learning
However, there are challenges related to data reporting and learning, particularly concerning reporting data analysis to the Director and hospital owners, as well as effectively implementing recommendations for improvement actions.

E. Expansion of Research Scope
This research could serve as a starting point for further, more in-depth research, especially in identifying specific factors influencing the quality and safety of patient care, and in developing more effective strategies to enhance healthcare service quality.For the suggestions, a. Strengthening Reporting and Learning Systems Hospitals need to strengthen their reporting and learning systems, especially in terms of reporting data analysis to relevant parties and implementing recommendations for improvement actions more effectively.This can be achieved through training and coaching for relevant staff.

B. Enhancing Inter-Departmental Collaboration
Closer collaboration between departments in hospitals can improve the efficiency and effectiveness of quality improvement and patient safety programs.This can be achieved through cross-departmental training and regular discussion forums.

C. Provision of Adequate Resources
Hospitals need to ensure that the resources required for implementing quality improvement and patient safety programs, such as funding, personnel, and information technology, are adequately available.This can enhance the overall performance and outcomes of the programs.

D. Routine Evaluation and Updates
It is important to conduct routine evaluations of quality improvement and patient safety programs, as well as to update them based on the findings of these evaluations.This will help hospitals to continually adapt to environmental changes and improve the quality of healthcare services.

E. Active Stakeholder Engagement
Actively involving stakeholders, including staff, management, and patients, in the decision-making process and implementation of quality improvement and patient safety programs can enhance overall program support and success.

ACKNOWLEDGEMENT
Thank you is extended to all parties who have contributed to the implementation of the accreditation survey and the publication of this article.