Analysis of Hospital Pharmacist Credentials in Yogyakarta Region

Competent human resources such as doctors, nurses, pharmacists and others will improve the patient safety of a hospital. To assess the competence of hospital human resources can be measured by credentials. The credential process needs to be done to the pharmacist because although a pharmacist has received a pharmacist's diploma from an accredited college, the hospital remains obliged to perform competence verification through the credential process for the patient safety in the hospital and also considering the competence of a person influenced by several factors. The purpose of this study is to analyze the pharmacy credential system in Indonesia, especially the pharmacist credential system in the Yogyakarta area hospital. A qualitative study using in-depth interview and focus group discussions were conducted in three hospitals in Yogyakarta with different characteristics. In-depth interview was attended by 1 participant, consisting of the representatives of the professional organization. Every FGD was attended by 5-10 participants, consisting of pharmacists working in hospitals in Yogyakarta. The results of the in-depth interview and FGDs were analyzed with a qualitative approach. Currently there is no specific law enforcement regulation related to the credential system for pharmacists. The credential system becomes a hospital requirement after the accreditation and fulfillment of administrative requirements of accreditation become the main motivation held pharmacist credentials. Pharmacist has the needs of improving the credential system both in theory and application. The absence of legally enforceable regulations has resulted in many unfamiliarities. Expectations of pharmacist practitioners on the process of ideal pharmacist credentials are possible with supporting elements of professional organizations.


Background
Nowadays, patient safety is important part of the hospital system. Patient safety can be achieved by the competent medical personnel (e.g. doctor, dentist, nurse, pharmacist, ect). The competency level of medical personnel can be measured by credentials. Credentials are the process of obtaining, verifying, and assessing the qualifications of health care practitioners to provide patient care services in health care organizations 1 . The purpose of the credentials is applied for several purposes, namely to support practitioner development and development through training, support practitioner validation, to ensure guaranteed quality, and advanced evaluation of practitioners 2 .
In general, the basic credential steps consist of application, verification, analysis and decision 3 . In Indonesia, the process of credentials of health personnel has been regulated in legislation, regulations or decisions of the Minister of Health. Pharmacists are responsible for providing drug care so that the hospital must ensure that the pharmacist must be competent to provide drug care.

Research Method
A qualitative study using in-depth interview and focus group discussions (FGDs) were involved representative pharmacist of pharmacy organization profession in Yogyakarta and pharmacist of two hospitals in Yogyakarta region. In-depth interview was attended by 1 participant, consisting of the representatives of the professional organization. Every FGD was attended by 5-10 participants, consisting of pharmacists working in hospitals in Yogyakarta. The locations of FGDs are RSUD Panembahan Senopati Bantul and RSU PKU Muhammadiyah Bantul. The results of the in-depth interview and FGDs were analyzed with a qualitative approach.

Results & Discussion
The informant who was involved in this research was Hisfarsi Chairman who also served as Secretary of Credential Team of Regional Hospital Administrator Association of Indonesian Pharmacist Association of Yogyakarta Region as resource persons of interviews representing professional organizations, then informants who participated in FGD were pharmacist RSU PKU Muhammadiyah Bantul amounted to 6 people and the pharmacist RSUD Panembahan Senopati Bantul amounted to 9 people. Characteristic standards in determining informants to be interviewed or participating in FGDs are pharmacists who have experience involved in the credential process, whether involved as an assessment team or a credential participant.
Pharmaceutical workers as one of the health workers providing health services to the community have an important role because they are directly related to the provision of services, especially pharmaceutical services. This is clarified in the Government Regulation of the Republic of Indonesia No. 51 of 2009 on Pharmaceutical Works.
Professional organizations then make guidelines as outlined in the Decree of the Central Committee of Indonesian Pharmacist Association No.PO.006 / PP. IAI / 1418 / IX / 2017 as a response from the questions of Indonesian Pharmacist Association members regarding the urgency of regulations related to this pharmacy credential and become the main policy document used as the basis in the pharmacist credential process. In the policy stated that the decree is a national policy and an organizational regulation that binds all pharmacists in Indonesia. The Central Committee of Indonesian Pharmacist Association mandated the Region Committees of Indonesian Pharmacist Association throughout Indonesia to form a credential team whose membership is in accordance with the competence to carry out credentials in accordance with its specialization field and to monitor evaluation of the implementation of credentials.
Some hospitals that have been implemented credentials by the Region Committees of Indonesian Pharmacist Association Credential Team sourced from the primary data of the Region Committees of Indonesian Pharmacist Association Hospital Pharmacist Credential Team are as follows: Table 1. Data of Credential Participant Related to the system of credential regulations for Pharmacists, informants stated that indeed there is currently no specific regulation from the government regarding the credential system for pharmacists. The informant also stated that the credential system became a hospital requirement after accreditation. Pharmacist credentials only use guidelines from Indonesian Pharmacist Association and there is no technical implementation guideline so that the potential of each region to carry out credentials in a different way due to differences in perception in its implementation.
As an illustration, in Yogyakarta more hospitals carry out credentials independently. Some have not even done it because they have not been accredited or are still in accreditation improvement. This is in accordance with the quote from the informant's answer as follows: "…jadi memang masih beberapa rumah sakit, belum semua rumah sakit. Kan ada sekitar 60 rumah sakit ya di Yogyakarta, nah itu belum ada setengahnya." The Region Committees of Indonesian Pharmacist Association Credential Team tried to overcome this problem by holding socialization through web media and seminars. The Region Committees of Indonesian Pharmacist Association Credential Team acknowledged that the socialization related to credentials by Indonesian Pharmacist Association had not been implemented effectively because Indonesian Pharmacist Association still believed that the credentials carried out by the Region Committees of Indonesian Pharmacist Association Credential Team were not coercive and because of the team's limitations.
The informants thought that the guidance of professional organizations was still global so that it needed adjustments in each region, such as in Yogyakarta, the credential guidelines were modified based on the collection of references that became the pharmacist's credential standards from various countries, including learning and adopting the credentials of other health professions. Modifications made still refer to Indonesian Pharmacist Association's competency standards.
Pharmacist credentials are agreed upon as recognition of the presence of pharmacists along with their quality assurance and responsibilities in their respective fields by assessing the competence and jobdesc of the pharmacist. This will affect the quality of hospitals associated with clinical and non-clinical problems that may impact on the effectiveness of patient care services to avoid treatment errors and Adverse Event.
For management, the potential pharmacist can be the basic data for the development and mapping of human resource career paths through the assessment of competencies and special authority of pharmacists. For pharmacist practitioners, pharmacist credentials can be a medium of learning and self-reflection for old practitioners as well as new practitioners to remember the basics of pharmacy and jobdesc in the hospital until they know their authority. This is in line with the concept of credentials which is in the form of a process to recognize the practitioners' achievement of the knowledge and skills needed to carry out their work as health professionals, especially pharmacists in hospitals 6 .
The main motivation why pharmacist credentials must be done is just to fulfill the accreditation document and if it is influential for the continuity of pharmaceutical practice. Pharmacist credentials are carried out only to participate in other health workers who already have credentials and for mere formalities. This is not in line with the conceptual concept of a professionalism credential system in which the existence of a social contract between health workers and the community aims to ensure the quality of health services and prioritize the interests of the community, not just for administrative purposes 7,8 .
The current credential implementer differences between independent credentials and credentials with credential team from Indonesia Pharmacist Association are also not in accordance with the recommended competency assessment focused through the mechanism of credential team from Indonesia Pharmacist Association or by professional organizations for pharmacists in Indonesia, particularly in Yogyakarta. The assessing team is recommended to consist of clinical experts, academics and managers. The composition of this team will be difficult to obtain if credentials are held independently 9 .
Although the executors of credentials are different, the basic principle is the same, namely following the Deutsch & Mobley credential model. The Deutsch & Mobley credential model that can be applied in every health worker before being given clinical authority consists of four main components: application, verification, analysis and decision. First, health workers apply to obtain clinical authority with the self-assessment method. Second, the credential team reviews and recommends the medical authority submitted by the applicant. Third, the head of the hospital publishes a clinical assignment letter based on recommendations from credential teams that apply for a certain period. Fourth, the applicant was notified of the clinical assignment. This credential process is not only valid at the time of recruitment, but these steps also apply to initial credentials and recredential processes 3 .
Pharmacist credentials, especially independent credentials, are still not ideal because the credential team is only based on seniority, the assessment is still subjective because there are no standard details on how someone is called competent and the measurement parameters are too broad and not updated. The form of authority made is also only based on the job that has been done. Clarity in the implementation of credential duties also contradicts the provisions of accreditation with the wishes of professional organizations.
The constraints of the pharmacist credentials are that it takes a special time to see the process directly so that contradictions often occur between the competencies written, the results of the interviews, the number of certificates held and practices in the field. Besides looking at the certificates and legality, the pharmacist's credentials should also see the process of practice and skill in the field comprehensively.
To answer some of the credential process needs above which are obstacles and that are in line with Indonesia's needs, there are already recommendations for a credential model that: (1) responds to patient safety goals, (2) in accordance with the concept of professionalism, (3) has been tried in various countries with good results based on the Joint Commission on Accreditation of Healthcare Organization in 2003. This credential model relies on three core processes. First, health workers carry out clinical pivilege applications with self assessment methods. Second, the credentials must be carried out by the best partner, the partner should review and approve the application based on the white paper. This White paper is a standard reference that contains the requirements of a health worker to perform certain medical actions. Third, the hospital issued clinical appointments based on recommendations from best partners. Periodically, health personnel will go through a recredential process, where the three core processes will be repeated. In addition, if a health worker is considered to endanger patient safety, his clinical privileges can be partially or completely suspended, so that the health personnel concerned are not allowed to take medical action at the hospital 10 .
The majority of hospital FGD participants agreed that pharmacist credentials still have many obstacles and are not ideal. One of them is a competent definition in the pharmacist credentials still confusing. On this matter, the hope of FGD participants of RSUD Panembahan Senopati Bantul Yogyakarta in the pharmacist credential process is to be held briefly first about the process and the definition related to the credentials before the pharmacist credentials done. In fact, in the General Provisions described in the attachment to the Decree of Central Committee of Indonesian Pharmacist Association, the definition of competent has not been explained. So it is necessary to make a definition of competent so that it can be delivered during a briefing before the pharmacist credentials are carried out. While one of the expectations of participants of FGD PKU Muhammadiyah Bantul who carry out internal credentials in the process of credentials of pharmacists is the presence of pharmacists who already have a certificate of assessors for internal credentials, or performed by professional organizations in a standardized manner and directly done credentials when there are new employees. Actually this problem will be resolved if the pharmacist credential regulations require all hospitals to be held pharmacist credentials by professional organizations as best partners who already have their own standards in accordance with the recommended credential mechanism 9,10 . In the attachment of the Decree of Central Committee of Indonesian Pharmacist Association, there are already standard credential team requirements in the form of: 1) appointed team members from pharmaceutical service facilities, pharmacist education institutions, appropriate seminary or collegiate associations, 2) integrity, 3) participated in the Training of Trainers (ToT) about credentials, 4) experienced in the field concerned at least 3 years, 5) members amounted to at least three people.

Conclusion & Recommendation
The results of the study can be summarized as follows: 1) Indonesian Pharmacist Association as a professional organization has formed a credential team to help hospitals carry out credentials by Indonesian Pharmacist Association Credential Team, 2) The existence of the Indonesian Pharmacy Association credential team has not been effectively socialized to members who need it, 3) The development of credential instruments is carried out continuously through the search for references to overseas pharmacist credentials and modifications from other health professions, 4) Hospital coverage involving the IAI credential team as a partner is still low, 5) The hospital has organized credentials carried out with different implementers between the professional organization credential team or the hospital's internal credential team, 6) The main motivation of the credential system is only to complete the administration of accreditation, 7) Not all hospitals know the socialization of the existence of the Indonesian Pharmacist Association Credential Team, 8) Pharmacist credentials still have many obstacles and are not ideal.
Basically, the pharmacist has the need to improve the credential system both in theory and application. The absence of regulations that are legally enforceable and the free implementation of credentials is carried out by internal hospitals or by professional organizations resulting in many ideals being found, so that accreditation is recommended requiring pharmacist credentials to be carried out by best partners. As a qualitative study, this finding contributes information to professional organizations to develop strategies for developing pharmacist credential systems in Indonesia, especially Yogyakarta. From the research above, further research is needed for hospitals located outside Yogyakarta. Hospital management in Yogyakarta can also use the results of this study to improve the quality of human resources, especially in the field of hospital pharmacy personnel.