Keywords:

Hospital Bylaws, Hospital Internal Regulations, Guidelines, Legal Issues

Introduction

Law of the Republic of Indonesia No.44 of 2009 concerning Hospital stated the obligations, rights, and the operation of hospitals in Indonesia. One of the hospital's obligations is to prepare and implement internal hospital regulations known as hospital bylaws. According to the explanation of the Act, internal hospital regulations (hospital bylaws) are hospital organization regulations (corporate bylaws) and hospital medical staff regulations (medical staff bylaws). The hospital bylaws are made to implement good corporate governance and good clinical governance. Furthermore, hospitals should fulfill arrangements regarding the organization, clinical management, accreditation, networking and referral systems, patient safety, hospital legal protection, legal responsibilities, and the form of the hospital. Every hospital must have an effective, efficient, and accountable organization. In addition, hospitals must carry out hospital governance and good clinical governance is stated in the clinical management of article 36 of the Hospital Law (Widjaja & Permanasari, 2016). To improve the quality of hospital services, a hospital must be accredited every three years. Accreditation is an acknowledgment of the quality of hospital services after assessments to the hospital have met accreditation standards. Accreditation in Indonesia that is recognized by the government is held by independent national and international accreditation bodies approved by the Minister of Health. The Indonesian National Accreditation Body recognized by the Minister of Health is Komite Akreditasi Rumah Sakit abbreviated as KARS (Hospital Accreditation Committee).

Hospitals are influenced by the development of health science, technological advances, and the socio-economic condition of the community. Hospitals need to improve their services to the highest quality and still affordable by the community in realizing the highest degree of health. The paradigm shift of the hospital into a socio-economic unit has an impact on the complexity of the hospital. It creates conflicts in the relationship between the owner, manager, and medical staff if it is not properly regulated. Hospitals as an organization engaged in health services and dealt with patients and other stakeholders are very complex and high-risk institutions, especially in regional and global environmental conditions that are changing very dynamically nowadays. Public complaints are often heard when hospitals do not provide good services. Some hospitals are even legally prosecuted because they are considered to provide services beyond the expectations of patients and families as reported in the mass media. Hospital conflicts, both internal and external parties, can become legal problems if not properly handled.

From the data available at the Hospital Information System of the Directorate General of Health Services at the (Ministry of Health Republic of Indonedis, 2019), there were 2925 hospitals throughout Indonesia. Most of them, 2395 are general hospitals, meanwhiles the rest are specialized hospitals. The five most common specialized hospitals are 354 mother and children hospitals, 42 mental hospitals, 32 eye hospitals, 30 surgery hospitals, and 30 dental hospitals. The largest hospital ownership is private, followed by district governments. Private hospitals are owned by profit-making companies and social organizations. There are 30 hospitals owned by the Ministry of Health. There are 859 hospitals that have achieved the complete accredited hospitals, 790 hospitals with primary level accredited hospitals, 302 hospitals with major level accredited hospitals, 293 hospitals with intermediate level accredited, dan 149 hospitals with basic level accredited hospitals.

This study aims to determine the conformity of the hospital bylaws of Persahabatan General Hospital with the statutory regulations and the hospital management standards of hospital accreditation. It will also look at the implementation of the preparation of operational policy instruments at the Persahabatan General Hospital, a class-A hospital owned by the Ministry of Health with excellence in respiratory health, using the hospital bylaws to solve legal problems in the hospital

Literature Review

To formulate and implement internal hospital regulation (hospital bylaws) as one of twenty hospital obligations is mentioned in the Hospital Law and the implementing regulation. It is article 27 of Government Regulation of the Republic of Indonesia No.47 of 2021 regarding the Implementation of the Hospital Sector. More detailed regulations on Hospital bylaws are stated in the Minister of Health Decree No.772/MENKES/SK/VII/2002 concerning Hospital Internal Regulation (hospital bylaws), hereinafter referred to as MOHD 772/2002. Hospital bylaws which are prepared and written are internal regulations of the hospital. It is a legal product made by the hospital owner or the representatives. It will regulate the organization of the hospital, the relations, the roles, duties, and authorities of the owner or its representatives, the Board of Directors of the hospital, and the medical staff in the hospitals. Article 1 point 4, 5, and 6 of Minister of Health Regulation No.755/MENKES/PER/IV/2011 (MOHD 755/2011) concerning the Organization of Medical Committees in Hospitals states that internal hospital regulations (hospital bylaws) are the basic rules that regulate the governance of the hospital. The hospital bylaws cover internal corporate regulations (corporate bylaws) and internal medical staff regulations (medical staff bylaws). Corporate bylaws are rules that regulate good corporate governance by regulating the relationship between owners, managers, and medical committees in hospitals. Internal medical staff bylaws are rules that regulate clinical governance to maintain the professionalism of medical staff in hospitals.

According to HCPRO, hospital bylaws are the corporate bylaws required under state law in all jurisdictions for business corporations, whether for profit or not to profit. It will organize the business. The medical staff bylaws are a document approved by the hospital's board, treated as a contract in some jurisdictions, that establishes the requirements for members of the medical staff (which includes allied health professionals) to perform their duties, and standards for the performance of those duties. In comparison, in Malaysia, the format of Hospital bylaws is not defined by the government. The internal regulation of hospital corporations follows the format of the corporate constitution is regulated by the Companies Act 2016 (Act 777) division 5 section 31 to 37. Similar to Malaysia, the format of Hospital bylaws in Canada is determined by the Province government dan regulated under Hospital Act by the Federal government.

The function of Hospital bylaws in MOHD 772/2002 is a guideline for hospital owners in conducting hospital supervision. As a guideline for hospital directors in managing hospitals and formulating operational technical policies; it will ensure effectiveness, efficiency, and quality. It will provide legal protection for all parties related to hospitals. It should be used as a reference for resolving conflicts in hospitals between owners, hospital directors, and medical staff, as well as to meet accreditation requirements. The hierarchy of hospital bylaws in hospitals in Indonesia can be seen in Figure 1.

According to Shaw (as cited by Mansour, Boyd & Walshe, 2020) accreditation can be defined as “a public recognition by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance concerning the standards”. Hospital accreditation in Indonesia began in 1995 and has used accreditation standards based on the yearly standard for assessment. In 2018 Indonesia issued Standar Nasional Rumah Sakit abbreviated as SNARS (the National Standard for Hospital Accreditation) first edition. Accreditation is one of the hospital administrations that must be fulfilled by every hospital in Indonesia at least once every 3 years. In Minister of Health Decree No.12 of 2020 (MOHD 12/2020) concerning Hospital Accreditation, it is stated that accreditation is held periodically every 4 years. Accreditation is carried out by an independent institution that administers accreditation from within or outside the country determined by the Minister of Health. The Hospital Accreditation Commission known as Komite Akreditasi Rumah Sakit (KARS) is an independent institution implementing the national accreditation of hospitals in Indonesia through the Minister of Health Decree No.HK.01.07/MENKES/406/2020 concerning the Establishment of the Hospital Accreditation Commission as an Independent Institution for Hospital Accreditation. The standard currently used is SNARS edition 1.1. consisting of five standard groups. They are the Patient safety target group; the Patient-focused service standards group; the hospital management standards group; the national program group, and the Integration of Health Education in the hospital services. According to Hospital Governance Standards 1 SNARS ed 1.1, the organization and the authority of the owner and owner's representatives are explained in the regulations set by the hospital owner. The element of assessments are the owner established regulations that regulate:

a) owner's organizational structure and owner's representation, the owner's legal entity status; responsibilities and powers of the owner and the owner's representation;

b) delegation of authority from the owner to the representative of the owner or director of the hospital or other individuals in accordance with the laws and regulations;

c) appointment/stipulation and evaluation of the performance of the owner's representation;

d) appointment and performance appraisal of hospital’s director;

e) determination of qualifications, requirements for hospital directors under statutory regulations; and

f) hospital organizational structure.

Hospital accreditation in Malaysia is carried out voluntarily by the hospital concerned and depends on the needs of the hospital. Accreditation in Canada follows the priorities program of the federal state. Main federal priorities are mental health, long-term care, and indigenous health. Every jurisdiction except Ontario has a regional health authority model with a varying scope of services and regulation of accreditation. Quebec requires accreditation for all health and social organizations that receive public funding including privately owned facilities. Alberta and Manitoba have adopted legislation that mandates accreditation in their regional health authorities, including acute care hospitals, contracted providers in continuing care, community, mental health and addictions, and emergency medical service (Tarasova, 2017).

In the hierarchy of hospital regulation, hospital bylaws are used as a reference in formulating hospital operational technical policies. Reference Guidelines, according to guidelines in health care practice -WHO, are generally defined as systematically developed statements to assist practitioners and patients make decisions about appropriate health care for specific circumstances. The legal definition of guidelines according to (The Law Dictionary, 2021) is a practice that allows leeway in its interpretation. Guidelines according to Law Insider (2021) means “those standards adopted to implement the policy of this chapter for regulation of the use of the shorelines of the state before the adoption of mater programs. Such standards shall also provide criteria to local governments and the department in developing master programs.” Another opinion states that the guideline is a statement or plan by which to determine a course of action. A guideline aims to streamline particular processes according to a set routine or sound practice. Guidelines according to Kamus Besar Bahasa Indonesia (Great Dictionary of the Indonesian language, 2021) are a collection of basic provisions that give direction on how something should be done; things (principals) that become the basis (handling, instructions, and so on) to determine or carry out something. Operational technical hospital policy according to hospital bylaws of Persahabatan Hospital are made in the form of guidelines, president director decree, and standard operational procedures. All these kinds of hospital policies are needed to manage and run the proper operations of the hospital, including handling legal issues. Legal issues according to the Collins Dictionary are matters related to law that are debated and discussed. Legal issues are also defined as ratification of a case because of a legal vacuum, namely the existence of community needs that do not yet exist or are not accommodated in statutory regulations or laws, both written and unwritten. Legal problem solving is a process, method, action, resolving a matter related to the law that is being debated. Legal problem resolutions are the possible legal solutions to everyday problems, including issues such as personal debt, problems with consumer purchases, disputes with employers and landlords, injury or ill-health arising from accidents or negligence, and issues arising from a relationship breakdown.

These everyday problems may have a legal solution through the civil justice or tribunal system (Franklin, Budd, Verrill & Willoughby, 2017).

Research Methods

This research is descriptive normative juridical research. The normative juridical research will be conducted to review the compliance of Hospital Bylaws of Persahabatan Hospital with the laws and regulations governing hospital internal regulations (Hospital Bylaws) and hospital governance standards SNARS ed 1.1. The Hospital Bylaws of RSUP Persahabatan as the object of the research is the Hospital Bylaws ed VI+ established in 2018 under the Minister of Health Decree No.HK.02.02/I/4172/2017 concerning the Enforcement of Hospital Internal Regulations (Hospital Bylaws) RSUP Persahabatan. Furthermore, the research will review the implementation of hospital bylaws as a guideline for the director's policy formulation related to the resolution of legal problems by reviewing the policy tools of the Persahabatan Hospital Director in the form of Guidelines, Decrees, Standard Operating Procedures related to the resolution of legal problems.

The sources of legal materials in this study consist of primary, secondary, and tertiary legal materials. Sources of the primary legal materials used consist of the Law No.44 of 2009 concerning Hospital (the Hospital Law), Government Regulation No.47/2021 concerning the Implementation of the Hospital Sector, the Minister of Health Regulation no. 12/2020 concerning Hospital Accreditation, Minister of Health Regulation no.755/2011 concerning the Implementation of Medical Committees in Hospitals, Minister of Health Decree no.772/MENKES/SK/VI/2002 concerning Guidelines for Internal Hospital Regulations (Hospital Bylaws). Secondary legal materials consist of legal books, non-law books, legal scientific papers, journals related to this research. Tertiary legal materials are other legal materials that provide meaningful instructions or explanations in the form of encyclopedias and dictionaries. This research was carried out after having passed the ethical review from the Health Research Ethics Committee of the Persahabatan Hospital and located at the Persahabatan Hospital Jakarta Indonesia.

Results and Discussion

According to the explanation of Article 29 letter r of the Hospital Law, Hospital bylaws are structured in the context of implementing good corporate governance and good clinical governance. Furthermore, Article 51 of the Government Regulation of the Republic of Indonesia no.47 of 2021 states that the preparation of internal hospital regulations through the preparation and implementation of general hospital services policies that support good corporate governance and clinical governance. The hospital's internal regulations consist of hospital organization regulations and hospital medical staff regulations. Organizational regulations in question are rules governing the relationship of the owner or the representatives with the head/director of the hospital. Hospital medical staff regulations are rules regarding clinical governance to maintain the professionalism of hospital medical staff. In addition to medical staff regulations, hospitals can create other hospital clinic staff regulations according to hospital needs. Provisions regarding the preparation and implementation of hospital internal regulations are stipulated by the Minister of Health. These Ministerial provisions are Minister of Health Decree No.772 of 2002 concerning Guidelines for internal hospital regulations (Hospital Bylaws) and Minister of Health Regulation No.755 of 2011 concerning the organization of Medical Committees. Article 20 letter a of the Regulation of the Minister of Health No.755 of 2011 states that the Minister of Health Decree no. 772/MENKES/SK/VI/2002 concerning Guidelines for Internal Hospital Regulations (Hospital bylaws) that all the arrangements for medical staff are revoked and declared repealed. There are different understandings of corporate internal regulations (corporate bylaws). According to Minister of Health Decree No.772/2002, the internal regulations governing the relationship of the owner or the representatives with the director of the Hospital (Hospital Management) are called corporate bylaws. According to Minister of Health Regulation No.755/2011, internal corporate regulations (corporate bylaws) are rules that regulate corporate governance to be carried out properly through regulating the relationship between owners, managers, and hospital medical committees. The mentioning of the medical committee in the context of corporate bylaws gives rise to an interpretation as if the medical committee is a separate party. The medical committee is a hospital instrument to implement clinical governance so that the medical staff in the hospital can maintain their professionalism through the credential mechanism, maintaining the quality of the medical profession, and maintaining professional ethics and discipline. In article 17 of Presidential Regulation No.77/2015, the Medical Committee is an organizational element that has the responsibility to implement good clinical governance. The medical committee is formed by and required to report to the head of the hospital or the hospital director. Thus, the Medical Committee is part of the management.

Hospital bylaws RSUP Persahabatan edition VI+ is prepared according to MOHD 772/ 2002, based on the values of professionalism, integrity, collaboration, perfection, customer orientation. It regulates the relationship between hospital owners or their representatives, hospital directors, and medical staff. These internal hospital regulations provide the roadmap for the operation of the hospital to create good governance as a health institution. Meanwhile, the internal regulations for medical staff provide a framework to create good clinical governance in which all medical staff who join the hospital can carry out professional functions. Meanwhile, the medical staff shall always be oriented towards quality and safety under the Organizational Structure and Management of Persahabatan Hospital based on Minister of Health Regulation No.1679/MENKES/PER/XII/2005. In the hospital bylaws of Persahabatan Hospital, it is stated that the reference for the President Director of Persahabatan Hospital to formulate operational technical policies is the internal hospital regulations (Hospital bylaws). The aforementioned operational technical policy is the Decree of the President Director.

The functions and objectives of the Hospital bylaws at the Persahabatan Hospital as stated in the preamble, follow the functions and objectives of the hospital bylaws listed in KMK 772 of 2002, including meeting the hospital accreditation requirements. In hospital accreditation, Hospital bylaws are one of the documents assessed in Hospital Governance standards. The standard assessment of effective leadership is implemented from the hospital owner or representative to the hospital manager up to the underneath level of the head of the working unit or team. The standard states that the requirements are needed to meet the standardized hospital governance, including the vision and goals set by the hospital owner. It shall also describe the hospital organization that must be determined by the owner; delegation of authority from the owner to the hospital director. Analysis of the contents of Hospital Bylaws of Persahabatan Hospital proved that there are differences in the vision and mission, hospital logo, hospital organization, the arrangement of the supervisory board as a representative of the owner, as well as the nomenclature and arrangement of the Committee as part of the hospital management.

The scope of the Persahabatan Hospital vision at Hospital Bylaws covers the Asia Pacific region, while the latest vision when this research was conducted was a world-class hospital. Persahabatan hospital currently has 4 missions, namely Quality and safety-oriented services, Education, Research and training of medicine and other health workers, Integrated research and education services in the field of respiratory health, hospital governance, and International standard clinical governance. A change was made in the 3^rd mission namely carrying out the national respiratory referral function, to carry out the supervisory function of other hospitals in the area related to respiration. The hospital logo used in the Hospital bylaws of Persahabatan Hospital still uses the former logo in the shape of a globe, while the new one is in the form of a hospital cross. Both mission and vision relate to an organization's purpose and are typically communicated in a written form. The mission statement communicates the organization's reason for being how it aims to serve its key stakeholders. On the other hand, the vision statement reflects a future-oriented declaration of the organization's purpose and aspirations. The strategy should come directly from the vision and thus satisfy the organization's mission. The vision and mission are included in the Strategic Business Plan which refers to the Strategic Plan of the Ministry/Agency (Article 44 of the Minister of Finance Regulation No.129/PMK.05/2020 concerning Guidelines for the Management of Public Service Agencies). Badan Layanan Umum (Public Service Agency) is an agency within the government that was formed to provide services to the community in the form of providing goods and/or services that are sold without prioritizing seeking profit and in carrying out its activities based on the principles of efficiency and productivity. Public Service Agency prepares Business Plan and Master Budget by referring to the Business Strategic Plan. This Business Strategic Plan is signed by the President Director and the Supervisory Board. The same term is fulfilled for the revision of the Business Strategic Plan.

The Supervisory Board as a representative of the owner is declared the position, duty, and authority in Hospital bylaws of RSUP Persahabatan was created based on the Minister of Health Regulation No.10 of 2014 concerning the Hospital Supervisory Board. However, the Supervisory Biard may not coordinate with the Head/Director of the Hospital in formulating the Internal Hospital Regulations (hospital bylaws) and the governance pattern documents. Only the owner can do it. In fact, in the preparation of hospital bylaws, the Director of the Hospital forms a team consisting of the Director, Committee, and Internal Examination Unit, but there is no element of the Supervisory Board. From the Management element, the position and membership of the Board of Directors, in hospital bylaws there are President Director and 3 Directors. At the time of this research, there was the addition of one director and the separation of duties of the Director of General Affairs, Human Resources, and Education. in the organizational structure and governance of Persahabatan Hospital, namely the Director of Planning, Organization, General affairs. The Director of Finance becomes the Director of Finance and State Property. The change and addition of the director is the will of the Ministry of Health as the owner of Persahabatan Hospital as outlined in the Minister of Health Regulation no.68 of 2020 concerning the Organization and Work Procedure of the Persahabatan Hospital. The position, membership, duties, functions, obligations, and authorities of the Board of Directors are different in the Hospital bylaws which is different from Minister of Health Regulation no. 68 of 2020. The Minister of Health also states that the Director in carrying out his duties is assisted by functional officials. The functional position group has the task of providing functional services in carrying out the duties and functions of the director following the field of their expertise and skills.

In addition to the Board of Directors, as the hospital management, there is Committee and Internal Audit unit which is directly under the President Director. The committee is a hospital functional unit, is a non-structural forum consisting of experts or professions, formed to provide strategic considerations to the President Director. The committees regulated in the hospital bylaws are the Medical Committee, the Ethics, and Legal Committee, the Infection Prevention and Control Committee, the Quality, and Safety Committee, the Nursing Committee, the Pharmacy and Therapeutics Committee, the Research and Development Committee, and the Education Coordination Committee. Currently, the Research and Development Committee was dissolved and replaced by the Health Research Ethics Committee. An additional committee is formed by the miscellaneous Health Personnel Committee. The reduction and addition of the Committee are adjusted to the needs of the hospital, including the hospital development plan contained in the hospital's strategic business plan. Several committees are regulated by the Minister of Health Regulation. They are:

1) Minister of Health Regulation No.755/2011 concerning the Implementation of Medical Committees;

2) Minister of Health Regulation No.80 of 2020 concerning Hospital Quality Committees;

3) Minister of Health Regulation No.42 of 2018 regarding the Ethics and Law Committee;

4) Minister of Health Regulation No.49 of 2013 concerning the Nursing Committee.

Other committees have not been specifically regulated in the Regulations or Decrees of the Minister of Health. The Therapeutic Pharmacy Committee is mentioned in the Minister of Health of the Republic of Indonesia Decree No.HK.01.07/MENKES/200/2020 concerning Guidelines for Preparing Hospital Formularies. The management of the membership in the Committee and the main duties of the Committee in the hospital bylaws of Persahabatan Hospital has been made in accordance with the regulations on the related committees. Committees that are not stipulated in the regulations will follow the pattern of organization of other committees. Their main duties and tasks are devised following the aims and objectives of the Committee being formed. The regulation of the Internal Examination Unit follows articles 21 and 22 of Presidential Regulation No.77 of 2015 concerning Hospital Organization Guidelines

The second book of Hospital bylaws RSUP Persahabatan, namely Medical Staff Bylaws (MSBL) is a rule that regulates clinical governance (clinical governance) to maintain the professionalism of hospital medical staff. To actualize good clinical governance, all medical services provided are carried out by every medical staff in the hospital are based on clinical assignments from the Hospital Head/Director. Clinical assignment in the form of clinical privileges by the head/director of the hospital through the issuance of a clinical appointment letter to the medical staff concerned. A clinical appointment letter is issued by the head/director of the hospital after receiving a recommendation from the medical committee. The medical committee was formed to implement good clinical governance so that the quality of medical services and patient safety are guaranteed and protected. MSBL of Persahabatan Hospital follows the Minister of Health Regulation no.755/2011 concerning the Implementation of Medical Committees in Hospitals. The format of the internal regulations of hospitals in Indonesia is different from our neighboring country, Malaysia. The internal regulations of hospitals in Malaysia follow the corporate body constitution format set out in Companies Act 2016 (Act 777) division 5 section 31 to 37. The internal regulations of hospitals in Malaysia are not specifically defined. Corporate bylaws follow the regulations regarding the company. Whereas the format of internal hospitals regulations in Canada is determined by each province regulation.

Hospital bylaws of RSUP Persahabatan meet the hospital governance standard SNARS ed 1.1 with the following elements of assessment:

1) The owner determines the regulations contained in the aims and objectives which are written in the form of corporate bylaws..

2) There is a determination of the organizational structure of the owner including the owner's representation in accordance with the legal entity form of hospital ownership and accordance with statutory regulations. The title of the position in the organizational structure must be clearly stated.

3) There is a determination of the organizational structure of the hospital in accordance with the legislation.

4) There is a determination of the hospital director in accordance with the legislation.

The arrangement of responsibilities and authorities between the owner and the owner's representation including the performance appraisal of the owner's representation needs to be regulated in the hospital's internal regulations in the form of corporate bylaws. If the responsibility and authority of the owner as well as the owner's representation are delegated, then it is regulated in the regulations issued by the owner. Widjaja (2020) stated that every organization needs governance. Hospital governance includes corporate governance and clinical governance. In addition to good governance, hospitals are required to have an effective, efficient and accountable organization including effective leadership. This effective leadership is based on positive synergy and collaboration between hospital owners or representatives of owners, hospital directors, leaders in hospitals, and heads of working units/service units to achieve the vision and mission, and have a role in quality improvement and management. patient safety, contract management, and resource management. Effective leadership is the most important method in an organization to sustain a business when facing the problems of a fast-growing economy. Leaders are the ones who control and take charge of the operation of an organization. Good leaders can set optimistic goals and objectives while steering the operation of the company towards those goals through effective strategies. Leadership is the power that a person has to influence or change the values, beliefs, behavior, and attitudes of other people (Hao & Yazdanifard, 2015).

The hospital bylaws of Persahabatan Hospital are written to regulate the relationship of the three (triad) owners, managers, and medical staff. This regulation in the preamble of the hospital bylaws is mentioned as a guideline for the preparation of operational technical policies of the Persahabatan Hospital, including policies and procedures in the fields of administration, medical, medical support, and nursing. There are 2 operational technical policies related to legal issues resolution at Persahabatan Hospital, consisting of 1 President director policy and 1 Standard Operating Procedure. The policy is in the form of a Decree of the President Director of the Persahabatan Hospital no. HK.02.03/IX/11.37/2018 regarding the Resolution of Legal/Medicolegal Resolutions at the Persahabatan Hospital. According to the official script procedures of the Persahabatan Hospital (2017), the manuscript at the Persahabatan Hospital consists of directive official documents, correspondence official documents, special service documents, and reports. The Director's decision, included in the group of directives, is in the form of a stipulation text and contains the main policy or implementation policy which is an elaboration of the legislation, namely policies in the context of management, implementation of tasks, delegation of permanent authority.

The official authorized to determine and sign the Decree is the President Director of the Persahabatan Hospital. The composition of the decree consists of the head, preamble/consideration, dictum, the body of decree, and footer The preamble consists of reasons/objectives/interests/considerations regarding the need to stipulate a decision and laws and regulations as the basis for issuing decisions. In this President Director's Decree, the preamble which contains laws and regulations, contains a series of laws, government regulations, and related ministerial regulations, including the Minister of Health Decree no.772/MENKES/SK/VI/2002 concerning Hospital Internal Regulations (Hospital bylaws), the Hospital bylaws of Persahabatan Hospital are not included as a reference for the preparation of this Board of Directors Decree. Standard operating procedures no. OT.02.02/6.2/04 concerning the resolution of medicolegal/legal issues issued on January 10, 2018, and signed by the President Director of RSUP Persahabatan, contains Hospital Bylaws RSUP Persahabatan and Medicolegal Guidelines for the Ethics and Legal Committee as the basis for policy. There is an inconsistency in the use of hospital bylaws as a guideline in the preparation of technical policies for solving medicolegal/legal problems. Hospital bylaws as a reference for hospital operational technical policies have not been fully understood by policymakers at Persahabatan Hospital. Darmanto & Ayuningtyas (2013) stated that the implementation of hospital bylaws in hospitals was hampered due to communication of hospital bylaws policies and the lack of resources available in hospital bylaws implementation. In addition, hospitals that compile hospital bylaws was only to accomplish accreditation requirements, do not even implement hospital bylaws as a reference for hospital operational technical policies.

Conclusion

Hospital bylaws of Persahabatan Hospital were written systematically following the law and legislation governing Hospital Bylaws and also met the hospital governance standard of SNARS ed 1.1. The function of hospital bylaws as a guideline in the preparation of hospital operational technical policies for legal problems resolution is still not consistently implemented. Considering the change that occurred at Persahabatan Hospital and also the rapid changes in legislation, some recommendations from this research are:

1) proposing ministerial-level regulations governing the Internal Hospital Regulation by following global changes and by benchmarking with hospital bylaws from other countries;

2) revising Hospital bylaws of Persahabatan Hospital based on the latest laws and regulations regarding the Supervisory and Management Board (Board of Directors and Committees);

3) conducting socialization and internalization of hospital bylaws to the Persahabatan Hospital employee and community for better knowledge and comprehension of implementing hospital bylaws.

Acknowledgement

Thank you to the Ethics and Law Committee of Persahabatan Hospital and the Functional group of Legal, Organization, and Public Relation of Persahabatan Hospital.

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