LEGAL RESPONSIBILITY ANESTHESIA ADMINISTRATOR IN THE HEALTH SERVICE

Good, quality and quality health services are one of the basic needs that everyone needs. Therefore, in the health world, the authority of anesthetist administrators within the scope of anesthesia services is direct, mandated, and collaborative where the mandate obtained from anesthetist administrators is not only from specialist doctors but also from the Government, as regulated in Article 14 Paragraph (1) and Paragraph (2) Ministry of Health Regulation No. 18 of 2016 concerning Licensing and Implementation of Anesthesia Administrator Practices. Now the delegation based on government assignments is carried out if there is no anesthetist in an area. The authority falls to the anesthetist in that area who has received training. This study aims to determine how the legal responsibility of anesthesia administrators in health services. The method used in this research is juridical normative, which examines legislation (statute approach) by examining all relevant regulations or statutory regulations and looking at the facts in the field. The research approach used is qualitative. This study's results indicate that anaesthesia services' general responsibility lies with anaesthetists in the practice of anesthesia services. What needs to be considered in the delegation of tasks from doctors to nurses is that the primary responsibility remains with the doctor who gives the assignment, nurses also have executive responsibility, delegation can only be carried out after the nurse has received sufficient education and competence to receive the delegation, delegation for the long term or continuously given to health nurses with special skills (specialist nurses), which are regulated by separate rules (standing orders). Anaesthetist administrators' role when carrying out health services to delegate authority according to these norms can only be performed by anaesthetist administrators who have received training.

In the world of health, in carrying out their duties as anesthetists, administrators must have a license as proof of the validity of the profession based on statutory regulations. This provision is contained in Article 1 Permenkes No. 18 the Year 2016 concerning Licensing and Implementation of Anesthesia Administrator Practices. In carrying out medical actions, the anesthetist and anesthetist nurse perform these tasks based on orders from the anesthetist specialist on duty when an anaesthetist in the work area does not have a specialist and performs other actions case, such as passive or invasive measures. Where invasive action is an action that can directly affect the integrity of the patient's body tissues, while passive action is to accept the delegation of roles through oral instructions from a specialist where at the same time the doctor is unable to attend and does not directly supervise the action taken, the anesthetist is not can directly cause its legal consequences in the future.
Based on the description above, in this study, the authors formulated the following problems what is the role of a mandated anesthetist in the absence of an anesthetist specialist in the area? What is the form of an anesthetist's legal responsibility when there is a specialist doctor in an area?
This research uses the empirical juridical method or is included in sociological, legal research and can also be called field research, which looks at the implementation of the laws and regulations that are realized in society. 6 Juridical normative legal research, which is applied to this research, is applied to the problem of implementing the role and legal accountability of anesthetist administrators who are given the rights and obligations of their performance by the Government based on the provisions of the applicable laws and the accountability for the implementation of anesthesia by the anesthetist when an anesthetist is present. This study uses a sociological juridical approach, which emphasizes research that aims to obtain empirical legal knowledge utilizing a direct approach to the object to determine the relationship with anesthetists' legal responsibility when handling patients. There are specialist doctors in an area. A statutory approach is carried out by examining all regulations or statutory regulations related to the legal issue.
B. Discussion

The Role of Mandated Anesthetist Administrators in the Absence of Anesthesia Specialist in an Area
Anesthesia administrators carry out tasks based on the Government's authority through rules or legal norms established by the Government, such as health law, hospital law, Minister of Health Regulation or Peraturan Menteri Kesehatan (Permenkes) No. 18 of 2016 Licensing and Implementation of Anesthesia Administrators Practice. Another regulation is the Regulation of the Minister of Administrative Reform and Bureaucratic Reform or Peraturan Menteri Pendayagunaan Aparatur Negara dan Reformasi Birokrasi (Permenpan RB) No. 11 of 2017 concerning the Functional Position of Anesthesiologist. 7 Anesthetist administrators play a role in the implementation of anesthesia compliance care in health services to produce professional anesthetist administrators, careful in carrying out pre-anesthesia, intra-anesthesia, and post-anesthesia arrangements in-home service settings, so that they can play a role in improving the health status of all Indonesian people who are healthy, self-sufficient and justice. 8 Anaesthesia compliance care includes preanaesthesia, intra-anesthesia, post-anesthesia care. As part of an anesthesiologist hospital institution, it has a significant role in carrying out health efforts to the community, helping hospitals provide excellent service. 9 In this case, the role of the Government in public health services has a large portion. However, due to limited government resources, the community's potential needs to be explored and included in these health service efforts.
In carrying out surgical services, an anesthesiologist must participate as a team member. An anesthesiologist will ensure patient comfort with the exceptional standard of anesthesia needs in the operating room and provide medical information relating to critical aspects of the patient's condition during the operation process in monitoring blood pressure, heart rate, and breathing, and assisting in the postoperative care process. 10 The anesthetist's duties include the maintenance of anesthesia management, which is the obligation of anesthetist administrators who carry out regional hospitals' duties.
Implementation of anaesthesia compliance care starting from pre-anesthesia, intraanesthesia, post-anesthesia. The regulation issued by the Ministry of Health in the fourth part of Permenkes No. 18 of 2016 concerning Licensing and Implementation of Anesthesia Administrator Practices discusses rights and obligations. The right of anesthetist administrators contained in Article 19 states that anesthetist administrators must obtain legal protection when carrying out practical tasks under professional standards in their field of expertise, service implementation standards, and standard operating procedures contained in each hospital, get factual information from patients and so forth. The provisions in Article 20 explain anaesthetist administrators' obligations, including respecting the patient's rights, keeping patient secrets, providing information to patients, requesting consent to carry out actions from the patient or patient's family, and complying with other standards following legal laws and regulations.
The implementation of the professional anaesthetist administration practice should assist anaesthetists. However, at Kota Agung Regional Hospital, which for some time did not have, our leadership decided that services must still be carried out with anaesthetist administrators from the anesthetist. The responsibility rests with the implementing doctors as surgeons and Obstetricians. 11 The legal basis for implementing anesthesia services at Kota Agung Hospital, Tanggamus Regency is the Decree of the Director of the Kota Agung Regional General Hospital No 1886.B/41/2019. This decision gives the authority to carry out anaesthetic procedures under the operator doctor's responsibility (a specialist doctor who carries out the operation) and the Hospital Director. 12 In the absence of an anaesthetist, other doctors who are considered to be executors or whom we know as operator doctors such as surgeons, obstetricians, ear, nose, and throat doctors, and other doctors coordinate with anesthetists who have the task of assisting in the implementation of surgery within the scope of service Anesthesia. 13 Anaesthesia services are performed very well, but the patient's physical condition must be considered. The hospital facilities and infrastructure are considered, as well as the scientific-based expertise of an anesthetist. These components become benchmarks for anaesthetist administrators to carry out the Government's role in the implementation of anaesthesia services. The services provided by anesthetist administrators are needed to answer the problems and expectations caused by the absence of specialist doctors and services to the community. 14 Implementation of anaesthesia services can sometimes lead to conditions that may provide unpredictable risks, but scientifically it can occur as medical risk. As an anaesthetist, I believe that anaesthetist administrators must provide anaesthesia services with good scientific views in providing the services needed by patients in implementing support for surgery in the form of anaesthesia services. 15 The results of the interview with dr. Dian assesses that an anesthetist's obligations and rights have been carried out through the performance of a day's duties as a functional anesthetist from preanesthesia, intraanesthesia (including anaesthesia), and post-anaesthesia have been carried out well by the anesthetist. I also think that the anesthetist is sure. Provide optimal ability to save the patient's life where anaesthetist administrators can do things beyond their authority set by the Government, such as the Kota Agung General Regional Hospital or Rumah Sakit condition Umum Daerah Kota Agung (RSUD), which does not have an anaesthetist. Anaesthetist administrators are given the additional task of carrying out anesthetic procedures where this authority is the anesthetist's authority. However, the local Government provides this authority with additional competence and the absence of an anesthetist. The administrator carries out the service, and the person in charge is at the operator doctor and is carried out by receiving a mandap from the person in charge. 16 In the practice of anaesthesia management at Kota Agung Regional Hospital, when an anaesthetist is not available, the anaesthesia administrator is given full authority to carry out anaesthesia services. The anaesthesia service is a particular task given by the Tanggamus Regional Government through the Hospital Director to solve the institution's problems. The operation that requires anaesthesia services is an essential and inseparable thing. This is because it is impossible for the operation not to require anesthesia to relieve pain during surgery.
The implementation of the tasks given in the form of anesthetic, medical action services at Kota Agung Hospital has been running for several years. The Ministry of Health provides options for solving health problems experienced by areas that still lack Human Resources for Health or Sumber Daya Manusia Kesehatan (SDMK) for specialist doctors, elementary specialists such as Internal Medicine, Gynecology, Children, Surgery, and Anesthesia. Specialist Doctor Compulsory Program or Program Kerja Dokter Specialis (WKDS) The WKDS program requires graduated specialist doctors to serve for one year at Government Hospitals but based on Supreme Court decision Number 25 P/HUM/2018, the program's implementation is terminated. Planning for the fulfillment of SMDK at Kota Agung Hospital, which opens up job opportunities as State Civil Servants in health professions where there is no registrant from the medical profession-specialist doctors is a problem the temporary implementation of anesthesia is given authority to the anesthesiologist administrator profession. The authority is based on the applicable regulations and the legal basis for the anesthetist's practice or/and administration of anesthesia care. 17 Anesthesia Administrators carry out tasks based on the authority given by the Government through the rules or legal norms established by the Government such as the Health Law, the Hospital Law, the Minister of Health Regulation ( Application of Article 14 of the Minister of Health Regulation No. 18 of 206 concerning Licensing and Implementation of Anesthesia Administrators Practices regarding the delegation of authority based on government assignments is carried out if anesthesiologist specialists cannot be found and carried out by anesthetist administrators who have received training, These two elements have been fulfilled so that the anesthesia administrators based on the Decree of the Director of the Hospital Number 1886.B/41/2019 concerning the Implementation of Anesthesia Action Services at the Kota Agung Hospital are legally justified. He can only assist in carrying out general and regional anaesthesia in carrying out an anaesthetist administrator's particular tasks with the first anesthetist administrator's position. 20 Implementing general anaesthesia with measured breathing if in carrying out the task there are conditions that are different from the job description described by the Government through Permenpan RB No.11 of 2017 there is a clash of rules.

Responsibilities of the Anesthesiologist in the Presence of an Anesthesia Doctor
The legal bond between doctors, health workers and patients, doctors' ties, health workers, and the patient and hospital association is a legal bond to mutually agree to bind ourselves as parties to the engagement (Verbentenis). For this reason, the enactment of all laws and regulations regarding health or medical provides the seriousness and caution of medical personnel in carrying out their duties. As with the delegation of authority in the world of health is a dangerous thing because the authorities and the recipients of authority have different responsibilities. 21 This means that the delegation of authority has legal consequences if there is negligence (malpractice in the world of health) caused by a person or legal entity. But in fact, what happens in a legal case is the nurse who is responsible, even though the nurse only carries out the authority given by an anaesthetist specialist. Nursing's legal consequence is when nurses carry out coordinative and therapeutic roles and functions in collaborative nursing actions that place nurses as partners and work together with doctors, other health workers, including fellow nurses. 22 This means that in these two functions, the nurse carries out the medical treatment for the delegation. Thus the delegation of authority should be the responsibility of giving the authority and the recipient of the authority so as not to burden either party.
Doctors' delegation of authority to nurses occurs when a nurse takes actions that are not competencies in health services. The delegation of authority carried out by nurses may not be carried out verbally by a doctor, but there must be a written request from the doctor. However, the reality often occurs when a doctor gives authority to be done verbally either in the form, online media or by telephone. As a result, there are many errors in administering drugs or   23 Although this shows that nurses can only perform a medical action if there is a written authorization by the doctor. This is done to avoid legal consequences if the nurse makes a mistake, and the two parties must be responsible (doctor and nurse).
In implementing the delegation of authority from doctors to nurses, several things must be considered to be under the provisions and standard operating procedures for health handling. The things that must be considered in the delegation of tasks from doctors to nurses: 24 a. The primary responsibility remains with the doctor who gives the assignment. b. Nurses have executive responsibilities. c. The delegation can only be carried out after the nurse has received sufficient education and competence to receive the delegation. d. Long-term or continuous delegations may be given to health nurses with special skills (specialist nurses), governed by separate rules (standing orders). Doctors in delegating authority to nurses are only given to those who have the title of specialist nurses or nurses if they are capable of doing so. 25 This means that the delegation of authority cannot be carried out to all nurses. Only nurses who have received nurses are entitled to the delegation of authority. The delegation of authority in nursing can also occur in other health service facilities, namely health centres located in each region, whether they have an anaesthetist or not. Nurses who provide health services at health centres perform specific medical actions according to their expertise. Nurses who serve in health centres carry out the profession and an extension of the Government in carrying out government functions in terms of providing adequate health facilities and services and remaining responsible to the giver of authority.
Nurses' implementation of duties, both at the health centre or the like, cannot take medical action or treatment without the doctor's approval, who gives the authority as the person in charge. 26 However, in reality, nurses often do not wait for doctors' directions and orders to provide medical services at Puskesmas or the like. However, they are carried out based on personal considerations, human values, and competence. This is often done by medical personnel, especially nurses, in carrying out first aid. Health services in the form of medical actions should require delegation from doctors. An anesthesiologist who has passed the field of anaesthesia nursing, or anaesthetist is different from nurses who have undergone anaesthesia training. But historically, an anesthesiologist is a separate part of nursing, given special skills regarding anaesthesia nursing care.
Anaesthetist doctors are the executors of anaesthesia and other actions, the anaesthetist specialist colleague's competencies, namely the Indonesian Anesthetist Association or performed during education are given the category A Teaching Hospital. 27 Not all hospitals have complete or adequate medical equipment, such as hospitals in Kota Agung Regency, an anaesthetist can carry out not all competencies. 28 According to article 12 (a) Permenkes No. 18 of 2016 concerning Licensing and Implementation of Anesthesia Administrators Practices, Anaesthesia administrators carry out duties under the supervision and delegation of authority of anesthesiologists and other doctors, where this transfer is implemented in the legal relationship between anaesthetist and anaesthetist.
The doctor and anaesthetist profession is part of the hospital, where these two professions are part of the Anesthesia Installation part of the Operating Room. Carry out tasks in the field of anaesthesia and the competencies determined by the collegiate but readjusted to the facilities and infrastructure of the hospital, such as the Kota Agung District Hospital and the Pringsewu District Hospital have different medical devices so that the competencies performed by anaesthetists and anaesthetists are readjusted to the facilities and infrastructure, usually matters related to tasks contain details of their respective duties. 29 Judging from the relationship between the two professions, which have different job descriptions, a legal relationship can occur if seen from an anaesthetist's particular assignment to an anesthesiologist, either under supervision or not. This is related to the shortage of anaesthetist doctors, who work in 3 hospitals, two at the Regional Government Hospital and one at the Sawasta Hospital. In contrast, the Tanggamus District hospital has a three-day schedule during working hours. This is due to the scarcity of anaesthetists, where the Government, through the Ministry of Health, launched the Specialist Doctor Compulsory Work Program. This program requires doctors who have finished their education to devote one year to an area designated by the Government to meet specialist doctors' needs in that area.
However, this program is no longer valid because we have been sued and won by us, so that some areas do not have specialist doctors that should be urgently needed, such as anaesthetists in Tanggamus District. The expectations given to anaesthetist administrators to perform anaesthesia are significant expectations where surgical services require anaesthesia, one of which is acceptable as long as it is based on a reasonable assessment and consideration of the patient's clinical conditions. 30 Regarding legal liability, as long as an anesthetist is working in the hospital, the responsibility lies with us, whereas if there is no anesthetist is the operator because the one who assesses and considers and carries out the action the operator (anesthetist) is not another doctor or the director as the leader, carries out Anesthesia services are following the ability. Other doctors may be responsible such as surgery, ENT, and eyes.
The hospital's implementation is more oriented towards curative services or what is known as medical services, not rehabilitative or promotive. There are many problems in services at the Regional Hospital of Kota Agung Tanggamus Regency or Rumah Sakit Umum Daerah (RSUD) Kota Agung. At the end of 2019, we did not have an Anesthesia Specialist where anaesthesia service is one of the services needed to carry out services in the operating room. As the Kota Agung Regional Hospital leader, I tried to answer this problem by contracting an anaesthetist specialist. The anaesthetist doctor named dr. Arif is willing to practice at Kota Agung Hospital with an agreed schedule to carry out anesthesia services at Kota Agung Hospital. 31 I started working at the end of February until now. I provide services that have been assigned, one of which is anaesthetic service.  2021E-ISSN: 2745 The relationship between anaesthetists at each hospital is the relationship between doctors and patients, the relationship between anaesthetists and the hospital, the anaesthetist's relationship with other doctors, and the anaesthetist's relationship with the anaesthetist, the relationship between doctors and nurse anaesthetists, the relationship between anaesthetists and nurses, intensive, and the relationship between anaesthetist and midwife and other relationships that have a relationship with rights and obligations. 32 The relationship between anaesthetist and anaesthetist is carried out through a process of mandate and delegation.
Responsibility for the anaesthetist's actions as long as it is carried out based on instructions from me as an anaesthetist, I assume that the responsibility for such medical action lies with the mandate. Conditions where anaesthetist administrators and other doctors who carry out medical actions which are the domain of the anaesthetist's competence are carried out without coordination with the anaesthetist and, are carried out outside of the instructions given, then the responsibility lies with the person who acts. 33 So far, if there is an anaesthetist as the doctor in charge, I always coordinate with him based on the patient's condition and supporting data such as laboratory results, heart record results, body imaging results, and other data where necessary in determining the decision of the action he will carry out and provide assistance both independently and collaboratively. 34 Many medical practices in health services are found that tasks, including medical action to health workers, are carried out orally, not written or orally, will cause problems. The condition of the delegation of duties to grant authority for medical action given orally is considered to have weak legal force. In medical practice in hospitals, the delegation of authority is often verbally recorded by CCTV or has a recording of instructions via telephone. Legal experts consider electronic conversations as evidence that is categorized as clues. Concerning evidence, Article 184 Paragraph (1) of the Criminal Procedure Code determines that evidence includes the testimony of witnesses, expert statements, letters, instructions, and statements of the defendants, but the instructions in the Criminal Procedure Code Article 188 Paragraph (2) make it clear that the evidence is obtained from witness statements and the statement of the defendant. It can be concluded that the delegation of authority that is given orally does not have a strong and permanent legal force.
During my work at the Kota Agung Hospital as an anaesthetist, I thought that the anaesthetist always carried out what I instructed. There was no anaesthesia that I didn't know about and additional measures that I didn't know about in the anaesthesia service for patients. There is no contradiction between these two professions, where anaesthetist and anaesthetist have different job descriptions. I am a medical action practitioner in the scope of anaesthesia and an anaesthetist as a profession that helps us carry out anaesthesia services. As the head of the Kota Agung Hospital, I know that the anaesthetist is not always there. This is because he works in another hospital. Anaesthesia services do not have problems. This is the coordination between anaesthetist. Anaesthesia administrators work independently and collaboratively and carry out anaesthetists' instructions based on their knowledge and competencies. Anaesthetist administrators may refuse the assignment if viewed with science and competence that it cannot be done or has certain clinical risks. However, anaesthetists have carried out their duties independently, collaborating and delegating tasks by anaesthetists. 35 The responsibilities that had been before the presence of an anaesthetist were with the operator doctor, according to the Decree of the Director of the Kota Agung Regional General observation results show that Kota Agung Hospital has made a work agreement with an anaesthetist specialist. Anaesthetist administrators in the authority of clinical performance (clinical privilege) published by RSUD Kotagung explain independent competence and implementation of anaesthesia with inherent responsibility on the anaesthetist or operator doctor.
Implementation of anaesthesia services is an anaesthetist's responsibility because it is an anaesthetist's realm to carry out medical action services and be responsible for patients' services. The responsibility attached to anaesthetists in anaesthesia services means implementing anaesthesia services, which is always based on standard operating procedures, professional standards, ethics, and applicable laws.

C. Conclusion
Delegation of the exercise of authority exercised by anesthetists to anesthetist nurses based on government assignments referred to in Article 10 (b) Ministry Health Regulation No. 18 of 2016 concerning the Implementation of Anesthesia Administrator Practices, is carried out if there is no anesthesiologist specialist in an area. A specialist doctor in the context of the delegation of authority as described by law can only be accepted and implemented by anaesthetist administrators who have received training and a license to practice so that responsibility is still given to the doctor who gives the mandate. Anaesthesia administrators carry out health services in the context of delegating authority as referred to in Permekes paragraph (2), covering anesthesia services following additional competencies obtained through training. Based on this, all forms of authority delegation based on government assignments can be carried out in government-owned and/or local government health service facilities. Anesthetist administrators who are nurses who have received anesthesia education or anesthetist administrators receive authority under the supervision and delegation of authority mandated by anesthetists and other doctors so that responsibility is tied to the mandate giver is the anesthetist or other doctor who gives the mandate.