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SUMMARY

EVALUATION OF SERVICE PERFORMANCE IN IGD RSUD PRAYALOMBOK TENGAH AFTER APPLYING QUALITY MANAGEMENT

SYSTEM OF ISO 9001 CERTIFICATION

I Ketut Sudarsana09/308520/PKU/11783

POST GRADUATE PROGRAMOF GADJAH MADA UNIVERSITY

MEDICINE FACULTYJOGJAKARTA

2011

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EVALUATION OF SERVICE PERFORMANCE IN IGD RSUD PRAYALOMBOK TENGAH AFTER APPLYING QUALITY MANAGEMENT

SYSTEM OF ISO 9001 CERTIFICATION

Filed byI Ketut Sudarsana

09/308520/PKU/11783

Has been approved by

Supervisory I Supervisory II

Dr.C.Tjahjono Koentjoro,MPH Dr.PH Ir.Valentina Dwi Yuli S, M.KesDate: Sept 2011 Date: Sept 2011

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ABSTRACT

Background: Anticipating the operationalization of new airport in LombokTengah province, in 2009 IGD RSUD Praya has been awarded ISO9001:2000 certificate as a result of some efforts to improve its quality.However, in the last 4 years there have been increasing number opatients in RSUD Praya with some complaints of IGD services, the resultof patients satisfaction survey in IGD RSUD Praya which has not beenreaching the expected target, and there has not yet been any evaluation tothe service performance improvement after applying ISO 9001:2000certification.Objective: Evaluating service performance in IGD RSUD Praya Lombok

Tengah Province after employing quality management system of ISO9001:2000 as well as finding out the causes of performance changes in

IGD RSUD Praya in accordance to articles in ISO 9001:2000.Method: The design of this study is explanatory case study with specialholistic single case design to evaluate service performance in IGD RSUDPraya after applying quality management system of ISO 9001:2000.Analysis and Result : Respond time service performance, IGD stafcompetency, and medical record completeness tend to improve matchedby the result of evaluation of applying ISO IGD RSUD in article 4, 5, 6, 7,and 8 of ISO 9001:2000 which findings from previous audit didnt appear inthe next audit. While the patient satisfaction to the service performancehas not reached the expected target as its stated in ISO. This is supportedby the result of interview stressing on the need to do survey towardpatients need and want in IGD RSUD Praya, and to evaluate optimally theresult of satisfaction survey, complaint, critics, and suggestion fromPatients in IGD RSUD Praya.Conclusion and Suggestion: There were different service performancein IGD RSUD Praya between pre and post application of qualitymanagement system of ISO 9001:2000 in which the service performancein IGD RSUD Praya tend to improve, yet patients satisfaction of serviceperformance in IGD RSUD Praya was below the expected target stated inISO. It is suggested that the application of ISO 9001:2000 should beconducted and evaluated continually.

Keywords: Evaluation, Quality Management System of ISO, Performance

Service in IGD.

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INTRODUCTION

The hospital is an organization engaged in health services and as a

referral center below the level of service, the hospital needs to improve the

quality of service to people in need and can provide quality service with

quality. Quality management system to support the micro-system service

to work optimally so as to meet the needs, expectations, and values o

customers.1

In the ISO 9001:2000 quality management system has been

revised to ISO 9001:2008 quality management system is based on the

quality management system and process model approach consists of five

elements or elements of the essential requirements of the quality

management system, management responsibility, resource management,

the realization products, as well as measurement, analysis and

improvement where there is a measurement of patient satisfaction in orde

to be eligible customers.2

ISO quality management standards for assessing hospital

performance using standardized quality system compared with the

assessment of function and purpose of the hospital, where there are 12

performance indicators as an instrument to measure the performance o

hospitals that must be taken to be a source of information for community.3

Praya Hospital as a hospital grade C of the Government of Central

Lombok regency, with a capacity of 147 beds TT, is the only government-

owned hospitals in NTB who already have the ISO 9001:2000 quality

standard of service to the Council obtained ISO 9001:2000 certification in

May 2009 from the Quality Assurance throughout the world, to anticipate

the operation of the New Lombok International Airport is located in Central

Lombok regency, and the efforts hospitals Praya, Central Lombok to win

the competition in improving the quality of the product or service that

meets customer and appropriate regulations.2

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ISO 9001:2000 certification assessment area hospital emergency

room Praya, Central Lombok by the number of employees as many as 33

people, consisting of 6 doctors, nursing staff 22 people,4

people porte

personnel, and administrative staff person, but before the implementation

of ISO 9001: 2000 IGD Praya Hospital has been accredited 5 service, one

of the emergency services in 2006 but until now has not done the

evaluation of the performance improvement of hospital services.

In implementing the ISO 9001:2000 IGD Hospital Praya, Central

Lombok have to set quality objectives as set out in clause 5.4.1 of ISO

9001:2000.4 Quality Objectives are established, among others : The

response time of ER patients, ER patients waiting times further for the

management, the incompleteness of the charging status of patients with

ER, the ER staff competence, and patient satisfaction. Quality objectives is

an indicator that should be measured to determine whether the Hospital

ER Praya, Central Lombok can achieve what purpose. Based on data from

the fields of development and quality control services Praya Hospital

(2010), there are still complaints from patients and the introduction o

Praya Hospital emergency room services, both in facilities, comfort,

cleanliness, and staff skills.Patient satisfaction survey results at Praya

Hospital ER ever do not ever reach their intended target, and results o

RAP-Home I (2006) and II (2008) regarding the SPM measurement

indicators in a hospital emergency department found the results of the

response time of 2, 25 minutes and 13.05 minutes, and the competence o

ER to 29% of doctors and nurses 71%.

In the implementation of quality management ISO 9001:2000, IGD

Hospital Praya, Central Lombok began certification in May 2009 has been

conducting internal audits four times, followed by four times the

management review, and 2 times the external audit in February 2010 in

J anuary 2011, but until now This has never been an evaluation o

performance enhancement services at the Hospital ER Praya.5

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RESEARCH METHODS

Evaluation is an activity to assess, measure, or compare what has

been done and achieved with what must be achieved and implemented.6

The study design will be used is a case study explanatori a holistic single

case design, to evaluate the service performance Praya Hospital

emergency room after the certification of ISO 9001:2000 quality

management. This design was chosen because of the problem under

study is a contemporary problem with multiple sources of data and

researchers are not there to control the events under study.7

The research was conducted in a hospital Praya Road. HLHasyim

Praya, Central Lombok which is the C-class hospital that is owned by the

government of Central Lombok district, and the only government-owned

hospitals in NTB who have obtained the certificate ISO 9001:2000.

In this study collected primary data in the form of quantitative data

on patient satisfaction to the emergency services, response time of

emergency patient handling, competency IGD, the completeness of filling

the ER medical records, as well as the suitability of the implementation of

ISO 9001:2000.

Patient or the introduction of 100 people who were given a

questionnaire relating to patient service satisfaction Praya Hospital

emergency room, while emergency room doctors and nurses involved

before and after ISO certification as much as 2 person interviews were

conducted to determine changes in the pattern of performance before and

after ISO 9001:2000 certification. Interview form of open questions with

interview guidelines, observation of emergency room patients and medical

records to determine the response time Praya Hospital emergency room

services started coming up to the patient's physician was calculated and

recorded the time, making the percentage of emergency room service

response time < 5 minutes. Check the list and form filling completeness of

patient records Praya Hospital emergency room by looking at the

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completeness of medical records to fill the relevant forms required ER

medical records are used, the percentage of patients who complete IGD

makes the filling of medical records. Chek conformance clause of ISO

9001:2000 list is used to determine the suitability of the implementation of

ISO in hospital emergency rooms Praya to see articles 4, 5, 6, 7, 8 ISO

9001:2000 is required, using the guidelines of ISO clause examination of

the suitability list. As for knowing the competency of trained personnel in

the emergency room doctors and nurses who have done and have a

certificate of competency required to use data Praya Hospital personnel.

Secondary data in the form of reports or documents concerning the

service performance Praya Hospital emergency room patient satisfaction,

response time, personnel competence, and completeness of medical

records prior to the implementation of ISO 9001:2000 IGD in 2008 and

after the implementation of ISO 9001:2000 in 2009, the year 2010. All data

both primary data and secondary data obtained and carried out data

processing and continued with the presentation of data.

RESULTS AND DISCUSSION

1.ER patient satisfaction service performance Praya

From the research results of service performance satisfaction ER

patient satisfaction results obtained with 82.4% of patients, with the

number of male respondents than female respondents are more numerous

and the largest age group is between 41-50 years. The result is still above

the minimum service standards for emergency >70%,8 but still below the

standard of hospital performance indicators by 90%,3 and is still below the

target achievement of the ISO quality by 85%. J udging from the

achievement of the ISO quality Praya Hospital emergency room on service

performance declined from the previous ER patient satisfaction by 84% in

March 2011, probably due to the understanding and needs of patients

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keiinginan Praya Hospital emergency room, this can be seen from the

findings of conformance clause of ISO 9001 using an instrument

assessment of an organization's quality management system of clause 4,

article 5, article 6, article 7, and paragraph 8 of ISO 9001:2000 with ISO

management representative and head of Praya Hospital ER IGD chief

Praya Hospital, but does not involve the management and support units

Praya Hospital emergency room, where the differences seen in verse 5

Management responsibility has not been set of customer needs and

desires are good, according to the guidelines,9 the importance of

communicating customer requirements and legislation Act, and clause 7

Product realization that not make the most of their communication with

customers by looking at the complaints of customers such as the use of

suggestion boxes, impressions and user messages, such as guidelines,9

of article 7 of the customer communication in which an organization must

establish and implement effective arrangements to communicate with

customers about the customer feedback, including customer complaints,

and according to,10 that service quality is a little hard to measure because

it generally is subjective because it involves patient satisfaction, it depends

on perception, background, socioeconomic, norms, education, culture,

personality and even It depends on perception, background,

socioeconomic, norms, education, culture, and even personality.

Prior to obtaining certification of ISO 9001 Implementation of patient

satisfaction with the performance of 60% increase in pre-certification to

ISO 9001 certification in May 2009 by 70%, probably due to the time at

which the previous certification preparation IGD Praya Hospital has also

undergone accreditation and RAP-Home, but in research These

researchers did not identify the impact of accreditation and RAP-Home.

Where by,11 revealed significant improvement in patient satisfaction in the

emergency room after the intervention and the nurse patient

communication.

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In the present study did not measure the external customer

satisfaction is employee Praya Hospital emergency room, where in the

opinion of,10

quality-oriented health services both internal and external

customers.

2. Service response time performance Praya Hospital ER

In this study conducted with the patient's medical record the

observation of emergency room Praya Hospital, regardless of the

classification of emergency room patients, such as emergency care

guidelines,12 which classifies patients with emergency, no emergency

room patients, emergency patients are not life threatening, no patients

emergency department did not use observations form the medical records

of emergency room response time Praya Hospital, obtained the results of

91%, judging from the achievement of quality objectives of ISO Praya

Hospital ER on the ER performance of the service response time has

increased compared with the previous March 2011 by 87% , and above

target at 85% ISO quality might be due to the understanding and

implementation of the ER response time communications, this can be

seen also from the results of ISO conformance clause, although the

differences are found clause 4 of the quality management system

requirements, where not all employees know IGD IGD operational

processes and management responsibility clause 5, where not all ER

personnel to get the quality policy of socialization, is due to new

employees in the ER so it is necessary to perform additional socialization

for the understanding of the ISO and operational processes Praya Hospital

emergency room, but in the resource management section 6 and

subsection 8 Measurement, analysis, improvement has been correspond

with reality. This is in accordance with the opinion,13 paragraph 8

Measurement, analysis, and improvement in which organizations must

plan and execute the process of measuring, monitoring, analysis and

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improvement is needed in order to ensure conformity of the quality

management system.

Before the implementation of ISO 9001 to obtain the response time

performance with 70% rise in pre-certification to ISO 9001 certification in

May 2009 by 80%, probably due to the time at which the previous

certification preparation IGD Praya Hospital also experiencing

accreditation and RAP-Home. Although pre-certification audit findings in

paragraph 4 where the quality management system requirements have not

been up to understand the quality policy is applied so that the necessary

understanding of the quality policy of the Hospital emergency room Praya

socialization.

Figures Praya Hospital ER response time of 3.9 minutes is

obtained, is the proper guidelines,14 to 858 Kepmenkes / Menkes / SK / IX

/ 2009 on standard hospital emergency room, where emergency room

patients should be treated no later than 5 (five ) minutes after the ER.

3. competence of service performance Praya Hospital ER

In this study physicians obtained Praya Hospital emergency room a

number of 6 people (100%) have had training and certification needed to

work in the ER, whereas ER nurse about 22 people (82%) have training

and have the necessary certificates, so that the results obtained from 91%,

the result is still above the standards of hospital performance indicators by

50%,3 and is above the target of achieving ISO quality objectives set at

90%, but still below the minimum standards of emergency services 100%.8

In terms of achieving IGD Praya ISO quality is still the same hospital from

the previous March 2011 for 91%, this is because in the span of time is not

been to the addition of Praya Hospital emergency room nurse who had

attended the training needed to meet both personal competence and

assistance to management, it This can be seen also conformance clause 6

Resource management in accordance with reality, accordance with the

guidelines,9section 6 in human resources, where the personnel performing

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work affecting product quality must be competent on the basis of

education, training, skills and experience.

Before obtaining ISO 9001 certification authority Competence IGD

implementation performance by 50% rise in pre-certification to ISO 9001

certification in May 2009 was 77%, probably due to the time at which the

previous certification preparation IGD Praya Hospital has also undergone

accreditation and RAP-Home, as well as before certification of all general

practitioners on duty at the hospital Praya was given a job as a doctor in

the emergency room Praya Hospital, but before certification of the ISO has

designated only six general practitioners who have the competence

requirements of duty in the ER, is in accordance with the guidelines,14

through Kepmenkes 858 / Menkes / SK / IX / 2009 standard hospital

emergency room, where general practitioners should receive emergency

training GELTS, ATLS, ACLS, and nurses trained in emergency nursing

BTLS, BCLS.

4.Completeness of medical record service performance Praya Hospital ER

This study obtained the medical records IGD is a complete fill 92%,

the result is still below the standard of hospital performance indicators by

95%,3 but still above the achievement of the ISO quality objectives set at

85%, and earlier than in March 2011 increased by 90%, it This can be

seen the absence of findings regarding the completeness of medical

record in paragraph 4 of the quality management system requirements, in

the opinion,13 and guidelines,9 where the organization should establish,

document, implement, and maintain a quality management system ISO

9001:2000 and continually improve effectiveness in accordance with the

requirements of paragraph 7 of standards and realization of products,

such as opinions,13 and guidelines,9 which organizations must plan and

develop the processes needed for product realization, planning of product

realization shall be consistent with the requirements of other processes of

the quality management system.

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Before the implementation of ISO 9001 performance of the

completeness of medical records obtained by the ER 65% increase in pre-

certification to ISO 9001 certification in May 2009 by 70%, probably

caused during the preparation for ISO certification, which previously IGD

Praya Hospital also experiencing accreditation and RAP-Home, but in this

study researchers did not identify the impact of accreditation and RAP-

Home, as well as the views of the audit findings pre sertfikasi clause 7

Product realization of the medical records that must be ensured that a

complete fill after repair did not reappear later audited.

5. Trend of changes in service performance Praya Hospital ER

Results Praya Hospital emergency room service performance

before and after application of ISO 9001:2000 is displayed in the form of

an image to see the trend of changes in performance post-implementation

services ISO 9001:2000 quality management system, in accordance with

the opinion,15 which monitors the activity of the development trend in

activity in several years can be seen on the graph by comparing against

established standards.

In this study measures the performance of personnel competence,

response time, completeness of medical records, patient satisfaction,

without a measure of financial performance because it has not been

specified in the ISO quality objectives Praya Hospital emergency as

performance goals and objectives Praya Hospital emergency services.

From the results of the evaluation of the implementation of ISO's

Hospital emergency room to see Praya in accordance with ISO 9001:2000

clause in the audit prior to certification, certification, until after the

certification audit findings, there are still improvements to be carried out,

followed in the management review to evaluate the improvement and

implementation of target , where the findings in previous audit findings are

not repeated in subsequent audit that shows the quality management

system performed consistently, such as guidelines,9 which clause 4 of the

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quality management system requirements, where the processes for quality

management system includes processes for management activities,

provision of resources , product realization and measurement, and

appropriate consultation,6 where the suit is the fulfillment of the

requirements or criteria, or a condition within the tolerance limits or

requirements established criteria, where the suitability of the quality

management system compared to the standard ISO 9001:2000.

After achieving ISO certification obtained ISO quality Praya Hospital

emergency room in the ER changes in patient satisfaction performance

improvement is less significant results obtained, most likely will remain,

although the performance of patient satisfaction is still above the target

ISO quality targets, but after the target increased to 85% quality

performance results Praya Hospital ER patient satisfaction has not

reached its intended target, this may be due to a lack of understanding of

the needs and desires of emergency room patients, according to the

results of interviews indicate that the survey will be added to the wishes

and needs of emergency Praya Hospital patient satisfaction

questionnaires as a complement to the room existing patients, and the

findings of the survey maximum, both from complaints, feedback, and

suggestions from patients Praya Hospital emergency department, and

need to be addressed in the management review to improve future, this

opinion,13 and guidelines,9 clause 8 Measurement, analysis and

improvement, the organization must plan and execute the process

measurement, monitoring, analysis and improvement is needed in order to

ensure conformity of the quality management system, and according to the

findings in paragraph 5 Responsibility management responsibility in which

the provision has not been keiinginan customer needs and good, and

clause 7 Product realization where communication with customers that

have not performed optimally, but the results of the study,16 revealed the

perception of quality of service to the patient and family satisfaction with

Servqual attributes do not all have a positive correlation.

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Changes in the performance of services which tend to increase the

response time, this might be due to the understanding and communication

of nurses and doctors who attended Praya Hospital emergency room,

according to an interview that emphasizes cooperation and communication

between doctors and nurses who know and understand and responsive in

responding to every patient who came to the emergency room Praya

Hospital, as well as findings regarding response time, both in Clause 4 of

the quality management system requirements, management responsibility,

paragraph 5, article 8 Measurement, analysis, improvement, does not

appear in a subsequent audit that shows the quality management system

implemented consistent, where according to,17 in his research stated

adherence to the response time identified beneficial for survival, and

reduce the severity of the disease.

Changes in the competence of service performance remains but the

phase tends to increase, this is because there is a phase in which the

absence of additional staff both doctors and emergency room nurse who

has been trained to the competencies required to work in the ER both

personal fulfillment and management assistance Praya Hospital , as well

as improved performance due to the addition of ER personnel who have

done the necessary training and competence of staff turnover has not

been competent IGD IGD with personnel who already have the

competencies required to work in the ER Praya Hospital, consistent with

the interview, stressing that the doctors and nurses on duty in the ER

Praya Hospital must have the competencies needed by way of personal

fulfillment and to help the hospital management, as well as findings

regarding the fulfillment of the competence of workers, both in Clause 4 of

the quality management system requirements , paragraph 5 Management

responsibility, Resource management section 6, in accordance with that

opinion,13 and guidelines,9 which organizations must apply and provide

necessary resources to properly implement and maintain QMS ISO 9001:

2000, as well as personnel performing work affecting product quality must

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be competent on the basis of education, training, skills and experience,

where the findings do not appear again showed the quality management

system applied consistently audited next.

Changes in the completeness of medical record service

performance is likely to increase significantly, this may be due to the habit

of doctors and nurses Praya Hospital emergency room, assisted by

administrative personnel in completing the medical records of patients'

medical records Praya Hospital emergency room, according to the results

of this interview, which emphasized in the doctor's habit to complete

medical records and emergency room nurse's role in helping to fill the

completeness of patient records of emergency room Praya Hospital, and

the role of medical records to remind and return the medical records of

patients who are not yet complete and periodically provide input to the

emergency room Praya Hospital . Audit findings regarding the

completeness of medical records IGD, both in Clause 4 of the quality

management system requirements, in accordance with that opinion,13 and

guidelines,9 which organizations establish, document, implement, and

maintain a quality management system ISO 9001:2000 and continually

improve effectiveness in accordance with standard requirements, clause 7

Product realization, clause 8 Measurement, analysis, improvement, does

not appear in a subsequent audit that shows the audit results are always

followed up and discussed in management review, and the quality

management system is implemented consistently.

From interviews to see the cause of emergency room services

Praya Hospital which is generally perceived performance tended to

increase after the implementation of quality management system ISO

9001:2000, felt after the implementation of ISO, IGD Praya Hospital may

work regularly use established standards to achieve the objectives to be

achieved in the ER quality objectives, but the results of the study,18 in

which hospitals are implementing ISO 9000 QMS is not all experience

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improved performance, as well as hospitals that implement CQI measures

do not all have an impact on hospital performance improvement.

Achievement of quality objectives IGD monitored and evaluated

through internal audits, management review, external audit, which

measures the performance does not automatically provide answers to how

well the actual performance of current and alternative fixes do not give to

be done and is simply a beginning point for further analysis,19

Changes in service performance Praya Hospital emergency rooms

as well as causing changes when viewed with the clauses of ISO through

interviews and checklists of compliance clauses of ISO 9001:2000, as in

the study,20 in which the ISO 9001:2000 quality management system can

be used as an indicator of performance by using ISO 9000 clause 4:20,

conducted in accordance with established standards and continuously

evaluated for improvement in order to improve the quality of services

provided, and in accordance with the guidelines,9 that the organization

that successfully manages to systematically and transparently to

determine the process that leads to improved organizational performance

and customer-oriented, and uses the principles of the eight quality

management, the organization will move toward improved performance.

CONCLUSION

From the results of research and discussion, and refer back to the

formulation of research questions and problems, it can be summed up as

follows:

1. There is a difference in the performance of emergency room

services Praya Hospital after the application of ISO 9001:2000

quality management system is seen from changes in the

emergency room service Praya Hospital performance before and

after implementation of quality management system ISO

9001:2000.

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2. Trend change in the performance of emergency services Praya

Hospital in general tend to increase after the certification of ISO

9001:2000 quality management system, but the performance of

emergency services Praya Hospital rooms of patients satisfaction

improvement has not reached the targets set in the ISO quality

objectives.

3. Changes in the performance of medical record completeness IGD is

quite dominant in the post sertfikasi ISO 9001:2000 seen from the

results change Praya Hospital emergency service performance and

conformance clause of ISO 9001:2000.

SUGGESTION

1.For Praya Hospital:

a. Implementation of ISO 9001 quality management system should be

implemented and evaluated consistently in order to improve service

performance Praya Hospital emergency room.

b. Applying ISO 9001 quality management in other units in order to

improve the environmental performance of hospital services Praya

Hospital as a whole.

c. Praya Hospital Management continues to implement ISO

9001:2000 quality management system has been updated with the

ISO 9001: 2008 with the proposed budget.

2.For further research:

Can be used a reference for future studies to better reduce the

flaws in this study that categorizes the response time in the triage criteria,

to evaluate the service performance of internal customer satisfaction /

employee IGD IGD financial performance and service, and involve the

relevant units / IGD support.

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