Strategic Plan for the Development of the RS Bersalin Grha Mutiara in 2019-2023 : Policy Implementation

This research discusses the Strategic Plan for the Development of the RS Bersalin Grha Mutiara in 2019-2023, using the theory of Strategic Planning to observe and evaluate external environmental opportunities and threats as well as the internal strengths and weaknesses of the hospital, to determine the right strategic plan. This study is a qualitative research using primary data, in-depth interviews with informants, observation and decision making with CDMG (Consensus Decision Making Group), and secondary data obtained from the BPS (Central Bureau of Statistics), Dinas Kesehatan Subang (District Health Office) Profile, Profile and Financial Report of RS Bersalin Grha Mutiara. From this study, the position of RS Bersalin Grha Mutiara, according to IE Matrix, is in Cell V (Hold and Maintain) and SWOT Matrix in Quadrant II (Internal Fixed It Quadrant). The matching stage resulted in a Product Development strategy, which, through the QSPM matrix, determine that the chosen strategy would be the development of HCU / NICU / PICU. This plan then elaborated in the implementation plan using the Balanced Scorecard.


INTRODUCTION
The hospital is a health service institution that conducts individual health services in a comprehensive manner providing inpatient, outpatient, and emergency services (Law No.44 of 2009 on Hospitals). Hospital, a health service facility that uses heavily on technologies and experts, plays a strategic role in accelerating the improvement of public health status. In order to survive and developed, a hospital must adapt to the growth and influence of the environment. The hospital management paradigm must be changed to be effective, efficient, and can accommodate change (Aditama, 2010).
In the Minister of Health Regulation No. 56 of 2014 concerning Hospital Classification and Licensing, the definition of Specialized Hospital is a hospital that provides primary services in one particular field or type of disease based on scientific discipline, age group, organ, gender or other specificities. In addition to the types of specialized hospitals stipulated in article 59, the Minister may stipulate other types of specialized hospitals, which can be in the form of a combination of specific types of new types of specificity based on studies and obtain recommendations from hospital associations and related professional organizations. With the increasing number of General Hospitals in the Subang Regency, efforts must be made to obtain and maintain sustainable competitive excellence, by continuously adapting to changes in trends and external activities and capabilities, competencies, and internal resources as well as by effectively formulating, implementing, and assessing various strategies that further strengthen these factors.
Maternity Hospital has limitations in serving maternal hospitalization with obstetrical and uterine cases as well as neonates, an effort should be made to continue to survive by always developing themselves, for example by developing into RSIA so that it can provide inpatient services for children (aged 0-14 years) or General Hospital with the addition of other types of specialist services. With the change to a General Hospital that has a variety of services, it is expected to increase both outpatient and inpatient visits.
Essential strategy formulation techniques can be integrated into a three-stage decision-making framework consisting of stage 1, the Input Stage containing the necessary information needed to formulate a strategy.
Stage 2, the Matching Stage, focuses on creating alternative strategies that make sense by taking into account the main external and internal factors, including the Strength-Weakness-Opportunities-Threats-Threats-SWOT matrix, Strategic Position and Action Evaluation (SPACE), Boston Consulting Group (BCG) Matrix, Internal-External Matrix (IE).
Stage 3, the Decision Stage, involves only one technique, the Quantitative Strategic Planning Matrix (QSPM), showing the relative attractiveness of various alternative strategies, thus providing an objective basis for the selection of alternative strategies.
The Balanced Scorecard consists of two words: (1) a scorecard and (2) balanced. Balanced Scorecard uses four perspectives in measuring performance which are financial perspective, customers, internal business processes, and learning and growth (Kaplan and Norton, 2000) The role of the Balanced Scorecard in the programming and budgeting stages of making strategic objectives that are formulated comprehensively in the strategic planning stage will motivate personnel to look for various strategic initiatives in realizing these broad strategic goals. The role of the Balanced Scorecard in the implementation phase is used for personnel performance in four perspectives, which are finance, customers, business processes, and learning and growth. While at the monitoring stage, the results of performance measurements of personnel in the four perspectives are compared with targets set in the budget and targets set in strategic planning. (Ayuningtyas, 2015) Methods This study is an Operational Research with qualitative data analysis which analyzes external and internal conditions in the development plan of the Grha Mutiara Maternity Hospital. Data and information used in this study were primary data and secondary data. Primary data were collected qualitatively by conducting in-depth interviews (in-depth interviews) and CDMG (Consensus Decision Making Group). Secondary data were collected from the Subang Regency BPS, Subang District Health Office, internal data from the Grha Mutiara Maternity Hospital. The study was conducted at RSB Grha Mutiara on Jln. Brigadier General Katamso No. 4 Subang. The study began on 30 November 2018 -1 June 2019.
Changes in hospital operating permits can be made when there is a change in ownership, type of hospital, name of the hospital, and classification of the hospital. In the Regulation of the Minister of Health Number 56 of 2014 Article 79 (d), stipulated that Specialized Hospitals that use names other than those specified in article 59 paragraph 1, must adjust to the provisions no later than one year after the Regulation of the Minister of Health is promulgated.
The purpose of this study is to formulate appropriate strategic planning in the development of Graha Mutiara Maternity Hospital with a strategic planning approach from Fred R. David through external and internal situation analysis. Analysis using this Balance Scorecard approach can identify strengths, weaknesses, opportunities, threats, and strategic positions, to produce several alternative strategy recommendations and translate the selected strategy into a work program.

Literature Review
Strategic management, according to David (2010), is the art and knowledge in formulating, implementing, and evaluating cross-functional decisions that enable an organization to achieve its goals. So from that understanding, strategic management focuses on efforts to integrate management, marketing, finance, production/operations, research, and development as well as computer information systems to achieve organizational success.
According to Hunger and Wheelen (2003), strategic management is a series of managerial decisions and actions that determine the company's performance in the long term, which includes environmental observation, strategy formulation, strategy implementation, and evaluation and control. Strategic management as a field of science that combines business policy with the environment and strategic pressure.
The benefits of strategic management, according to David (2010), for financial and non-financial, allows an organization to be more productive in directing and influencing various activities, thereby controlling its destiny. Strategic management helps organizations formulate better strategies through approaches to strategy choices that are more systematic, logical, and rational. Businesses that adopt strategic management show improvements in sales, profitability, and productivity, usually showing relatively better longterm financial performance. In addition to avoiding financial disasters, strategic management offers other tangible benefits such as raising awareness of external threats, improving understanding of competitor strategies, increasing employee productivity, decreasing resistance to change, and a clearer understanding of the reward performance relationship.
This study uses the theory of strategic planning from Fred R. David with modifications to adjust the conditions of the hospital where the study. After the primary and secondary data were collected, then data analysis proceeds as follows: a. Input Stage The data were grouped according to the variables, then the results of data processing are conveyed in the CDMG to identify the factors that become opportunities, threats, strengths, and weaknesses then determine the critical success factors.

b. Matching Stage
This stage is divided into two stages. First is the matching stage with two matrices (TOWS Matrix and IE Matrix) to determine the position of competitiveness along with strategy recommendations. Then the second stage is asking the CDMG members to provide input on the possibility of developing the Grha Mutiara Maternity Hospital with proposed alternative activities following the recommendations of the strategy.
c. Decision Stage CDMG will determine the possibility of developing Grha Mutiara Maternity Hospital. Several alternative activities will be analyzed using QSPM analysis based on priorities by making a list of critical factors taken directly from the IE matrix and then assigning points to each of the external and internal factors. The process then followed by determining the value of attractiveness (Attractiveness Score), which indicates the relative attractiveness of one activity against other activities.

d. Implementation Plan Stage
After using the QSPM matrix priority to determine the strategy, then the strategy elaborated in the work program along with the KPI and its size with four Perspectives from the Balanced Scorecard, which are financial, customer, internal business and learning growth perspectives.

Results
In this section, we will discuss the results of the research consisting of the Input Stage, which is the analysis of external and internal factors, the Matching Stage, which consists of the IE Matrix, the TOWS Matrix, Position and the determination of Alternative Strategies. In the Decision Stage (Decision Stage), which consists of determining the chosen strategy and decision making with QSPM, then finally for the Strategy Implementation Plan with the Balanced Scorecard approach for the next five years.
External factors that will be assessed are Government Policy, Geography, Demography, Epidemiology, Economy, Education, Technology, Competitors, Suppliers, and Customers.
After identifying external factors, the variables will be grouped as an opportunity or threat to the development of Grha Mutiara Maternity Hospital through CDMG with the Director and the Head of the Department.
Critical success factors that exist will be given a point that ranges from 0.0 (not important) to 1.0 (very important). This point indicates the relative significance of a factor in the company's success. The amount of point given must be 1.0 (one). A rating of 1 to 4 will be given on each significant external factor, to find out how effective the company's current strategy is in responding to these factors, where 4 = very good response, 3 = above average response, 2 = average response, and 1 = response below average. Ratings are based on the effectiveness of the company's strategy. (David, 2010) From the list of available opportunity and threat factors, a critical success factor is determined, and the total points and rating of each factor are determined, as in the table below: From the list of strengths and weaknesses, then the critical success factors were determined by adding points and rating to each factor, as in the table below: We determine the points of each critical success factor, between 1.0 (very important) to 0.0 (not important). Then, we determine the rating on a 1-4 scale based on the influence of the factors to company condition. Variables that are strengths are rated 1 to 4 (very good) by comparing it with industry or competitor averages while the negative variable is the opposite.
The total value obtained from the IFE matrix is 2.06, and the EFE matrix is 2.95. So based on the IE matrix is in quadrant V which is Hold and Maintain (maintain and maintain), the recommended strategies are Market Penetration and Product Development.
Based on the TOWS matrix, the opportunities are more significant than threats, and weaknesses are more considerable than internal strengths. So that the TOWS Matrix is in quadrant II, which is the Internal Fixed It Quadrant.
Then the strategy recommendations obtained from the TOWS matrix and IE matrix are Product Development (Product Development), which is a strategy by seeking to increase sales by improving or modifying existing products or services.
From the results of the CDMG, several alternative activities will be developed to become the chosen strategy, which are: The results of the CDMG said that adding variations in specialist services will increase the number of patient visits so that it impacts on revenue and profit growth.
In the decision-making stage, the chosen strategy uses QSPM (Quantitative Strategic Planning Matrix) to determine priorities that can be implemented using critical success factors on the IFE Matrix and the EFE Matrix. The result of point multiplication and the Attractive Score (AS) with the highest total is the top priority.
On the Determination of the Atractivenes Score (AS) on 1-4 scale, score 1 means the variable is not attractive, or there is no correlation, and score 2 means it is likely to be attractive, or there may be any correlation. Then, score 3 means it is attractive, or there is a correlation, and score 4 means it is the most attractive or most correlated.
The results of the proposed alternative activities QSPM, this is the following priorities:

Geography
The location Grha Mutiara Maternity Hospital is among public facilities such as densely populated housing, offices, supermarkets, and educational facilities such as kindergarten, elementary, junior high, high school to Subang University. These conditions make it easier for the Subang community to access services at Grha Mutiara Maternity Hospital and support for service development.

Demographics
Demographics affect the mindset, behavior of people, and organizations. The population is relatively fast to develop, therefore, organizations that are influenced by population (density or infrequency) are also relatively fast to develop (Rivai, 2015). There are more than 50% of the productive age population and children in the Subang Regency, which is an opportunity for Grha Mutiara Maternity Hospital to develop its services, especially for productive age and child health.
Hospitals are organizations that are affected by population demographics. With the increase in population, the hospital will be affected by the increasing public demand for health services. The total number of beds is 731 beds for a population of 1,546,000 people, so the ratio of 1 bed is intended for a 2,115 population. The ratio is still not ideal, according to the Indonesian Ministry of Health, which is 1: 1000. This is an opportunity for Grha Mutiara Maternity Hospital to develop its services.

Epidemiology
Many diseases found are in a general category.

Economy
A critical economic variable for hospital development opportunities is community income. Most community services are standard goods, so an increase in family income will increase demand for health services (Trisnantoro, 2005). With the increasing economic growth of the Subang Regency, it becomes an opportunity to develop Grha Mutiara Maternity Hospital in meeting the community's need for quality health services.

Education
The low awareness of the importance of education in the Subang District community, whereas with a higher level of education, will increase the ability to think in absorbing health information. Awareness of the importance of health will also help to make decisions in choosing the right health services. The low level of education is a threat to the development of Grha Mutiara Maternity Hospital.

Technology
In providing maternal and neonatal health services with rapid development in health technology, can be an opportunity for hospitals as health care providers in providing high-quality services to patients. Many technologies are developing in the field of obstetrics and gynecology, such as Reproductive Health technology in handling infertility, Fetomaternal in the prevention and early detection of genetic diseases, as well as parts of Gynecological Oncology, Reproductive Endocrinology, and Reconstruction Urogynecology. Those developments are currently integrated with a child health service called the Maternal and Child Health Service (PKIA).
The development of health technology that will provide convenience in supporting examinations for diagnostics or in the management of therapies and intervention is an opportunity in the development of Grha Mutiara Maternity Hospital.

Competitors
The number of hospitals in the Subang Regency is ten hospitals with a total number of beds of 731 beds to a population of 1,546,000 people, so that the ratio of 1 bed is for 2,115 people. The ratio is still not ideal, according to the Indonesian Ministry of Health, which is 1: 1000. With only 1 (one) specialized hospital, Grha Mutiara Hospital in Subang, which focuses on maternal and child health services, this is an opportunity in developing Grha Mutiara Maternity Hospital.

Suppliers
Suppliers for hospitals is ranging from producers of drugs and medical equipment to professional doctors (Trisnantoro, 2005). Good collaboration with suppliers of medicines and medical devices will become an opportunity for the development of Grha Mutiara Maternity Hospital. The limited supply of health workers, particularly in skilled and experienced 81 intensive nurses, is a threat to the development of Grha Mutiara Maternity Hospital.

Customers
The 2017 visitation data of Grha Mutiara Maternity Hospital showed that 99.7% of outpatient and 89.3% of inpatient visits are coming from Subang Regency, and 0.3% are from neighboring districts such as Indramayu, Purwakarta, and Sumedang. All of the patient's visits also dominated by Subang Subdistrict that is 32.8% of inpatient and 26.8% of inpatient care. Customers that are not only from Subang Regency but also surrounding areas such as Indramayu, Sumedang, and Purwakarta, which has excellent satisfaction, is an opportunity to develop Grha Mutiara maternity hospital.
Analysis of internal factors that will be assessed are these variables:

Vision and Mission
With the enactment of Permenkes No. 56 of 2014 for the extension of Grha Mutiara Hospital's maternity hospital operational permit, it is necessary to have a vision and mission if it is going to be developed into a Mother and Child Hospital. The vision and mission that already have been set are relevant because it is following the development goals, and it has superior maternal and child health services that in line with the goals.

Organization
The success of an organization in the ability to achieve predetermined goals is affected by external and internal organizational factors (Wibowo 2016).
In law No. 44 of 2009 article 33 paragraph 2 states that the organization of the hospital consists of at least the Head of the Hospital or Hospital Director, Medical Services components, Nursing components, elements of Medical Support, Medical Committees, Internal Audit Unit (SPI) and General Administration and Finance. The organizational structure of Grha Mutiara Hospital Maternity, in general, follows the applicable regulations, but there is no Internal Audit Unit (SPI) that has the authority to supervise and nontechnical development within the hospital. The hospital organization is one of the weaknesses because it still needs to add human management resources to comply with applicable regulations.

Finance
Hospital financial statements describe the financial condition and hospital operational result in a certain period (Suyanto, 2018). Financial statements in the form of a balance sheet, activity report, and cash flow statement can provide information about the overall financial condition of the hospital.
Grha Mutiara Maternity Hospital does not have a budget plan; it is a weakness that needs to be addressed because in achieving the hospital's objectives, one must consider several factors, which are the source of funding used, the potential income from service products, short-term, medium-term and long term income projections. The form of budget planning should be in the form of a Feasibility Study and Business Plan.

Marketing
Market segmentation of Grha Mutiara Maternity Hospital is a productive age woman and elderly who need midwifery and obstetric services in Subang Regency and also 0-14 years old children because there are child health clinic services that provide services for them.
Distribution channels are still limited because there is no collaboration with insurance or companies. The data above shows the absence of marketing is a weakness of Grha Mutiara Maternity Hospital in the development of Grha Mutiara Maternity Hospital.

Health Care Products
Grha Mutiara Maternity Hospital has a 4D ultrasound service and Perinatal services that can handle category IIA sick babies, which are cares for newborns more than 32 weeks' gestation with physiological immaturity problems with mild disease. These healthcare services are an excellent opportunity to develop Grha Mutiara Maternity Hospital. While unavailable medical support facilities, such as radiology services, are a weakness in the development of Grha Mutiara Maternity Hospital.

Human Resources,
Human Resources is a vital hospital asset and is a resource that plays a significant role in hospital services (Sabarguna, 2011 Performance is the appearance of the work of personnel in an organization. It is necessary to evaluate the work of personnel with performance appraisal instruments in order to obtain information on the effectiveness of HR management and for the interest in making decisions on personnel development such as promotion, transfer, rotation, termination, and compensation adjustments (Ilyas, 2012). The 2018 inpatient satisfaction survey with 125 respondents resulted in 88.9% of the respondents stated that the service was good, 10.8% was quite good, and 0.3% was not good.
Registration is still in a manual system where the patient comes and then queuing for a doctor's examination. Grha Mutiara Maternity Hospital has not optimized the technology for text messages notifications to reduce queues in the waiting room, and the disciplines of medical personnel are still needed to increase.

Conclusion
Based on the strategic plan discussion results in the previous section, the conclusion is that it is currently feasible to develop the Grha Mutiara Maternity Hospital into a Mother and Child Hospital. The background of this development plan is the absence of classification of maternity hospitals in Permenkes No. 56 of 2014, the existence of maternal and infant mortality rates, and infrastructure and human resources that are available today.
Development of Grha Mutiara Maternity Hospital into a Mother and Child Hospital through the preparation using Fred R. David's strategy management model consists of 3 (three) stages, which are the input stage, matching stage, and decision-making stage. The final step is the strategy implementation plan of the chosen strategy with the Balanced Scorecard approach.
The analysis of external factors from the EFE matrix resulted in a score of 2.95, and internal factors of the IFE matrix is 2.06. The matching stage with the TOWS Matrix shows that the position of Grha Mutiara Maternity Hospital is in quadrant II, which is the Internal Fixed It Quadrant, while in the IE matrix, it is in cell V which is the Hold and Maintain strategy. The chosen strategy is Product Development, then from QSPM analysis resulted in HCU / NICU / PICU service development as a top priority.

Recommendation
After determining the objectives of the next implementation strategy, we suggest that: A. For related institutions 1. Preparation of a feasibility study for the development of the Maternity Hospital into a Mother and Child Hospital.
2. The selected strategy is then developed in an annual program in each section/unit to be implemented and evaluated.
3. Conduct a cost analysis and then prepare a financial and funding plan related to the planned activities 4. In determining intensive service product costs (HCU, NICU, PICU), it is necessary to pay attention to Unit Cost Analysis.
5. Creating a comprehensive marketing plan for available service product marketing.
6. The addition of other specialist services to increase outpatient visits. For example, Internal Medicine Doctors, due to the cases of infection and degenerative diseases that are still high in Subang Regency. Also, adding more surgeons, ENT, and ophthalmologists to increase the utilization of the operating room.
7. Adding more examination services (clinical and radiology laboratories) in both equipment and personnel as supporting services that can increase revenue with operational collaboration.
B. For further research 1. Marketing plan by analyzing the target segmentation of service positions at Grha Mutiara Maternity Hospital.
2. Hospital performance assessment through the application of both unit and individual Key Performance Indicators (KPI).