STUDY ON DIRECTOR ’ S POLICY ON DISCHARGE WAITING TIME OF INPATIENTS IN UNIVERSITY OF MUHAMMADIYAH MALANG HOSPITAL

Completion inpatient discharge administration is a combination of some unit performance in services of a particular patient in a hospital. Delay in inpatient discharge due to delays in the completion process of administration have an impact such as prolong the waiting time of inpatient discharge. Waiting time can change patient’s perception of the service quality of RS UMM. This study aims to determine the difference between waiting time of inpatient discharge service before and after enactment of director policy administration. This study is descriptive research with the research design use pre and post intervention. Development of data use observation in three (3) point of research, that is the ward, pharmacy, and cashier. The relationship between the director policy with inpatient discharge waiting time in RS UMM tested by using independent T-test in statistical software SPSS 20.0.The result showed no difference between waiting time of inpatient discharge services before and after implementation of director policy administration, although the data obtained that the waiting time before greater than waiting time after enactment of director policy administration (3,222 hours > 2,802 hours). The process of observation found another factor that suspected to affect the administrative process, they are the time of visiting from specialist over at 20.00 and under 07.00, the giving information of discharge patient not by the doctor in charge, a weak system of evaluation program by the managerial, and manufacture of prescription drugs that are not according with hospital formulary.

University of Muhammadiyah Malang Hospital (RS UMM) was experiencing fluctuation in the number of patients in every month for 3 years (2014)(2015)(2016).Although it is fluctuating, the number of inpatients tends to in-

Study on Director's Policy on Discharge Waiting Time of Inpatients
questions about the satisfaction of administration service.From the data obtained, 85% mention that the information on the administration of patient discharge or discharging patients from a hospital is in contrast to the actual time of discharge.The average obtained from the result of the interview with the discharged patient, it takes 3-4 hours to complete the administration process of discharge.Based on the Decree of Ministry of Health Number 129/ MENKES/ SK/II /2012 on Minimum Service Standard of Hospital, the information on inpatient's bill is given in d" 2 hours.The information on the billing information of inpatients includes all bills of services that have been given.The information on the bill of inpatient is given since doctor declares that the patient can be discharged from the hospital until the billing information is received by the patient.
Completing the administration of discharged patient is a series of processes which is very complex and is a combination of performances of several parts related to certain service of patients in the hospital.The administration process of discharged patient, which is done by cashiers in RS UMM, needs the confirmation of hospitalization room, installation of pharmacy, and supporting medical facilities.Hospitalization room does some things when the patient is allowed to go home; nurse completes resume of the patient, enter patient's data, waiting for a doctor visit, and put the emergency action and nursing actions first.When inpatient is discharged, hospital pharmacy waits for the remnant of drugs used by the inpatients from hospitalization room.In addition, hospital pharmacy prioritizes outpatient than inpatients.
The delay of inpatient discharge time, which is caused by the long process of administration completion, gives impact on the long discharge waiting time of inpatient.Finally, the delay affects patient satisfaction.Long waiting time can change the patient's perception of the service quality of RS UMM, especially for inpatients who want to complete the administration process fast (O, Connell et al., 2008;Zeitz& Tucker, 2010) According to the Ministry of Health Indonesia in 2012, waiting time is the time spent by health zation of hospitalization service of RS UMM has reached the standard of efficiency value.
The increase in the number of inpatient visits and BOR in RS UMM is followed by an increase in patient's complaints, particularly inpatient.Patient's complaints are increasing every month and reached the top in December 2015.A complaint which dominated in December was about the slow administration service.The complaints appeared because the demand for patient's health care is increasing.The demand for good service is not only for medical care, but also for administration service, financial management, and non-medical supporting element (Mulyono, 2002).Patient's complaint is the indicator and sign of dissatisfaction with the service of RS UMM.The dissatisfaction with service is caused by internal and external factors.Internal factors include doctor service, nurse care, speed service support, and administration.External factors are factors that affect the use of service, including geographical factors, such as the distance between patients and the place of service, transportation, cost, and opening hours (Supriyanto & Ernawati, 2010).
If the service offered is the service which is expected, then a patient is not interested in using the health care provider anymore (Ariadi, 2005).The patients who are not interested in using the health care provider anymore can express their dissatisfaction to other people, which finally form the perception of other people on the quality of hospitalization in RS UMM as a whole.
Parasuraman, Zeithaml, and Berry, as quoted by Kotler and Amstrong (2006) identify the gap between the perception of patient and the perception of hospital management, which leads to the failure of providing qualified service.Although quality improvement of health service has been conducted, especially non-medical service in the section of hospitalization, there are still complaints that appear.
The preliminary study which was conducted in January 2016 obtained data that there are 20% of patients who are not satisfied and 60% of patients are quite satisfied with the administration service.Those data were followed up with open workers in the hospital to provide services to patients.Waiting time is the problem which often leads to patient's complaints in several hospitals.Long waiting time reflects how a hospital manages the components of service adapted to the situation and expectation of patients.
To reduce the dissatisfaction of patients in waiting for administration process, change in the administration service for inpatient is required.One of the changes needed is shortening the waiting time of administration process of inpatient discharge in RS UMM.This change needs director's policy on the administration inpatient discharge in RS UMM.
The policy is fundamental instruction for employees in carrying out their job.With the policy, it is expected that employees do what they should do and work optimally.Carrying out task efficiently does not only rely on the ability/ skill, but it is also influenced by the work procedure, which contains the steps to do the task clearly.The guideline is an important factor in translating and interpreting the direction and policy that will be run (Notoatmodjo, 2003;Pahlevi, 2009).
This study aims to know and explains the difference of waiting time of administration service of inpatient discharge before and after the implementation of director's policy on the administration of inpatient discharge in RS UMM.
This research is expected to generate the results of the development of hospital management science and become consideration and evaluation of service for management in improving the quality of administration service of inpatient discharge.

METHOD
The type of this research is descriptive research, which was conducted by identifying the waiting time of administration service of inpatient discharge in every point of recording, including the point of recording in the field of treatment, the field of pharmacy, and in the field of cashier in RS UMM.This study also used the research design of pre and post intervention.The populations in this study were discharged inpatients in June -September 2016.This study used nonprobability sampling technique with purposive sampling, which is choosing samples from the population, which is in accordance with the goals and problems set in this research; therefore, the sample can represent the characteristics of the population.The total number of samples in this study is 100 respondents.
The variables in this research include director's policy as independent variables and long waiting time of inpatient discharge as the dependent variable.The data collection method includes primary data and secondary data.Primary data were obtained from observations in three points of administration process of inpatient discharge, which is the waiting time in hospitalization room (point 1), waiting time in the hospital pharmacy (point 2), and waiting time in cashier (point 3).The secondary data were obtained from the annual report and pre-intervention data.The implementation of director's policy consists of 4 stages, namely setting agenda, formulating policy, implementing policy, and evaluating the policy (Pitayarangsarit, 2004).
The data obtained from observations were recorded on the observation sheet.The average of waiting time, deviation standard, maximum and minimum value (in a minute) in each waiting time was analyzed in inpatients.Data analysis used to determine normal distribution was Kolmogorov-Smirnov (K -S).
Quantitative data about the mean of pre and post intervention were analyzed with SPSS 20.0 by using independent T-test, which is the test of difference of the average of 2 groups which are not paired and have a scale of interval/ ratio data.Independent T-test was used to test the difference before and after the implementation of treatment with the different sample.It used the value of significance/ P-value, if the value of significance/ P-value> 0.05 then Ho is accepted, if the value of significance/ P-value <0.05 then Ho is rejected.By using the comparison between t count and t table, the value of T table is obtained from  with a degree of freedom (df).If t count > t table, then Ho is rejected, if t count< t table, then Ho is accepted.

RESULTS
Data of the length of waiting time before the implementation of director's policy is secondary data; therefore, the waiting time in hospitalization room, pharmacy room, and the cashier cannot be separated.The entire administration process of inpatient discharge before the implementation of policy on inpatient discharge took 19452 minutes, see Table 1.From Table .5.1, it can be seen that patients need more than 120 minutes to process the administration of discharge in RS UMM, in fact, the time set by Decree of Ministry of Health Number 129 / MENKES/ SK/ II/ 2012 is  2 hours ( 120 minutes).
The entire patient discharge administration process after the implementation of director's policy took 156.89minutes (more than 120 minutes), which is in accordance with the time presented in Tabel 2. The average time required for the process in hospitalization room took 104.38 minutes.Very far difference between the shortest time and the longest time in three points of this research was due to the irregular schedule of doctor visit in inpatient room, the attempt of pharmaceutical officer to get drug which is appropriate to doctor's prescription, and cashier who coordinates by coding if there is the case of cost sharing for BPJS patients.
Based on the results of independent T-test, it can be seen in Table 3, which normality of data has been tested, that there is no difference between the

Hospitalization room
Complaints about a long waiting time of inpatient discharge administration process are received by many parties; one of them is a nurse in hospitalization room.When a patient has utilized a service, the patient will assess the service by comparing the expectation with the fact experienced by the patient.In the theory of expectation-fact, it is mentioned that if the fact is in accordance with the expectation, consumers will be satisfied, if the fact exceeds the expectation, consumers will be very satisfied, and if the fact is not in accordance with the expectation, consumer will be disappointed (Devi &Listyowati, 2014).The lack of standard service of inpatient discharge makes nurse act as the habits in each hospitalization room.

Pharmacy
There is still no policy governing the service process on the drug.The pharmaceutical officer knows Decree of Ministry of Health Number 129/ MENKES/ SK/ II/ 2012 on pharmaceutical services, stating that the waiting time of drug concoction 60 minutes and finished drug 30 minutes, but because there is no policy about it, pharmaceutical officer works without a standard in serving drug.The pharmaceutical information system in RS UMM is made by IT personnel there.Error in data entry mostly occurs in hospital pharmacy.As a result, the cashier cannot process bill repayment of patients through a system, therefore the cashier processes it manually.

Cashier
Principally the process of administration service of inpatient discharge in cashier is waiting until the administration process in hospitalization room and pharmaceutical are completed.If those two units have been completed, the administration process in cashier is processed quickly.

Illustration of Implementation of Director's Policy on Inpatient Discharge Administration Process in RS UMM
Strategic policy of hospital as Decree No. 003/ SK.Keb/ RS-UMM/ VI/ 2016 is expected to overcome the problems related to waiting time of inpatient discharge administration process.Policy about service of inpatient discharge administration requires employee engagement to improve the ability of the organization and provide value to customers.This condition is also because human factor is the most important dimension in improvement and product quality (Wijayanti&Damayanti, 2013).
The research which was conducted in RSUD BudhiAsih East Jakarta explained that working efficiently does not only rely on the ability or skill, but it is also influenced by work procedure containing clear job description.The guideline is the most important factor in determining the direction, policy, and strategy that will be run.Therefore, the policy of administration service of inpatient discharge is socialized to related sectors (Pahlevi, 2009).
Socialization is a fundamental factor in the implementation of a new procedure.Socialization is a place to learn about a new procedure.Learning, for every hospital officer can increase their technical skill, professional expertise, and the quality of service (Wijayanti&Damayanti, 2013).
Cooperation of everyone on each layer is needed to improve the quality and can be carried out if the top management totally commits to working (Wijayanti&Damayanti, 2013).
Commitment to service quality should be started from the top of the institution.This means that the program makers have to be committed to the program, even they have a different level of perception on the importance of program implementation.The commitment of program makers has to be communicated to all employees who can participate and has the same commitment to the program implementation (Wijayanti & Damayanti, 2013).
Commitment made by management is in the form of program supervision.Supervision conducted aims to know the progress of the program, whether it is in accordance with the plan that has been set or not, know problems arising in the implementation, and solve problems arising.The supervision by RS UMM management is not optimal because the results of supervision have not been submitted to the work unit staff, so automatically there is no clear and firm instruction from boss to improve the performance of employees in achieving a goal (Sukmawan & Indrayathi, 2014).
However, from the observations on a nurse, it is known that all nurses convey the Operational Procedure Standard (SPO) of information on waiting time of inpatient discharge to patient and patient's family.Giving information on waiting time of inpatient discharge to patient's family can minimize dissatisfaction of patient to the administration service of inpatient discharge (Sanjaya&Suarjana, 2013).Giving information to a patient on how long they will wait can improve the perception of the patient about a positive experience on health care (Dansky& Miles, 1997).

Illustration ofInpatient Discharge Administration Process after the Implementation of Director's Policy on Inpatient Discharge Administration Process in RS UMM Hospitalization room
When a patient is discharged from hospital by a doctor in hospitalization room, doctor completes medical resume in the file medical records of the patient and writes a prescription for outpatient if necessary.Then, nurse starts to do the administration task prepare the drug that will be returned to the hospital pharmacy, complete the status of patients in the medical records (RM), enter data of doctor visit, and write check up a letter and discharge planning.The remnant of the drug in the hospitalization room is returned to the hospital pharmacy and the file of medical record is sent to cashier.If the process has been completed, the nurse will tell the patient's family that the administration of inpatient discharge can be paid, and the patient can go home.
The first process of inpatient discharge in RS UMM consists of: a) the time required for doctor to inform that patient is allowed to go home b) time required for nurse to finish the administration process of inpatient discharge, including: outpatient's prescription and the remnant of drug that is not used by patient, patient's check up letter, filling discharge planning, doctor's treatment and care.Outpatient's prescription and the remnant of drug that is not used by the patient are given to hospital pharmacy, and the file medical record is given to the cashier.
There is a problem in the process above if doctors visit at the same time, which is at 20.00 pm, and visit below 07.00 am.An irregular doctor visit is not in accordance with Decree of Ministry of Health Number 129 of 2012 on Hospital Service standard, stating that the visiting hour of specialist is from 08.00 to 14.00.
In addition, the patient needs long waiting time in discharge administration process because the patients with the status of shared care have to wait for doctors responsible for their treatment, whether they can be discharged or not.This condition affects the perception of the patient about the waiting time for discharge because the one informing patient discharge is not the doctor responsible for patient's treatment (DPJP), but the first doctor who visit in that day.Perception is the process of someone in choosing, organizing, and interpreting a stimulus into a picture, which is meaningful and consistent with what has been one's way of thinking (Nugroho&Rochmah 2013).
Based on the observations done by the researchers, it is obtained that the process in nursing requires average time of 104.38 minutes to be able to complete the administration process since the last entry done, pharmaceutical officers have to wait for IT officers to revise the incorrect data.Unfortunately, IT officers are not in the hospital for 24 hours.Pharmaceutical officers deliberately do not connect the data to the cashier because they wait for confirmation from hospitalization room about the addition of patient's new prescription.If this happens, it will lead to longer waiting time.

Cashier
There is the condition in which BPJS patient is located in hospitalization room which is not appropriate to his/ her class.This situation allows cost sharing, which has to be done to determine the amount of the remnant of fees which have to be paid by the patient.According to the procedure, if there is the case of cost sharing, then the coding unit of RS UMM will verify the medical service, which takes a long time.

Waiting Time of AdministrationService before and afterthe Implementation of Director'sPolicy onInpatient Discharge Administrationin RS UMM
Measurement of the success of policy implementation can be seen from the process, which is the success of program implemented by staff and the success of the program objectives.In addition, it is described further that there are 3 concepts related to the success of policy implementation, namely: adherence level, a level of the continuity of activity, and the expected impact (2007).
Principally, the implementation of Operational Service Standard (SPO) of inpatient discharge administration service is a part of performance and individual's behavior in working in accordance with his/ her duties in the organization and usually related to adherence.Adherence is a social influence in which individual's activity or action is a response from direct command of other individuals as an authority figure.The adherence of officers in hospitalization room, pharmacy, and the cashier is the behavior of a professional on the suggestion, procedure, or regulation which should be done or obeyed (Ulum&Wulandari, 2013).
doctor visit.This condition is not much different from the results of research conducted in RS QadrTangerang, which takes 85 minutes for administr ation process in hospitalization room (Mutiarawati, 1996).There is no difference of the length of administration process of inpatient discharge in RS UMM is, between patients with long LOS and short LOS.This result is in contrast to the research conducted in RS GrhePermata Ibu Jakarta, that giving information on billing to the patient will be the longer if the patient is treated for a longer time.

Pharmacy
The process in pharmacy is started when a pharmaceutical officer receives outpatient's prescription and the remnant of drug which is not used by the patient from nursing section up to finishing data entry to the computer.The process is completed if there is confirmation to the cashier.If there is outpatient's prescription, then the officers prepare the drugs needed.If all drugs needed are available, then the prescription can be processed directly.
Based on the research which has been conducted, the average time required for the process in hospital pharmacy is 44.28 minutes.The fastest process can be done within 3 minutes and the longest process can be done within 159 minutes.agap between the fastest time and the longest is caused by a few things, including: a. Regarding the remnant of the drugs which are not used, officers take longer time, especially if the remnant of the drugs which are not used coming from patients who are hospitalized for a long time.The remnants of the drugs which are not used are checked to see patient's drug use with the number and type of the remnant of the drugs which are not used.Checking is done since the patient is hospitalized until the last day the patient was treated.The problem occurs because the computer system in hospitalization room and hospital pharmacy is still not integrated, so pharmaceutical officers have to rewrite the patient's drug use.b.Error in the data entry conducted by pharmaceutical officers.If there is an error in the data From the observation, it is obtained information that nurse, pharmaceutical officer, and cashier understand their own tasks in running the procedures of inpatient discharge administration service.This condition is evidenced by the objective of inpatient discharge administration services which has been achieved, which is waiting time of inpatient discharge administration process which is getting shorter.It influences patient satisfaction.
The research conducted by Rahmawati and Supriyanto (2013), confirms that the speed of medical and non-medical service is one of the variables that cause patient dissatisfaction.Speed in is required both in medical and nonmedical service, especially for the patient who is allowed to go home, but he/ she takes a long time to go home because of long administration process (Nugroho&Rochmah, 2013).
An activity that runs smoothly and the implementation of policy on inpatient discharge administration service cannot be separated from the function of manager in supervision.Supervision is a process to continuously oversee the activities of staff in carrying out the work plan that has been prepared and hold makes a correction if there is a mistake.The better the process of supervision, control, and assessment, then the achievement of indicators that meet the target is getting better.The low process of supervision, control, and assessment will affect the performance of the program in meeting the indicator target of the work program (Siriyei & Wulandari, 2013).
Three concepts which have been described have been met in this study, but there are several factors found by researchers in the process of observation, which may affect the administration.Those factors are the visiting hours of specialist above 20.00 and below 07.00, information on inpatient discharged that is not given by the doctor responsible for the patient, weak program evaluation system of management, and drug prescription that is not in accordance with the formulary of the hospital.

CONCLUSIONS AND SUGGESTIONS
The results of this research using T-test independent test show that there is no difference in waiting time of administration service of inpatient discharge before and after the implementation of director's policy in RS UMM.However, there is a difference in the average of waiting time.The average waiting time before the implementation of director's policy is 3.222 hours and average waiting time after the implementation of director 's policy is 2.802 hours, meaning that the average of waiting time before the implementation of director's policy is longer than the average of waiting time after the implementation of director 's policy (3.222> 2.802).
In addition, from the result of observation, there are several causes of long waiting time of the administration of inpatient discharge obtained, which is the visit of doctor above 20.00 and before 08.00, the information about the discharge of shared-care inpatient is not delivered by DPJP, drug permeation is not in accordance with the formulary of RS UMM, and pharmaceutical information systems and hospitalization room is not connected which causes waiting time for the addition of patient's prescription and re-write in hospital pharmacy on the use of drugs by inpatients.
The suggestions for RS UMM to improve the administration service of inpatient discharge in RS UMM are: 1) evaluating director's policy on the administration of inpatient discharge in RS UMM, 2) making policy on the visiting hour of specialists, 3) adding SPO about the delivery of inpatient discharge by doctor responsible in shared-care patients 4) re-reviewing and re-socializing the formulary of the practice of doctor in RS UMM 5) manufacturing integrated information system between hospitalization room, pharmacy room, and cashier.

Table 1 Statistic of length of time in giving infor- mation of patient billing before the imple- mentation of policy
Source: Processed data in 2016