Analysis of Discharge Planning Implementation at Siloam Hospitals Balikpapan

This study aims to analyze the implementation of discharge planning at Siloam Hospitals Balikpapan in 2018. The type of research conducted is a mix method research. The sample of this study was taken with a total sampling of patients in the Inpatient Installation which was then observed on 260 medical record documents to determine the percentage of completeness of filling items and the timeliness of returning medical record files, then 7 (seven) informants. The results showed that the results showed that the implementation of discharge planning at the Siloam Hospital Balikpapan inpatient had not been running according to the standards set by the hospital, namely 100%. In the discharge planning implementation, the most influential factor is the human resource factor, seen from the discharge planning cycle implementation from the initial HR involvement to the end. It is recommended for hospital management that the parts that are still not appropriate (14.5%) to be evaluated further, so that the causal factors can be immediately corrected. For the implementation of communication, it is necessary to convey clearly and accurately related to the information provided so that it is easy to understand and run in accordance with policy objectives such as holding regular socialization so that health workers understand the outline of the purpose of implementing this discharge planning.


Introduction
In Law Number 44 of 2009 concerning Hospitals it is explained that hospitals must regulate hospital governance and clinical governance so that they can become effective, efficient and accountable hospital organizations. This aims to ensure the quality of service and patient safety in the hospital.
Since January 1, 2014, the implementation of the National Health Insurance (JKN) program run by the Health Social Security Administration (BPJS) in accordance with Law Number 24 of 2011. Hospital accreditation policies in Indonesia have long been implemented since 1995, and revisions have been made and refined with the 2018 edition of the National Hospital Accreditation Standard.
In the assessment of hospital accreditation, discharge planning is an instrument as one of the assessment requirements. Discharge planning is one of the nursing intervention programs that begins when the patient arrives with an acute illness or a terminal illness to provide opportunities for patients to carry out independent care when returning home (Fox 2013). Hospitals often return patients with poor planning (Closs & Mphil 1993).
Discharge planning has been implemented in several countries for a long time, such as in Australia the implementation of discharge planning since 1998 with the aim of encouraging health care providers to review and improve health care processes and practices, while in the UK the patient care planning system must obtain discharge planning since 2004 (Wong, 2011). Discharge planning that is carried out in a structured manner can improve functional abilities, improve quality of life, psychosocial well-being, social support, satisfaction in health care, cost effectiveness and reduce re-admissions (Courtney, 2011).
Research findings that discharge planning is necessary in patients in transition (Graham et al. 2013). In implementing a quality discharge planning, first of all, it is necessary to know the needs of patients and nurses in carrying out discharge planning. This is influenced by many factors, such as from nurses, patients themselves, and other professionals.
The process of implementing an effective and comprehensive discharge planning can reduce the risk of death for patients, hospital costs, length of stay for patients, re-admission, functional damage due to patient's illness, patient and family anxiety after discharge, complications and increase patient, nurse and family satisfaction (Cherlin 2013;Fitzgerald 2011;Hager 2010;Gonçalves-bradley et al. 2016;Wales 2012).
Improper discharge planning can have a negative impact on patient discharge, resulting in long waiting lists for other patients and increased costs (Kamalanathan, 2013). Patient discharge is an important time for patients because of the possibility of errors in care after their hospitalization. The study found that one in five patients discharged from the hospital experienced at least one side effect within 30 days of hospitalization, 66% of which were drug-induced (Snow et al. 2009).
Based on the initial study on the implementation of discharge planning at Siloam Hospitals Balikpapan, the implementation was carried out at the beginning of the patient's admission to the inpatient unit using the available form. The contents of the form include the patient's condition, medications, and length of treatment as well as complications that may occur. The filling of this discharge planning sheet is usually not completely filled out. The initial assessment of inpatients is usually not given education on treatment planning, conditions, and so on.
Siloam Balikpapan Hospital is one of the private hospitals in Balikpapan City, with a total of 165 beds and a Bed Occupation Rate (BOR) for the last three years (2016-2018) of 54%, 62% and 47 respectively. % but the percentage of completeness of filling in patient medical records never reaches 100%. Based on the description above, the researcher is interested in conducting research on the implementation of the discharge planning program at Siloam Hospital, Balikpapan.

Methods
This research was conducted at Siloam Hospital, Balikpapan. The type of research in this study is a mix method research. The population of this study was taken with a total sampling of patients in the Inpatient Installation which was then observed on 260 medical record documents to determine the percentage of completeness of filling items and the timeliness of returning medical record files as quantitative data and interviews with 7 (seven) informants as qualitative data.
The instruments used in data collection are interview guidelines, document review and direct observation for qualitative data, then for quantitative data are 260 medical record documents. The data analysis was carried out by collecting all patient discharge plan sheets, grouping discharge plan sheets based on their disease, analyzing discharge plan sheets based on incomplete fillings, Conducting in-depth interviews with selected informants related to discharge plan SOPs, objectives, implementation process and follow-up implementation, Stages third, observing the filling technique and the implementation of the discharge plan in the inpatient unit.

Results and Discussion
As for the results of the discharge planning implementation at Siloam Hospitals Balikpapan inpatients, the overall discharge planning implementation at Siloam Hospitals Balikpapan inpatients has not been implemented in accordance with the policies that have been made. Compliance in the filling and implementation of SOPs has not yet reached the target with the achievement at the time of the study which was 85.5% where the SOP was declared complete if the step by step procedure was carried out completely This research is a qualitative research with a case study design which is intended to determine the implementation of discharge planning in inpatients at Siloam Hospitals Balikpapan.

Communication
The communication referred to in this study is an activity in interaction that involves behavior and allows individuals to relate to other people. There are 3 dimensions in the communication factor, namely the Information Delivery Process, information clarity, and consistency.
The process of delivering information regarding policy objectives, which occurs between policy makers and policy program implementers so that what is expected by policy makers can be achieved. In addition, the delivery of information must also be carried out between the implementers of the policy program and the target group.
The following is the author's interview with parties related to the implementation of the Discharge Planning implementation policy at Siloam Hospitals Balikpapan.
"…. Before it was socialized, we held a meeting in the related unit, the results of the meeting will be disseminated to the DPJP and other health workers…" (P1, 51 years old) Based on interviews and documents found in the field, in this case, all of the informants stated that they had held and attended meetings with related units. Likewise, the training carried out by Siloam Hospital Baikpapan (in house training) by inviting competent doctors and nurses in the field of Discharge Planning was confirmed by all informants and documentary evidence in the form of assignment letters to resource persons.
In addition to delivering information regarding the procedures and objectives of the program or policy, another aspect that is no less important is the clarity of the information conveyed. Communication received by policy implementers or parties involved in policy implementation must be clear and not confusing so that there are no differences in perceptions between policy makers, implementers and target groups. The following are the results of an interview with the CEO of Siloam Hospitals Balikpapan about the contents of the policy regarding the goals and objectives of the policy.
"It is very clear… about the implementation of the Discharge Planning procedure where this procedure is a policy that was officially issued by the CEO of the hospital… The targets are nurses, RMO and DPJP" (P1,51 years) Based on the results of in-depth interviews with informants and a review of policy documents on the implementation of the Discharge Planning procedure regarding the clarity of goals, it can be seen from the scheme that all of them state it is clear where the policy objective is to identify the special needs of patients in order to maintain or achieve maximum function after being discharged from the hospital.

Resources
The resources referred to in this study are everything related to the quantity and quality of resources in accordance with the work required by established policies. The quality of human resources relates to skills, dedication, professionalism, and competence in the field they are involved in, while quantity relates to the number of human resources, whether the entire target group is sufficient in implementing a policy. In terms of quantity, the results of interviews with informants and direct observations made by researchers at the research location in this case Siloam Hospitals Balikpapan as the object of this research are as follows: "…The number of personnel for now is still sufficient…only those who meet the patient's score criteria…" (P2, 41 years old) This is also in line with the results of secondary data analysis which shows that the total number of nurses in the inpatient department of Siloam Hospitals Balikpapan is 108 nurses. When compared with the 2015 MSS standards, the number of nursing staff at Siloam Hospitals Balikpapan does not meet the standards. Based on the 2015 SPM, the number of nurses is calculated according to the number of beds, ie per 3 beds, 2 nurses are needed. The number of beds at Siloam Hospitals Balikpapan is 165 beds. So that according to the 2015 SPM standard, the number of staff at Siloam Hospitals Balikpapan should be 110 nurses. Therefore, the current condition of nurses still does not meet the minimum standard of nursing staff because there are still less than 2 nurses.
In addition to an adequate number of implementers, it is also necessary to have competent implementers in carrying out the program, because if the number of implementers is sufficient, but without being balanced with the ability or expertise in running the program, the implementation process cannot run optimally. The availability of skilled human resources is very important so that the implementation of programs or policies is more efficient and effective.
The following are the results of interviews conducted regarding the availability of competent human resources in supporting the success of achievement "…nurses and doctors in inpatient rooms are responsible…the quality is unquestionable because they have gone through basic training when accepted to work and advanced training that must be followed" (P1, 51 years) "…yes all nurses, RMO and DPJP are competent because they have a good educational background and are supported by the training they participate in" (P3, 40 years old) Based on the results of interviews and documentary evidence obtained by researchers in the field, the seven informants stated that the number of nurses, RMO and DPJP was sufficient, this was evidenced by the data we obtained from the Talent Administration (TA) section. The total number of nursing staff at Siloam Hospitals Balikpapan when compared to the standard number based on the 2015 MSS has met the standard. The types of training that must be followed by every nurse working at Siloam Hospitals Balikpapan consist of Basic Life Support (BLS), International Patient Safety Goals (IPSG), Early Warning Score (EWS) and effective communication. While the training is not mandatory, nurses are free to participate in the form of health seminars.
In addition to human resources, one of the supporting factors of resources that is equally important in the implementation of programs or policies, namely the availability of facilities in the process of implementing a policy. One of the supporting facilities is the availability of infrastructure needed in implementing the policy because without supporting facilities such as buildings as offices to coordinate, without equipment, without supplies, it is very likely that the planned implementation will not succeed.
Similar to the implementation of Discharge Planning, in this case its implementation requires adequate supporting facilities (facilities and infrastructure). Regarding the problem of facilities in the form of providing facilities and infrastructure, the following are interviews with medical managers: "…the discharge planning forms that must be completed are all available as needed, the filling is simple…" (P4, 50 years old) Based on interviews and documentary evidence that the researchers obtained in the field, the seven informants acknowledged that there were facilities prepared in the form of forms for the implementation of Discharge Planning. In addition to the discharge planning filling form, the facilities provided by Siloam Hospitals Balikpapan to support the implementation of discharge planning are in the form of assistive devices for patients who need assistive devices and telephone lines that are used to monitor patient progress after discharge from the hospital and to remind patients for the next follow-up until they are discharged. recovery.
Another important resource is the authority to determine how policies are carried out. In general, authority must be formal in order for policies to be implemented. Authority is the authority or legitimacy for the implementers in implementing the established policies. When the authority is nil, then the power of the implementers in the eyes of the public is not legitimized, so that it can thwart the policy implementation process.
With regard to authority as an indicator of the resource factor in implementation, the following interview with the quality manager stated that: "… I was given the authority as a nurse for monitoring and evaluation and for the implementer it was RMO" (P4, 50 years old)

Disposition
The definition of disposition that the author means is the attitude of the implementer in carrying out the policy of implementing Discharge Planning at Siloam Hospital Balikpapan in this case the commitment of the implementer, the placement of employees / staff and the provision of incentives will make the implementation of the policy run according to the technical implementation instructions.
Based on interviews and documentary evidence that researchers got in the field, out of seven informants, three informants said they had often done socialization, while the other four informants stated that support in the form of socialization was rarely done. From the quantitative findings from training data or socialization regarding discharge planning, training is carried out regularly every 2 months. From the observations made, the officers have carried out according to the SOPs that have been set. So it can be concluded that the commitment of the implementers in implementing discharge planning at Siloam Hospitals Balikpapan is quite good, but socialization may need to be carried out every month so that each health service provider can improve their understanding of discharge planning.
In addition to the appropriate placement of employees, who have the same perception or attitude as the program or policy makers in order to achieve the goals set, one that also affects the attitude and commitment of the implementers is the provision of appropriate incentives. Because it is undeniable that the attitude and commitment of implementers can be improved by providing adequate incentives. This is in line with the results of interviews with one of the nurses, as follows: Based on the results of interviews and a review of documents in the field, the researchers got answers from seven informants that compensation as a form of reward given to employees/staff was felt unnecessary because a standardized salary matrix system had been applied that had been applied to the Siloam Hospitals Group group.

Bureaucratic Structure
In this study, the structure referred to is standard operating procedures and fragmentation in policy implementation, while the indicators are SOP (Standard Operating Procedures) and fragmentation.
The implementation of a program or policy requires a procedure that becomes the standard for its implementation. Meanwhile, according to the quality manager said that: "…there is an SOP as a technical guide for implementation… in the form of guidelines for filling out the discharge planning form and following up after the patient returns home" (P3, 40 years old) From the statement above, it is known that the procedures needed in implementing the policy of implementing Discharge Planning for implementing health workers in the field are regulated in the form of standard procedures for implementation, which are better known as SOPs and service guidelines. field.
On the implementation of fragmentation, based on an interview with the CEO of Siloam Hospitals Balikpapan stated:

"…actually, coordination and cooperation has been established between related parties…the main duties and functions are clearly stated but not all parties feel responsible for the implementation of this discharge planning" (P1, 51 years old)
Based on this statement, it can be seen that the form of coordination and cooperation between the parties involved in the implementation of this implementation policy has been going well.
Based on the results of interviews and a review of documents in the field, the researchers found that the seven informants stated that in implementing Discharge Planning, each professional group already had standard operating procedures or Clinical Practice Guidelines which became the basis for implementing Discharge Planning. This SOP Discharge Planning is a technical guide for nurses, RMO and DPJP in providing health services in their respective fields.
The data obtained from quantitative results where the implementation of discharge planning in Siloam Hospitals Balikpapan inpatients is an average of 85.5%. This data is obtained from compliance data in carrying out SOP discharge planning, which is 85.5%. From the compliance data in implementing this discharge planning SOP, it was found that in the category of filling out forms within 48 hours, it only reached 87%. This is probably due to the large number of patients admitted at the same time and the inconsistency in filling them out. In the category of completeness of filling out forms, the achievement is only 89.6%, from the results of observations, it was found that the most vacancies occurred in filling out the length of stay of patients, this may be because the officers forgot or could not estimate the length of stay for the disease case or were inconsistent in filling out the form completely. . Based on the data above, the researcher concludes that the implementation of discharge planning in inpatients is not in accordance with the specified standard, which is 100% carried out.
The cause of discharge planning has not been carried out in accordance with standards resulting from several factors that affect the implementation of discharge planning. The researcher wants to discuss the discharge planning cycle which begins with the same knowledge of every officer about what and how discharge planning is. The first time the patient enters the nurse will get data through anamnesis and physical examination.
Research conducted by Purnamasari & Ropyanto (2012) showed that the results of the evaluation of the implementation of DP through the DP guidelines were carried out, showing 46.6% was quite good. However, to improve discharge planning, it is proposed for hospitals to immediately develop more effective discharge planning standards. From this it can be seen that with the discharge planning guidelines or standards, it can improve the implementation of discharge planning for patients. Therefore, the strategy used in this research is to prepare the discharge planning format together with service providers in the brain center room, so that it can be used in carrying out structured discharge planning in the brain center room.
Another study by Baghae et al (2016) showed that through the implementation of continuous discharge planning from the time the patient entered the inpatient room until preparation for discharge was significantly able to reduce patient anxiety and increase patient and family knowledge regarding the health condition of patients with heart problems so as to speed up the treatment process. in the hospital. The results of Pemila's research (2011) also showed that the provision of discharge planning was able to shorten the average length of patient stay (AvLOS). The provision of discharge planning in question is since a new patient enters, undergoes treatment and prepares to return home, where the ability of the patient and family to cope with the disease has the potential to reduce the length of stay, the risk of severity (severity) and the risk of being hospitalized (readmission) in vulnerable situations. 30 days and reduce hospital costs (Krantz et al, 2006).
Communication is a human activity to convey what are their thoughts and feelings, hopes or experiences to others. The communication factor is considered a very important factor, because it bridges between the community and the government in implementing policies so that it can be seen whether the implementation of policies is running effectively and efficiently without anyone being harmed. Effective implementation will only occur if policy makers and implementers know what they are going to do, and this can only be obtained through good communication.
Research at Panembahan Senopati Hospital Bantul explained that the perceived obstacle in implementing the policy was that socialization was not given evenly and comprehensively. Information is conveyed through layers of bureaucratic hierarchies. Distortion of communication can occur due to the length of the information chain which can lead to information bias (Astuti et al., 2017). Limitations in understanding and inconsistency in roles occur due to lack of exposure to information. Education and training related to roles need to be carried out, so that policy implementers understand and can carry out their roles according to their duties, responsibilities and authorities (Sulahyuningsih et al., 2017).
At Siloam Hospitals Balikpapan, the media used as communication media are the first, the director's meeting with the board of directors, the second is the director's meeting with the relevant divisions which is strengthened by a decree on the implementation of the discharge planning policy and then disseminated through internal memos to be known by all employees of Siloam Hospitals Balikpapan. Prepare evaluation materials by listening to the results of audits conducted at each weekly coordination meeting scheduled for all levels of management. If something happens outside of what has been determined, each related function will write it down in an online incident report so that the report will reach the relevant division and if the incident has the potential to risk death then the report will reach the highest leadership not only the CEO but will go to the top management at the Siloam Group head office. This shows that the communication dimension has been structured by Siloam Hospitals Balikpapan to facilitate the implementation of discharge planning policies to achieve the expected goals.
Programs or policies are implemented by implementers where without implementing the program or policy it will not run properly and as it should. Without personnel to implement a program or policy, any program or policy cannot run properly and will only remain as a document without any realization. Therefore, the availability of sufficient implementers in encouraging the success of a program or policy is very necessary.
Based on the results of the research above, from the results of interviews and the existence of documents in the form of employee and doctor data, the number of nurses, RMO and DPJP, in Siloam Hospitals Balikpapan is sufficient in number. In addition to document data in the form of employee data in the Talent Administration in the form of macro data for all employees and micro data per department, each room has complete data on employees with qualifications according to their respective competencies.
The main resource in policy implementation is staff. Failures that often occur in policy implementation, one of which is caused by inadequate, sufficient, or incompetent staff in their fields. The addition of the number of staff and implementers is not enough to solve the problem of policy implementation, but it requires an adequate number of staff with the necessary skills and abilities (competent and capable) in implementing the policy or carrying out the tasks desired by the policy itself (Hasibuan et al., 2016).
Based on the results of in-depth interviews and documentary evidence obtained by researchers in the field, the seven informants stated that they no longer doubted the competence of nurses, RMO and DPJP because every nurse, RMO and DPJP had a Registration Certificate (STR) and Practice Permit (SIP) issued by each professional organization. In addition, in terms of training, the quality of nurses who provide health services based on the level of nursing and the training provided is in accordance with the qualifications in providing health services in the inpatient department.
In addition to human resources, which is no less important is the availability of nonhuman resources such as supporting facilities, rules, and so on. The implementation of a policy cannot run optimally if it is not supported by facilities or other resources that support the effectiveness of the implementation of the policy (Khaerah, 2018).
According to G. Edward III, facilities and infrastructure are all available for the implementation of the implementation of a policy and are used to support it directly. Facilities or infrastructure is one of the factors that influence the implementation of policies, the procurement of appropriate facilities such as buildings, land and office equipment will support the successful implementation of a program or policy.
In the implementation of discharge planning at Siloam Hospitals Balikpapan, it is directly related to the implementation of discharge planning such as medical equipment in the form of blood pressure meters, stethoscopes, oxygen saturation and others. Work completeness facilities such as required forms related to discharge planning implementation. Based on in-depth interviews and documentary evidence that the researchers obtained in the field, the seven informants admitted that there were facilities prepared in the form of a form for the implementation of discharge planning. In terms of existing facilities, Siloam Hospitals Balikpapan has provided facilities in the form of written records of discharge planning policies, implementation procedures, training provided, socialization and forms that must be filled which become the benchmark for discharge planning implementation. With these facilities, the discharge planning implementation can be carried out properly.
Based on in-depth interviews and documentary evidence that the researchers obtained in the field, all of the seven informants knew that there was authority given by formal policy makers in this case the CEO to nurses, RMO and DPJP. The policy regarding this authority is stated in the discharge planning SOP and the decree for the implementation of the discharge planning of Silaom Hospitals Balikpapan. This means that the authority process that runs at Siloam Hospital Balikpapan is official authority, namely official authority received from the authority above it. This authority has been running well where the top does it over the direct subordinates. Direct superiors give authority to their subordinates, their form is command authority and is reflected as a chain of orders that are passed down through the organizational level (Hani 2006).
One that affects policy implementation is the attitude of the implementer in implementing a policy. The implementer in question is starting from the highest leadership in a work unit and all people who are members of the work unit, all of them must support each other and be together in carrying out a policy for the common interest (Zulaeha, 2015).
Based on in-depth interviews and documentary evidence that the researchers obtained in the field, three of the informants said that they had frequently conducted socialization and training, reminding the implementers, while the other four informants stated that support in the form of training socialization was rarely carried out. This shows that the leadership's commitment to providing support or motivation to the implementers has not been running properly.
In addition to the appropriate placement of employees, who have the same perception or attitude as the program or policy makers in order to achieve the goals set, one that also affects the attitude and commitment of the implementers is the provision of appropriate incentives. Incentives are not only in the form of money, but can be in the form of a good work environment. With a good environment, this will support comfort at work and increase work performance. Likewise, the form of participation, namely the opportunity to participate and communicate with superiors, can provide a boost to work morale to workers. Based on the results of the study, it is known that the management is very supportive and gives a positive response to the implementation of the policy (Astuti, 2018).
In terms of the distribution of responsibilities among several work units or departments, coordination and cooperation between the relevant parties is required. Regarding fragmentation, it can be seen from the clarity of Standard Operating Procedures for each program that will facilitate the implementation of policies. Each relevant party knows the duties and responsibilities according to the applicable procedures. With the clarity of duties and responsibilities of each section, section and elements of implementing policies, it is hoped that it will be able to minimize the emergence of coordination barriers with other institutions that carry out related programs. In its implementation, it is recognized that it is not that easy, there are still obstacles faced, both from internal and external aspects of the organization and the community (Astuti, 2018).
Based on the results of interviews and a review of documents in the field, the researcher found that the seven informants already understood the duties and functions and responsibilities of each, but in practice, when viewed from the responsibilities of the implementing officers in the field, they were not in accordance with their proper duties and functions.

Conclusion
The results showed that the implementation of discharge planning at Siloam Hospital Balikpapan inpatients had not run according to the standards set by the hospital, namely 100%. In the implementation of discharge planning at the inpatient installation of Siloam Hospital Balikpapan, the most influential factor is the human resource factor seen from the implementation of the discharge planning cycle from the beginning to the end of HR involvement. It is recommended for hospital management that improvements are needed in the implementation of discharge planning at Siloam Hospitals Balikpapan so that the achievement can reach the appropriate standard. Parts that are still not appropriate (14.5%) should be evaluated further, so that the causative factors can be corrected immediately. For the implementation of communication, it is necessary to convey clearly and accurately related to the information provided so that it is easy to understand and run in accordance with policy objectives such as holding regular socialization so that health workers understand the outline in the purpose of implementing this discharge planning. For the resource factor, the availability of nursing staff requires additional personnel in accordance with applicable standards both in quantity and quantity. For the disposition factor, continuous improvement is needed even though the existing conditions are quite good. For the bureaucratic structure factor, it is necessary to evaluate every day within 48 hours on all newly admitted patients, patients with difficult cases and old treatments.