Strategy for Strengthening Work Culture in an Effort to Improve the Quality of Health Services (Case Study at Community Health Center in Tasikmalaya City)

The purpose of this study is to find out how strategies to strengthen work culture can improve the quality of health services at the Puskesmas. This study used a qualitative method with respondents at the Sangkali Health Center and Panglayungan Health Center in Tasikmalaya City who had measured the quality of health services. Whereas in the Panglayungan Health Center as a comparison Health Center, there are only two work cultures that need to be strengthened, namely professionalism and cooperation. In terms of service quality that has not been achieved, both Puskesmas do not have a Puskesmas quality policy. The Sangkali Health Center still lacks an understanding of quality, while the Panglayungan Health Center already has an understanding of service quality.


INTRODUCTION
The rapid development of the world of health is directly proportional to the awareness of everyone to have the right to get quality health services ("2006 Robert Wood Johnson Award: Celebrating 50 years of Health Service Excellence," 2006; Daraba et al., 2018;De Luca et al., 2021;Lal et al., 2020;Lyu et al., 2022;Niswaty et al., 2015;Rantanen et al., 2021). Health is one of the basic rights of society that must be implemented by the government in accordance with the mandate in the 1945 Constitution article 28H paragraph (1) "Everyone has the right to live in physical and spiritual prosperity, to have a place to live , and to have a good and healthy environment and entitled to health services".
Law Number 36 of 2009 Article 5 paragraph (2) states that "Everyone has the right to obtain safe, quality and affordable health services." Based on the rights of every person, it is the state's obligation to fulfill them in accordance with Article 34 paragraph (3) "The state is responsible for the provision of appropriate health service facilities and service facilities".
The Government of Indonesia's policy in the 2020-2024 RPJMN focuses on Utilizing the availability of appropriate health service facilities, and is adjusted to focus on efforts to increase access and quality of health services towards universal health coverage with an emphasis on strengthening basic health services (Primary Health Care) and improving promotive and preventive efforts are supported by innovation and the use of technology (Brice & Almond, 2020;Durocher et al., 2021;Feroz et al., 2021;Wiweko & Zakirah, 2020).
Presidential Regulation No. 72 of 2012 concerning the National Health System (SKN), states that Indonesia adheres to a tiered health service system, namely the first or primary level health service system, the second or secondary level health service system, and the third or tertiary recognized as very helpful to the people of Tasikmalaya City because of the three existing regional hospitals, The city of Tasikmalaya consists of 8 sub-districts and 69 sub-districts, with a population of 731,048 in 2021, with a density of 4,260 people/km of people, and the number of health facilities provided. There are 25 governments, as shown in table 1.1 above, so access is easy to reach and sufficient. All of the Government Health facilities above are under the responsibility of the Tasikmalaya City Health Office, in the bureaucracy it functions as an assistant to the Mayor. In carrying out the duties and authorities in the field of health management and is an implementing element of the City Government of Tasikmalaya which is under and responsible to the Mayor of Tasikmalaya.
The basis for the formation of the Tasikmalaya City Health Service is the Regional Regulation of the City of Tasikmalaya Number 11 of 2019 concerning Amendments to the Regional Regulation of the City of Tasikmalaya Number 7 of 2016 concerning the Formation and Composition of Regional Devices. Then the implementation is regulated in the Tasikmalaya Major Regulation Number 40 of 2016 concerning Organizational Structure, Position, Main Tasks, Functions and Work Procedures of Regional Devices. The Puskesmas is the Technical Implementation Unit of the District/City Health Office according to the Decree of the Minister of Health Number 128 of 2004 concerning the Basic Policies of the Puskesmas which stipulates that the Puskesmas is responsible for implementing health development in a work area. In order to carry out its obligations, the Puskesmas functions as (1) a center for driving health-oriented development, (2) a center for community empowerment, (3) First-level health service centers (individual health services and community health services). Preventive (prevention), promotive (health promotion), curative (treatment) and rehabilitative (patient recovery) services.
According to (Permenkes, 2019) Community Health Centers, hereinafter referred to as Puskesmas, are health service facilities that carry out community health efforts and first-level individual health efforts, with priority on promotive and preventive efforts, to achieve the highest degree of public health in their working area. Puskesmas as the first level of health facilities in the City of Tasikmalaya have at least 2 Puskesmas in 1 sub-district. This is in accordance with article 10 of Permenkes no 43 of 2019, paragraph (1) Puskesmas must be established in each subdistrict, and paragraph (2) Under certain conditions, in 1 (one) sub-district more than 1 (one) ) Puskesmas can be established.
All Community Health Centers in Tasikmalaya City have the authority and responsibility for maintaining public health in their working area. The health services provided by the puskesmas are comprehensive health services which include services: curative (treatment), preventive (prevention efforts), promotive (health improvement), and rehabilitative (health restoration) to all residents, regardless of gender and age group, since conception in the womb until death. Health services at the Puskesmas in Tasikmalaya City, although in terms of access, are adequate, there are still problems related to the quality of facilities and services.
Unequal health. In accordance with Law Number 36 of 2009 concerning Health that the Government is responsible for all forms of quality, safe, efficient and affordable health efforts. There are 4 dimensions that the Tasikmalaya City Government must pay attention to in order to achieve this goal, namely how large the population is guaranteed, how complete the health services are guaranteed, how large is the proportion of direct costs that are still borne by the population, and what is the quality of health services.  (1) Puskesmas, Primary Clinics, doctors' independent practice places, and dentists' independent practice places must be accredited. Accreditation is a tool to measure the achievement of the Puskesmas against the set service standards. Puskesmas is a functional organization that organizes health efforts that are comprehensive, integrated, equitable, acceptable and affordable to the community, with the active participation of the community and using the results of the development of appropriate science and technology, with costs that can be borne by the government and the community. These health efforts are carried out by focusing on services for the wider community in order to achieve optimal health degrees, without neglecting the quality of services for individuals. Community Health Centers with the best service standards will receive Plenary accreditation status, followed by Primary, Middle and Basic accreditation. Accreditation for 21 Community Health Centers was carried out simultaneously within a period of two years. The results of the overall accreditation of the 22 Community Health Centers can be seen in table 1. Puskesmas that have been accredited plenary means that they have met the highest standards in service quality and patient safety, protection for human resources for health, the community and the environment, as well as the Puskesmas as an institution; and the performance of the Puskesmas in providing individual and/or community health services.
In Table 1.2 the accreditation status shows 5 Community Health Centers with Primary Accreditation, 2 Community Health Centers with Basic Accreditation, and 14 Community Health Centers with Middle Accreditation. The large number of Community Health Centers with intermediate accreditation status indicates that Health Centers are not yet optimal in implementing service quality standards. This condition basically demands that the value system of the Community Health Center produces an environment that is conducive to the formation and continuous improvement of quality. (Goetsch DL and Davis DL, 2015: 110).
Quality and resource management is an integrated health center management system that is not separate from one another, and must be fully controlled by the health center management team under the leadership of the head of the health center, in an effort to realize quality health center performance , support the achievement of goals and objectives of implementing health efforts at the health center, in order to overcome the health problems faced by the community in the work area.
Puskesmas management will integrate all existing management (resources, programs, community empowerment, Puskesmas information systems, and quality) in resolving priority health problems in their working areas. (Permenkes 44 of 2016).
To complete the data needed in this study, in relation to the themes studied, the researchers also audited external and internal factors. The analytical method used is EFAS (External Strategic Factors Analysis Summary) and IFAS (Internal Strategic Factors Analysis Summary) analysis.
Puskesmas, like other health services, have multi-professional human resources, who must be able to work well with the internal and external environment, as stated by Routledge Schuler. RS (Mangkunegara, 2011) states the meeting point formed by an organization between its internal resources and expertise and the opportunities and risks formed through its external environment. The Puskesmas organization is a meeting point for health resources who have special professional expertise such as doctors, nurses and midwives with expertise to treat people who have the risk of transmitting or contracting disease from their profession if the quality of services is carried out optimally.
In accordance with the theory (Wheelen, 2008) a SWOT analysis is needed to produce a series of managerial decisions and actions that lead to the formulation of an effective strategy to achieve company goals. For example, if there are at least 2 companies operating with the same product (goods and services), then one of them wants to emerge as the winner in their business competition. Being a winner in the business world is often interpreted as getting the largest market share which will later have monopoly power and if monopoly is prohibited by the government, then at least the company becomes a company with the status of a leader or price leader (price setter or price leader).
Each party will always try to win the competition and conduct an analysis of each other's strengths, weaknesses, opportunities and threats. His weaknesses and threats from competing

Jurnal Ilmiah Ilmu Administrasi Publik: Jurnal Pemikiran dan Penelitian Administrasi Publik
Volume 12 Number 2 , July-December 2022. Page 613-630 companies will always be analyzed and anticipated which will then be corrected so that they are not easily attacked or subdued by competing companies.
Based on the above conditions, the researchers took two outpatient health centers, one health center as the main focus and the second health center as a comparison. The choice of locus for outpatient Puskesmas according to Permenkes number 43 of 2019 article 29 paragraph (6) Puskesmas that can become inpatient Puskesmas are Puskesmas in rural areas, remote areas and very remote areas, which are far from advanced referral Health Service Facilities. Whereas in Tasikmalaya City there are no rural, remote and very remote areas. Therefore, the status of the inpatient Puskesmas in Tasikmalaya City is being reviewed to be returned as an outpatient Puskesmas. Based on the Minister of Health above, Therefore, the performance evaluation of inpatient Puskesmas service quality is being re-discussed for several values which mostly refer to inpatient points which are not a function of the Puskesmas. This makes current researchers choose the locus of outpatient health centers. The researcher chose two outpatient health centers with different accreditation strata, namely the main accredited health center with the highest quality score, namely Sangkali health center as shown in table 2. The Sangkali Health Center was designated by the Mayor of Tasikmalaya number 50 of 2020 as a Health Center with the characteristics of an Urban Health Center in accordance with the provisions of Permenkes 43 of 2019 article 25 paragraph (2) which states that the Health Center Category must be determined by the regent/major. This condition is in accordance with Permenkes number 43 of 2019 article 26 paragraph (1) Urban area health centers as referred to in Article 25 paragraph (1) letter a are Health Centers whose working area covers areas that meet at least 3 (three) of the 4 (four) criteria for urban areas as follows: 1. Activities of more than 50% (fifty percent) of the population in the non-agricultural sector, especially industry, trade and services; 2. Has urban facilities, including schools within a 2.5 km radius, markets within a 2 km radius, has a hospital within a radius of less than 5 km, or a hotel; 3. More than 90% (ninety percent) of households have electricity; and/or 4. There is access to roads and transportation to urban facilities.
According to Perwalkot No. 50 of 2020, the Sangkali Health Center in Tasikmalaya City has the ability to provide non-inpatient services. Administratively, the working area of the Sangkali Health Center, Tasikmalaya City, is included in the Tamansari District, Tasikmalaya City, with an area of 17.08 km 2. Tasikmalaya City has 4 work areas, namely Tamanjaya Village with an area of 35.1 Ha, Tamansari Village with an area of 98.5 Ha, Mugarsari Village with an area of 20.2 Ha, and Sumelap Village with an area of 18.9 Ha.
The target areas of the Sangkal Health Center are infants, toddlers, pregnant women, women giving birth, postpartum mothers, school children, the elderly and the community in the Sangkal Health Center area. Sangkal Health Center was accredited in 2018 with main accreditation status.
The researcher chose the main focus of the research was Sangkali Community Health Center for four reasons. First, the Sangkali Health Center as the main accredited outpatient Health Center with the highest quality score compared to all other main outpatient Health Centers. Second, the Sangkali Health Center is a referral health center for the people of Tasikmalaya City and Tasikmalaya Regency because it is located on the border between Tasikmalaya City and Tasikmalaya Regency. Third, planning for the next development to become an infectious disease center in Tasikmalaya City. The fourth reason is that even though the Sangkali Health Center has main accreditation status, in the quality of health services there are still quality indicators that have not reached the target.
Marbawi Adamy (2016) stated that a leader will try to influence members to carry out tasks according to the job descriptions set by the organization. For this reason, a leader is expected to be able to create and support a conducive work atmosphere and culture so that it has a positive influence on its members such as giving praise and appreciation, taking corrective action, giving punishment or pressure for certain things, or helping members when needed.
Policies within the organization are closely related to the leadership of the Puskesmas in communicating its organizational goals. The explanation above is in line with Bangun (2012) leadership is the process of influencing other people in an organization so that they can carry out their duties properly in achieving goals.
Case Outcomes The percentage of hypertension that is managed according to the standard is less than 3 points and the coverage of services for people with DM who are served according to the standard is less than 3 points. Hypertension and DM are chronic diseases that require almost lifelong treatment for patients. The lack of achievements in this respect shows that the focus on work quality has not been sustainable and up to standard.
According to Masharyono, et al (2015) there are eight criteria that can be used as a measure in assessing or evaluating employee performance based on specific behavioral descriptions, namely: 1. Quantity of work: Is the amount of work performed in a specified time period. 2. Quality of work: Is the quality of work achieved based on the conditions of suitability and readiness. 3. Job knowledge: Is insight and knowledge about his work. 4. Creativeness: Is creativity or ideas raised in completing work 5. Cooperation: Is a willingness to cooperate with other employees. 6. Dependability: Reliable, trustworthy and responsible in completing work. 7. Initiatives: It is self-initiation or awareness to carry out its duties very well without having to be supervised and ordered. 8. Personal Qualities: Concerning personality, obedience, hospitality, The percentage of patient satisfaction is still less than 3 points. Satisfying consumer needs is the desire of every company. Apart from being an important factor for the survival of the company, satisfying consumer needs can increase the advantage over the competition. Consumers who are satisfied with products and services tend to repurchase products and reuse services when the same need appears in the future.
This means that satisfaction is a key factor for consumers in making repeat purchases, which is the largest portion of the company's sales volume. Consumer satisfaction is very dependent on the perceptions and expectations of consumers themselves. Westbrook & Reilly (in Tjiptono, 2014) suggests that consumer satisfaction is an emotional response to experiences related to the product or service purchased.
Factors that influence consumer perceptions and expectations when purchasing an item or service are the needs and desires felt by the consumer when purchasing an item or service, past experience when consuming the item or service and the experiences of friends who have consumed the goods or services and advertising.
Gaspers (in Meithiana, 2019) said that consumer satisfaction is very dependent on consumer perceptions and expectations. Band (in Meithiana, 2019) says that satisfaction is achieved when quality meets and exceeds consumer expectations, wants and needs. However, if the quality does not meet and exceed the expectations, desires and needs of consumers, satisfaction will not be achieved. Consumers who are dissatisfied with the goods or services they consume will look for other companies that are able to provide their needs.
The researcher chose the second locus, namely the Panglayungan Health Center as a comparison Health Center. The Panglayungan Community Health Center is located in the Cipedes District, Tasikmalaya City, which is located at Jl. The walls of Ari Raya Bumi Resik Panglayungan, Panglayungan Village, which is 1 km west of the Tasikmalaya City Center. The working area of the UPTD Panglayungan Health Center consists of one sub-district, namely Panglayungan Village which includes 21 RWs and 88 RTs.
The farthest distance traveled by the community to the Panglayungan Health Center is between 1 Km and a travel time of 15 minutes, conditions of easy affordability. The location of the Puskesmas is strategic because it is on the side of the main road and easy transportation facilities, can be passed by four-wheeled vehicles on city transportation routes or two-wheeled vehicles.
According to Yuli (2020) Top management must create, implement and document a quality policy that: is in accordance with organizational goals and context, supports the company's strategic direction, is the basis for setting quality objectives, including a commitment to fulfill all applicable requirements including a commitment to continuously improve the quality management system. The quality policy must be documented and made available to all interested parties, understood and implemented by employees.
Leaders and managers must be able to communicate and influence Puskesmas employees to understand and implement quality. In accordance with the opinion of Rivai (2004), said that leadership is a process of influencing or setting an example to his followers through a communication process in an effort to achieve organizational goals.
According to Robbins and Judge (2013), the behavioral characteristics of servant leaders are listening, empathizing, persuading, accepting stewardship, and actively developing the potential of their members.
A number of research results show the role of servant leadership in organizations such as: having a significant effect on organizational culture, organizational commitment, employee performance (Hawiki, 2016) or positively influencing employee engagement (Carter and Baghurst, 2014).
The percentage of patient satisfaction from a score of 10 has only reached 3 points. According to RA Supriyono (in Indrasari, 2012) service is an activity organized by the organization regarding the needs of consumers and will create a distinct impression, with good service, consumers will feel satisfied, thus service is very important in an effort to attract consumers to use the product or service offered.
Satisfying consumer needs is the desire of every company. Apart from being an important factor for the survival of the company, satisfying consumer needs can increase the advantage over the competition. Consumer satisfaction is very dependent on the perceptions and expectations of consumers themselves. According to Tjiptono (2012: 301), consumer satisfaction is a situation shown by consumers when they realize that their needs and desires are as expected and well fulfilled.
According to Kotler and Keller (2012) Satisfaction is a person's feelings of pleasure or disappointment that arise after comparing the performance (or results) of the product in question with the performance (or results) expected. If what is provided by service companies fulfills consumer desires, consumers will be satisfied. Vice versa if the consumer's desire is not what they want, the consumer will be dissatisfied.
According to Philip Kotler and Kevin Lane Keller (2012) say that Consumer Satisfaction is a person's feeling of pleasure or disappointment that arises after comparing the performance (results) that is thought of against the expected performance. There are five factors that affect the level of satisfaction. a. Quality of products and services. b. Quality of service, especially for the service industry. c. Emotionally, the consumer will feel proud and gain confidence that other people will be amazed at him when using products and services with certain brands that tend to have a higher level of satisfaction. d. Price, the more expensive the price of treatment, the patient has greater expectations. e. Cost, patients who do not need to incur additional costs or do not need to waste time getting services, then patients tend to be satisfied with services.
The internal quality inspection coverage points have only reached 7 out of the standard value of 10 points. Quality assurance is divided into two parts, namely Internal Quality Assurance (PMI) and External Quality Assurance (PME). The quality control that is carried out internally is called PMI or can be called internal quality control and that which is carried out externally is called PME or proficiency test (Siregar et al. 2018). Strengthening internal quality is prevention and control activities carried out by each laboratory continuously so that errors do not occur or reduce the occurrence of errors / deviations so that proper examination results are obtained.
Based on the explanation above, the researchers compared the achievements of the two Community Health Centers in fifteen indicators of service quality according to the Minister of Health Regulation number 44 of 2016. In total, out of the fifteen indicators, it turned out that there were 5 service quality indicators that have not been achieved by the Sangkali Health Center and Panglayungan Health Center.
Quality health efforts (Permenkes 44 of 2016), are efforts that provide satisfaction as a subjective statement of customers, and produce outcomes as objective evidence of the quality of service received by customers.
Therefore the Sangkali Health Center and Panglayungan Health Center must be able to achieve the service quality indicators they carry out or follow the service quality standards for each program / service that has been set by the Tasikmalaya City Health Office.
The Sangkali Health Center and Panglayungan Health Center are health services built by the government, so it is ensured that both human resources and infrastructure are the responsibility of the government in accordance with applicable regulations.
The Puskesmas is a health technical implementation unit under the supervision of the District/City Health Office. In general, they must provide preventive, promotive, curative to rehabilitative services either through individual health efforts (UKP) or public health efforts (UKM). To provide good service, of course, efforts are always made to improve the quality of service in order to achieve optimal health status for the whole community. The quality of health services is not a variable that stands alone but is the influence of various health factors. The realization of satisfactory service requires a strong management commitment. Meanwhile, if the organizational structure and resources are in accordance with the rules, then the possibility is in organizational governance and human resources. For this reason, according to (Bernhard, et al, 2017) it is necessary to understand human behavior in cooperation in organizations and it is necessary to clearly determine the level of analysis.
The effectiveness of organizational performance basically depends on the effectiveness of group performance, while the effectiveness of this group's performance depends on the effectiveness of individual performance. Furthermore, there are a number of factors that lead to effective performance at each of these levels.
The effectiveness of individual performance can be caused by factors such as intelligence, skills, attitudes, personality, learning capacity, motivation, stress, role, satisfaction and others. The effectiveness of group performance can be caused by factors such as cohesiveness, conflict, leadership, communication, power, politics, structure, norms and others. The effectiveness of organizational performance is caused by factors such as climate, technology, structure, culture, human resource management practices. However, from a systems perspective, the effectiveness of individual, group and organizational performance is also influenced by the environment.
In addition to organizational governance, another way to improve the quality of Puskesmas services is to improve the performance of Puskesmas staff, according to Prawirosentono & Primasari, (2015) that it is the human element that plays a very important role and determines the success of achieving organizational goals.
In addition to the human element, appropriate abilities, motivation and clear advantages are also needed, according to Robbins' theory (2018) that employee performance is a function of the interaction between ability, motivation and opportunity, so that it can be formulated that performance (P) = f(A x M x O), and M = V x E x I. In accordance with Moeheriono's theory (2012: 95) states that performance is a picture of the level of achievement of the implementation of an activity program or policy in realizing the target , goals, vision, and mission of the organization as outlined in an organization's strategic planning.
To ensure that the quality management cycle of the Puskesmas runs effectively and efficiently, the Puskesmas must establish a Puskesmas Management Team which can also function as the person in charge of quality management at the Puskesmas. The team consists of those in charge of health efforts at the Puskesmas and are fully supported by their respective staff. This team is responsible for achieving the performance targets of the Puskesmas, through the implementation of quality health efforts.
The Puskesmas Management Team must be able to work properly and professionally, under the coordination and supervision of the Head of the Puskesmas who carries out his leadership function properly and appropriately according to the situation and conditions for the implementation of quality health efforts for the community in his working area. The health efforts provided must always pay attention to the interests, needs and expectations of the community as external consumers, the interests and satisfaction of all Puskesmas staff as internal consumers, and the district/city regional government as the owner/owner. Community Health Center health efforts that are carried out evenly and with quality according to standards, are manifested by evidence of improvement and increased achievement of community and individual health indicator targets. Such as reducing the number of morbidity and sickness that is a priority for treatment, reducing child mortality, malnutrition and/or underfive and maternal nutrition, reducing the number of maternal deaths, overcoming public health problems in their working areas, and others.
Adequate resource support is needed both in type, quantity and function and competence according to established standards, and on time when it will be used. In conditions of limited resources, the available resources are managed as well as possible, available when they are to be used so that they do not hinder the running of the service to be carried out.
Resource and quality management is an integral part of the Puskesmas management system that is not separate from one another, which must be fully controlled by the Puskesmas management team under the leadership of the Puskesmas head, in an effort to realize the quality of the Puskesmas performance, support the achievement of goals and objectives of implementing health efforts at the Puskesmas.
Human Resource Management is an activity of planning, procuring, developing, maintaining, and using human resources to achieve goals both individually and organizationally. In relation to this background, the researcher formulated a study entitled "Strategy to Strengthen Work Culture in an Effort to Improve the Quality of Health Services (Case Study at the Tasikmalaya City Health Center)".

METHOD
The researcher uses the 3rd method, namely the Fishbone Diagram / Cause and Effect (cause and effect) / Ishikawa. It is said to be a Fishbone Diagram because it is indeed shaped like a fishbone with the snout facing to the right. This diagram will show an impact or result of a problem, with various causes. The effect or result is written as the muzzle of the head. While the fishbone is filled with causes according to the approach to the problem. It is called a Cause and Effect diagram because the diagram shows the relationship between cause and effect. In connection with statistical process control, causal diagrams are used to show the causal factors (cause) and quality characteristics (effect) caused by the causal factors.
The Fishbone diagram has created a brilliant idea that can help and enable any person or organization to solve problems thoroughly down to their roots. The habit of gathering several people who have sufficient experience and expertise regarding the problems faced by the company All team members provide views and opinions in identifying all the reasons why the problem occurred. In discussing proposition 1 regarding work culture at the Sangkali Health Center and Panglayungan Health Center in the City of Tasikmalaya, the researchers conducted interviews by looking at work culture through the formulation of the dimensions of work culture that were applied at the Sangkali Health Center and Panglayungan Health Center in Tasikmalaya City.

RESULTS AND DISCUSSION
Based on the results of the documentation study and interviews with research informants, there are 7 (seven) points which are the main dimensions of work culture in the Sangkali Health Center and Panglayungan Health Center in Tasikmalaya City, namely: Discipline, Accountability, Innovation and Creativity, Cooperation, Welfare, Professionalism, Focus on quality.
The Based on interviews with the two informants at the Sangkali Health Center, it was found that the two groups of informants, both managerial and professional, agreed that the work culture that was still hindering was discipline and welfare.
As for the work culture indicators regarding the indicators of Innovation and creativity, Professionalism, Collaboration and focus on quality, based on the results of interviews on proposition 1, it appears that there are differences in the results of the interviews with the two groups of informants at the Sangkali Health Center.
Innovation and creativity, according to the Sangkali Health Center managerial team, are not a weak work culture because the flow of production is according to the rules. Meanwhile, the professional team said that innovation and creativity were an additional workload.
Based on these differences of opinion, the researchers triangulated the methods and data by looking for innovation data sources at Sangkali Health Center. It turns out that the innovation at the Sangkali Health Center has been done in the past.

Proposition 2: Quality of Health Services
The results of the comparison of Proposition 2 between the two informants at the Sangkali Health Center and Panglayungan Health Center regarding service quality stated the same thing at the quality policy level. Meanwhile, regarding the understanding and implementation of the quality dimension, there were differences stated by the two informants from the two Puskesmas.
The difference lies in the understanding of the dimensions of quality, according to both managerial and professional informants. Panglayungan Health Center, Panglayungan Health Center employees already understand. Different statements were made by the two informants at the Sangkali Health Center, who stated that many employees did not understand the dimensions of quality. The two informants, both managerial and professional at the Sangkali Health Center and Panglayungan Health Center, stated similarities regarding the implementation of the quality dimension, that the quality dimension has actually been carried out every day even though it is not up to standard.
Panglayungan Health Center as a comparison Health Center, the two informants of the Health Center on the Understanding and Implementation of the Quality Dimension stated that the employees had understood, and the implementation was doing their best.
In the results of the interviews between the two puskesmas there were differences in the understanding of Puskesmas employees on the quality dimension, so the researchers conducted additional interviews with the Health Office which stated: The accreditation status of the Puskesmas determines the quality of the Puskesmas, when viewed from the accreditation status, the primary accredited Sangkali Puskesmas should have a better understanding and better implementation than the Panglayungan Puskesmas which has intermediate accreditation.
Triangulation using the data method, at the Sangkal Health Center in table 4.7 Performance Assessment of the Sangkal Health Center in 2021, it can be seen that the results of the performance assessment are still in the poor category and the quality management point is at 94.44. Data at the Panglayungan Health Center in table 4.14 Performance Assessment of the Panglayungan Health Center in 2021, the results of the assessment are in the medium category and the quality management points are at 96.67.
In the understanding and implementation of the national health center quality indicators, the two health centers stated the same thing, that is, they understood but their implementation was not up to standard. Achievement of service quality, the two puskesmas agreed to state the same thing, namely that it had not been achieved according to standards because there were still obstacles. The difference is that at the Panglayungan Health Center there are already procedures for handling if there are service quality achievements that have not been achieved.
Proposition 3: There are obstacles that need to be identified and minimized in efforts to strengthen work culture to improve the quality of health services The results of a comparison of the constraints and barriers to work culture in the two Puskesmas show that there are more obstacles to work culture in the Sangkali Health Center than the Panglayungan Health Center. The obstacles to the work culture at the Sangkali Health Center are discipline, innovation and creativity, professionalism, cooperation, welfare and focus on quality. Meanwhile, the constraints on work culture at the Panglayungan Health Center as a comparison Health Center, the constraints are only on the work culture of professionalism and welfare. So the similarity of constraints and barriers to work culture in the two Health Centers is professionalism and welfare.
Proposition 4: Appropriate work culture strengthening strategies will be able to improve the quality of health services Based on the SWOT analysis, the results of the EFAS and IFAS conditions, then also supported by Fishbone analysis, the focus of this strategy is to maximize by strengthening the strengths that are already owned by the Sangkal Health Center and seizing opportunities that are in favor of the goals of the Sangkal Health Center.
Thus, the strategy processed by researchers based on the results of interviews and observations, was developed into 3 main strategies for strengthening work culture, namely: performance strengthening strategies, bureaucratic strategies and external partnership strategies.
Based on the results with the informants regarding the performance strengthening strategy implemented at the Sangkali Health Center, namely the Application of Work Discipline, the managerial team said that the application of work discipline must be monitored, not enough discipline at the time of arrival and return. Meanwhile, the professional team expects strict sanctions if there are violations and at the same time sets an example from the leadership.
Informants from practitioners said it was important to apply discipline because since long ago the work culture of the Puskesmas seemed relaxed. Health academic informants said according to the professional team that there must be clear reward and punishment sanctions as well as socialization regarding ASN disciplinary rules. While the informant Director General of the Ministry of Health firmly stated that all the rules regarding ASN discipline already exist, it remains only to carry out proper monitoring in accordance with the managerial team.
The innovation and creativity achievements of the three informant teams, both the managerial team, the Sangkali Health Center professional team and the Puskesmas practitioners stated the same thing, namely the need to be given support by the Puskesmas leadership. According to the professional team, one form of support is the existence of awards or rewards.
Meanwhile, according to puskesmas health academics and the Ministry of Health, innovation and creativity should no longer be a problem for puskesmas that have carried out accreditation. If it is still not achieved, it means that you have to monitor the location of the problem again.
Collaboration in strengthening performance that is still problematic is on the side of the puskesmas leadership, so according to the managerial team this can be handled by a large number of informal meetings or formal meetings followed by informal meetings such as those carried out by the Panglayungan Health Center. According to the professional team, cooperation that feels stiff and clumsy must be eliminated because it makes performance not optimal. The same opinion from health center practitioners, academics and the Ministry of Health is that it is the leader who can make cooperative relations fun or scary in a fun or scary way or communication.
Based on the results of the analysis and in-depth interviews of the two Community Health Centers, the researcher looked for common threads between the three so that they could be classified into a comparison between the Sangkali Health Center as the main locus and the Panglayungan Health Center as a comparison Health Center as a conclusion through cross case analysis, this analysis aims to compare and integrate findings obtained from each research data results.
This data analysis includes activities to formulate propositions, compare and integrate findings, formulate theoretical conclusions. Researchers drew a common thread by looking at the differences and similarities between the three data which were conducted in 3 stages of interviews, starting from general interviews, special interviews, and triangulation interviews. Likewise with observations, starting from general observations, special observations to triangulation observations.

Proposition 1 difference:
A. Sangkali Health Center has 6 indicators of work culture that need strengthening, namely: Discipline, Innovation and creativity, Cooperation, Professionalism, welfare and focus on