Quality Service Strategy in Improving Performance of Puskesmas Service Area of Mranggen District

This study aims to analyze the quality of services available at the health center of Mranggen in order to formulate a strategy to improve the quality of health services of Puskesmas by analyzing the importance and level of performance in six dimensions of service quality (Tangibles, Reliability, Responsiveness, Assurance, Empathy and Accessibility) to produce performance (performance) that can satisfy customers. The data analysis of this research was conducted by qualitative descriptive method, to answer the problem formulation about how to improve the quality of health service of Mranggen in accordance with the quality standard set by the Government, then used "Importance-Performance Analysis" with Cartesian diagram, the number of samples of this study 75 respondents taken from three Puskesmas available at Puskesmas Mranggen. The result of the research shows that the dimension of Responsiveness is the main priority to improve the quality of service because it has the highest importance of 81.3%, while the performance is still low with the level of conformity of 71%, while the next sequence based on the level of conformity is Assurance dimension, Accessibility, Tangibles, Reliability, and Empathy. Thus the whole health center Mranggen considered good enough from the level of customer satisfaction.


Introduction
Health services to all citizens are the responsibility of the government by the mandate of legislation (Law No. 36 of 2009). However, it has not been implemented well because there are still many complaints from the public about health services. That can be proven from several studies on the quality of service in government agencies. Quality of service delivery is a strategic pillar for the implementation of hospitals, especially for local government-owned hospitals in the decentralization era. It is ironic to find that the quality of services provided by the Regional General Hospital (RSUD) is still below the expectations of the community while the poor, disadvantaged members of the community desperately need quality services (Mulyana, 2015).
Government-owned health services are required to respond to community demands in providing health services for their community. Quality improvement methods and techniques such as statistical processes are commonly used in other industries and have recently been proposed as a tool to improve service delivery and performance in public health environments (Boe, Debra Thingstad, 2009). Based on some research conducted by academics and bureaucrats about public services in Indonesia, the condition is still often "considered" not good and satisfactory. That is shown from the conclusions made by Agus Dwiyanto, et al. in GDS (Governance and Decentralization) 2002 in 20 provinces in Indonesia on the performance of public services mentions "... in general the practice of public service delivery is still far from the principles of good governance. Then the performance of the public bureaucracy service in Indonesia, based on a report from The World Competitiveness Yearbook in 1999 is in the group of countries that have the lowest competitiveness index among the 100 most competitive countries in the world (Cullen and Cushman, in Dwiyanto, et al., 2002).
According Dwiyanto (2001) states about the performance of public service bureaucracy: "The low performance of the public bureaucracy is strongly influenced by the still strong paternalism culture, which tends to encourage bureaucratic officials to be more oriented towards mastery rather than service, positioning themselves as rulers and treating service users as an object of service in need of assistance. Also, low performance is caused by a powersharing system that tends to focus on leadership. The hierarchical, bureaucratic structure encourages a concentration of power and authority on the superior so that bureaucratic officials directly linked to service users often do not have adequate authority to respond to the evolving dynamics in service delivery".
The poor performance of public services is partly due to the lack of transparency and accountability in the implementation of public services. Therefore public services must be implemented in a transparent and accountable manner by each unit of government agency services because the performance quality of public service bureaucracy has widespread implications in achieving public welfare. Given the type of service is very diverse with different characteristics, then fulfilling the service required guidelines used as a reference for agencies within the environmental health agencies. Puskesmas Mranggen located in Demak Regency is a health service provider with the working area covering all districts of Mranggen consisting of (three) Puskesmas namely Mranggen I, Mranggen II, Mranggen III. Based on Table 1. we can see the condition of the population from the work area of Puskesmas Mranggen based on the percentage of the number of healthy houses. Based on Table 1, it can be seen that the health center of Mranggen has a population condition with a tiny number of healthy homes, with the percentage of healthy homes only 48.2%, it means that there are still many houses of Mranggen residents who are not healthy, the increasing number of people in need of health services in health centers Mranggen. Very much needed health services by the community Mranggen, of course, is expected is a quality health service and give the satisfaction that can improve the health status of the community especially in the region Mranggen. To see the number of people using health services from 2014 -2016 at the public health center in Mranggen can be seen in the following table of patient visits: Based on data in Table 2, it can be seen that Puskesmas Mranggen1 experience fluctuation of the patient visit, and at Puskesmas Mranggen 2 decrease number of visit whereas at Puskesmas Mranggen 3 increase of patient visit number from year to year. However, for the overall number of patient visits at Puskesmas Mranggen can be seen in Figure 1 below: Source: Demak Regency Health Office, 2017

Figure 1. Overall Patient Visitor Data Chart
Based on Figure 1, it can be seen that the overall number of patient visits at Puskesmas in Mranggen decreased from year to year. So contrary to the number of healthy homes that only 48.2% means that the need for health services is essential but the number of visits at Puskesmas Mranggen decreased and based on the results of preliminary interviews (pre-survey) with some visitors in the health center Mranggen many complained about the service given in relation to some of the above-mentioned service quality indicators. One of the visitors said that to get free service facility in Puskesmas is not as easy as imagined, it is proved by the requirement required to bring a certificate issued by local urban village, even though the information is not socialized to the visitor either in the form of announcement or circular to each RT \ RW.
Another visitor recounted his experience while doing the treatment at Puskesmas Mranggen, the readiness of both administrative and medical personnel is very poor so often patients must be willing to wait to get health services. Also, the available facilities such as waiting room that is less comfortable cause the patient often feels abandoned, for that this research formulate a strategy to improve the quality of patient service that impact on the improvement of health institutions performance that ultimately can improve the degree of public health.

Literature Review
Quality of Service According to Lukman (1999), the conventional definition of quality usually describes the direct characteristic of a product such as: a. Performance (performance) b. Reliability c. Easy to use d. Aesthetics (esthetics) and so on.
Lukman expresses quality as everything that meets the wishes or needs of customers (meeting the needs of customers). Understanding quality basically refers to the basic understanding: a. Quality consists of some product features, both direct features and attractive features that satisfy customer needs and thus satisfy the use of the product. b. Quality consists of everything that is free from deficiencies or damage.
Furthermore, in relation to service, according to Zeithaml, Parasuraman, Berry (2006). To know the quality of service perceived significantly by consumers, there are indicators of customer satisfaction measure that lies in the five dimensions of service quality. The five Servqual dimensions include the following: 1. Tangibles (service quality in the form of physical office facilities, computerized administration, waiting room and place of information). This dimension relates to the modernity of the equipment used, the attractiveness of the facilities used, the neatness of the officers and the completeness of supporting equipment (pamphlet, announcement). 2. Reliability (ability and reliability to provide reliable service). Dimensions relate to the promise of accomplishing something as desired, handling customer complaints, performing the right service, providing timely service as promised and fixing the demand for recording errors. 3. Responsiveness (the ability to help and provide services quickly and accurately, and responsive to the desires of consumers). These dimensions include notification from the officer to the consumer about the services to be provided, the delivery of services quickly, the willingness of the officers to assist consumers and officers never feel busy to serve consumer demand.

Assurance (ability and hospitality and courtesy of officers in ensuring consumer confidence).
This dimension is related to the behavior of officers who remain confident so that consumers feel safe will the ability of officers and can answer consumer questions. 5. Empathy (firm but the attentive attitude of the officer to the consumer). This dimension includes, among others, the giving of individual attention to the consumer, the timeliness of service to all consumers, the company has officers who pay special attention to the consumers, the essential service of consumers and officers who understand the specific needs of its customers.
When described consumer ratings on service quality (servqual) are as follows:

Service Performance
According to Hoffman and Beteson (1997) without customers, service companies have no reason to operate. Meanwhile, according to Mowen (2002), Customer satisfaction is defined as the overall attitude regarding goods or services after the acquisition and use of the value of price relations. Performance can be viewed as a process or a result of work. Performance is a process of how work takes place to achieve work. However, the work itself also shows performance (Wibowo, 2011). Armstrong and Baron in Wibowo (2011) define performance as a result of work that has a strong relationship with organizational strategic goals, consumer satisfaction, and economic contribution. Based on the definition, it can be concluded that there is a strong relationship between performance and customer satisfaction

Puskesmas Management Performance
Puskesmas management performance is measured by two main conceptions of efficiency and effectiveness. According to Drucker (2008), efficiency is doing all the work right (doing the jobs right), while effectiveness is doing all the right jobs. Efficiency (effectiveness) of Puskesmas is the process of exploiting, saving and pushing of Puskesmas resources by doing the job properly, while effectiveness (the result of use) of Puskesmas is the success level of achievement of the purpose of Puskesmas by way of doing the right job. The effectiveness of Puskesmas also means being able to achieve the purpose of Puskesmas well. If efficiency is more focused on the process of utilization of savings and empowerment of resources (input), then the effectiveness is more focused on the output and outcome or performance results of employees and health centers as expected. Efficiency is related to the relationship between the output of health services with the resources used to produce output and outcomes (Handoko, 2003) Improving the quality of Puskesmas is the real demand of the community because the number of visits Puskesmas since 1997 has decreased. Priority setting by each Puskesmas is the first step for the development of a program to maintain health service quality of Puskesmas. Increased commitment and support of Puskesmas employees should be developed in order to improve the work process by formulating realistic health service healthcare standards in accordance with local needs and then monitoring progress. In other words, the quality assurance of Puskesmas health services is done through a problem-solving cycle approach and a chain of quality improvement with a sustainable performance appraisal. the quality assurance of the health services of the Puskesmas begins by establishing a health care quality control unit of the Puskesmas that will identify the problem, then look for the cause of the problem and at the same time monitor the implementation to meet the health service standard and ultimately will build a performance standard based on current information, technology and patient expectations. This activity will repeatedly, find the problem, determine the cause of the problem and implement corrective action and monitor the results, so as to create efforts to improve the quality of health services continuous health (Pohan, 2003).

Research Methods
This research uses descriptive qualitative research design or design that is mixed between qualitative and quantitative, by using technical data analysis Importance-Performance Analysis and Cartesian Diagram. Cartesian diagram is a build that is divided into four sections bounded by lines intersecting perpendicular to the point (X, Y), where X is the average of the average score of the execution level or customer satisfaction of all factors affecting customer satisfaction. So obtained sample = 68 respondents. Sample size greater than 30 and less than 500 is sufficient for most research, then to facilitate the calculation of statistics and to analyze, the sample used amounted to 75 Respondents, which then divided the three Puskesmas in the district Mranggen.
The data were collected using questionnaires using Likert scale 1-5 items. Because this study aims to find the gap between performance and customer expectations, the Likert scale is given the following weight: For performance variables, the scale used consists of very good, good, good enough, less good, and not good. For variable interest/patient expectations, the scale used consists of: very important, important, important enough, less important, and not important. To obtain accurate data and represent an unknown number of population, the questionnaires will be distributed to 75 After calculating the level of conformity to the interests or expectations of customers and the performance of Puskesmas Mrangggen over the dimensions of service quality then these values can be mapped into the following Cartesian diagram: Source: Primary data processed 2017