CHANGE MANAGEMENT IN GOVERNMENT AGENCY:

CASE STUDY OF THE IMPLEMENTATION OF PPK-BLUD POLICY IN

NTB PROVINCIAL MENTAL HOSPITAL

Julastri Rondonuwu1, Laksono Trisnantoro2

1 Mental Hospital of West Nusa Tenggara Province 2 Public Health Science

Program, Faculty of Medicine, University of Gadjah Mada, Yogyakarta.

ABSTRACT
Background: NTB Mental Hospital as the only major referral center for mental
health services in NTB was required to serve the community, to develop and be
self-sufficient, while at the same time must be able to compete in providing
quality and affordable services to the community. In order to fulfill these
demands, since January 29, 2011 NTB Mental Hospital has received full
endorsement as a Mental Hospital with Financial Management Patterns of Local
Public Service Agency (PPKBLUD). Therefore, indepth review of the
implementation of PPK-BLUD policy in NTB Provincial Mental Hospital (RSJP)
isrequired.
Objectives: To explore the transformation process and implementation of PPK-
BLUD policy in RSJP.
Methods: The design of this study is a qualitative research case study to describe
the dynamics of the change process and implementation of PPK-BLUD policy in
RSJP.
Results and Discussion: The phase of transformation process was not running as
expected. The implementation of PPK-BLUD policy is not optimal because some
flexibility as a hospital privileges with BLUD financial pattern have not been
implemented yet. The f inance manager was hesitant to implement the flexible
financial management and still following the local government financial
management mechanisms. For external stakeholders, the implementation of PPK-
BLUD policy implementation in RSJP did not harm local fiscal policy because
the revenue of RSJP was still counted as revenue for local government, as
opposed to independent PPK-BLUD. A survey was conducted, consisting of
community satisfaction towards the services in RSJP, data of revenue and
budgeting management and distribution of fee services to employees in RSJP. The
survey result described that the implementation of PPK-BLUD policy in RSJP
gives positive impacts on financial, services and benefits performances to RSJP.
The positive impacts were an increase in the number of income, increased of
service indicators measurement and increased incentive to all employees.
Conclusion: Management changes in the transformation process were not running
optimal so that the PPK-BLUD policy in RSJP is not fully implemented, although
there were some perceived positive results.
Keywords: Local Public Service Agency, policy, change management.

INTRODUCTION
Hospitals as one of the service institutions Public plays an important role for
Improvement of public health status. Home Sick is required to serve the
community, can Developing and independent and must be able to compete
And provide a quality service and Affordable for the community. The problems
are Emerged like a limited operational budget Which is available, the bureaucracy
is too deep The process of disbursement of funds, the rules of financial
management Which inhibits the smooth service, the lack of Support Human
Resources (HR), Need technology and capital very Big.
The form of public service is a form that Most appropriate for public hospitals.
Agency Services General (BLU) is a government quasi body Which is not aimed
at making a profit, improving Quality of public services, and providing autonomy
Or the flexibility of public hospital management, either Owned by the central
government as well as local governments.
Fulfillment of the demand for quality of service Quality then since 2008 Hospital
The soul of the Province of West Nusa Tenggara (NTB) seeks To get approval as
a service institution Public with a Public Service Agency status Regional (BLUD).
a hospital change becomes a public service agency is a form reforms mandated
directly in the law act no. 44/2010. based on the decree governor of west nusa
tenggara 56/2011 provincial mental hospital is designated as an agency regional
public service with full status since january 29, 2011. since the status setting,
various attempts have been made by the BLUD Team of NTB Province Mental
Hospital For the Mental Hospital (RSJ) NTB Province can Immediately operate
according to the KDP-BLUD mechanism. Implement On the Job Training to RSU
Moewardi Solo and to Surakarta Mental Hospital And proposes a draft of
technical guidelines / regulation The technical implementation of KDP-BLUD is
two activities The main purpose is to accelerate implementation implementation
policy of kdp-blud at rsj province. technical regulation is expected to
legalized and further strengthened the management system implementation of
KDP-BLUD at RSJ Provinsi. this new management system is expected
provincial hospitals able to improve the quality of service to society and welfare
for the people the employee. therefore, the purpose of this study is to explore the
implementation of the process transformation of mental hospital and
implementation the implementation policy of KDP-BLUD at the Hospital
The soul of NTB Province.

MATERIALS AND RESEARCH WAYS

This research is qualitative with design case study. The study involved 17
respondents Which consists of 6 external stakeholders and 11 internal
stakeholders. All respondents External is the echelon II officials within the scope
of Government And Provincial DPRD NTB. While respondents Internal is all
structural officials and Some functional personnel in the scope of the Hospital
The soul of NTB Province. The location of the study was conducted at NTB
Provincial Governance region. Data taken By purposive sample at Provincial
Bappeda Office, Provincial Government Finance Bureau, Legal Bureau
Provincial Government, Provincial Inspectorate Office, Provincial Health Office,
DPRD Office Provincial and Provincial Mental Hospital. Data collection was
done by interview Depth to the subject of research, observation Or observation of
its activities Became the subject of observation and study of documents against
Documents related to the problem research. Data analysis is done by way of
Reading and reviewing data (making observation notes And interview transcripts)
to detect Emerging themes or categories, Make the presentation of data and make
conclusions.

RESEARCH RESULT AND DISCUSSION

Transformation Process
Implementation of KDP-BLUD policy at provincial hospitals Begins with a
transformation process through Eight stages. Implementation of each stage
Determine the success or failure of the transformation process, As shown in Table
13. Results The research also shows that the problem At the stage of the
transformation process turned out to have an impact Also on the implementation
of policy implementation The.
Table 1. Eight Steps to Transform Organization
No Steps

1 Setting something urgent

2 Establish a strong guide co-ordinate

3 Creating a vision

4 Communicating the vision

5 Empower others to act on that vision

6 Plan and create short-term victories

7 Consolidate improvements and keep making change

8 Institutionalize a new approach

Raising this sense of urgency is not a It is easy because it is very difficult to move
People or staff from their comfort zone each. Fear of certain people With the new
provincial RSJ management plan Very disturbing their existence during This is
already comfortable with the mechanism The old one that is considered to be
compatible with the culture Their daily work. The fear was caused Because the
transformation of the organization is creating Major changes in structure, process,
culture Organization and environment-oriented Organization. The formation of
the BLUD Team as the Guiding Team Coalition has several replacements
Because it adjusts to the presence of members Teams are mutated. Changes to
existing teams affect Coalition forces to carry out the task change. Weak
coalitions that influence Time range of the transformation process In Provincial
RSJ and implementation performance next. Clear and easy-to-understand vision
helps Management of provincial hospitals to direct the Employees towards the
goal they want to gain from the initiative The proposed changes. Vision of the
Hospital The Provincial Soul (RSJ) is clearly stated in the document Business
Strategic Plan (RSB) .The vision is there Must be communicated clearly and
purposefully. Vision That exist in RSB socialized and communicated
Routinely to all staff of Provincial Hospital, Even the vision is also disseminated
to the stakeholders External to their understanding Good to the existence of
Provincial Hospital. Communication of vision to external stakeholders is not
Everything can be delivered to the fullest. This is evident from the existence of
external stakeholders Who do not understand the contents of RSB. The
Stakeholder Do not understand this gives a negative view over Provincial RSJ
plan for transformation Into the Service Provider Financial Management Pattern
General Area (PPK BLUD). Provincial Hospital Leader encourages Team to
More daring to issue original ideas And make creative breakthroughs. Employee
Which rejects the change of coaching and employees Which supports a valued
transformation program In a way more involved in each activity Trainings to
improve capability They are in the BLUD field. At this stage of assertiveness
Can not be done by the leadership of RSJ Provinsi, It is seen that until the
implementation phase Policy of inevitability and work culture with Old patterns
are still mostly done by employees Provincial Hospital. Creating a short-term
winner inside The transformation process is indispensable to cultivate Motivation
to employees. Settlement Assessment documents and workshop implementation
BLUD is the achievement of the long run Shorts achieved by the BLUD Team.
Victory BLUD team for short-term achievement Not the end of the process of
change but rather as a stage of achievement that must be followed immediately
Subsequent achievement. The team still has to do Consolidation to related parties
for improvement which is better for successful implementation KDP BLUD
policy. After a series of processes implemented then To strengthen the results of
the transformation process Then this mechanism is instilled in the institution
Through institutionalization into an institution Service with KDP BLUD through
the Governor's Decree NTB No. 56/2011.

Policy Implementation of Management Patterns Finance Regional Public

Service Agency
There are six variables that affect performance Implementation of policies at an
institution or organization. The six variables are standard And the objectives of
the policy, resources, relationship or Communication between organizations,
agent characteristics Implementers, socio-political and economic conditions as
well The disposition of the implementor or the attitude of the executors.

Standards and Policy Goals

Implementation of policy implementation of Pattern Management Finance
Regional Public Service Agency (PPK BLUD) at the Provincial Hospital is
intended for Making the Provincial Hospital as a service institution Which is
dynamic in the face of progress Era, technological advancement and able to
Quickly respond to patient needs. Organization It is necessary to carry out
innovation activities and in a manner Continuous improvement of products and
services Them to meet consumer demand Which is changing and in order to face
the competitors. Standards and policy goals are a Part of the content of a policy.
Triangle analysis policy states that one important factor In analyzing a policy is
with View and understand the content / content from The policy.
Stakeholder understanding of the content of the policy The implementation of
KDP BLUD encourages acceleration Implementation of the policy in RSJ
Province.
"We're pushing her into a BLUD because we see that many things must be
Immediately resolved and handled by the head the existing working units are
handled Can not be delayed so he Given greater authority in managing
Especially in improving Service "(E3)
"I judge the mechanism is good, I agree. The point is with that mechanism ..
Hope the service to the community Much better increased, more qualified,
Besides also the welfare of its employees It increases too because there is space
Creativity there, there is room to innovate, Creative in order to improve Service to
the public ... "(E1)
"The BLUD can be more flexible Faster then can be more flexible To overcome
the situation condition He is free or differentiated With other SKPD ... eh in terms
of human resources, within Finance thing, it's set ... yes it is "(E6)
Hospital BLUD can be said good quality If able to give positive results on three
The main performance of a BLUD hospital is impact Positive on financial
performance, service performance As well as performance benefits. To measure
the performance of benefits for the community The Provincial RSJ conducted a
satisfaction survey Society which refers to the Decision of Menpan No. KEP / 25 /
M.PAN / 2/2004. Quality of service performance Measured and evaluated
indicators Services contained in the document SPM. As for the financial
performance is measured from PAD attainment and the amount of JP that is
shared to Employees. Results of community satisfaction survey on Services
provided by provincial hospitals and surveys To the implementation of Minimum
Service Standards 2012 shows good scores. Happen Increasing the achievement of
SMEs in Inpatient Unit And Emergency Room while Outpatient Unit Experienced
a decrease in scores compared to 2011. This is understandable because of the
number of visits Patients and BOR data are considerably increased compared
2011. Some visitors complained about the time Wait for examination by sufficient
medical personnel Long because the medical personnel who served in the
Installation Outpatient must complete the examination Hospitalized patients first.
The results of this survey the Provincial RSJ know How far they have been able to
meet the needs Customers and can predict the forms Services that are likely to be
liked and Not liked by customers. System oriented Customers are forcing service
providers to be able Responsible to its customers. Customer Can choose to meet
their needs, Service providers should keep looking for feedback on Needs of its
customers and then Trying to fulfill it.
Operational financial performance with The mechanism of KDP BLUD is
not good but from In terms of performance benefits, achievement of revenue
targetsWhich each year has increased deliver Picture that measures the
implementation of the policy The setting of acceptance targets is the standard
Realistic in the midst of limited facilities and Existing infrastructure. The
hospital's income Increased can provide benefits for improvement Financing
hospital operations and benefits for the improvement of welfare Employee at RSJ
Provinsi.

Communications, Social Politics and Economics

Implementation of a policy needs support And coordination with other agencies or
cooperation With other agencies.
"RSJ should still be supported because of that obligation Government ... and that's
no problem .... That to meet the Service Standards Minimum we may have a
hospital Also can not fully from retribution So people still need funds Of the
APBD .... like a mental hospital "(E1).
"We still support him..supportnya employees His country remains paid through us
TKDnya through here .. then some Also financed from the local government as
well as for example Improvement of infrastructure facilities ". (E2)
The determination of budget allocation is not all responses Externally argue the
same. There are respondents Who argue that the RSJ should still be supported
Primarily in terms of meeting MSS Because the hospital can not be completely
dependent Of community levies, while respondents Others still think that BLUD
is meaningful Yes must meet the operational needs of the results own.
"That's why the BLUD is still understanding Is from the result .. yes hell ... yes
Right. "(E2)
 Not all external stakeholders provide A positive response to the
implementation of PPKBLUD At the Provincial Hospital. Pessimism is caused
Because of the lack of understanding of such stakeholders Business Plan Strategy
document. Related stakeholder understanding of flexibility Administration of
APBD funds and BLUD funds Is that there is a difference of opinion between
Inspectorate and law firm, it is related to Form of liability of BLUD fund
disbursement. The Inspectorate demands the existence of a Decree Governor for
disbursement of Services Fund Employees at the Provincial Hospital while the
Legal Bureau feels there is no need for a Governor's Decree because
Disbursement of Service Fund is sufficient with SK Director of Provincial
Hospital. This situation illustrates that communication between the inspectorate
and the bureau The law does not go well. Good communication between
organizations Also supported by external environmental conditions. The socio-
political and economic environment is not conducive can be the source of the
problem of failure Implementation performance. The release of the Decree (SK)
the determination does not necessarily make Provincial RSJ in 2011 automatically
executed BLUD financial management practices. This matter Due to the absence
of legal tools Will be used as an umbrella of legality to carry out Any operational
activities that apply flexibility in financial management Provincial RSUD BLUD.
Changes in the management system Hospitals depend on political policy
Government. Most of the external respondents argued That the implementation of
KDP-BLUD policy in Provincial hospitals do no harm to policy Fiscal area or
does not interfere with receipts area.
"I think the fiscal area is not disturbed Altogether ... keep the revenue from the
unit It must still we count as Reception area though physically The money we do
not manage. "(E1)
Mechanisms at Provincial hospitals to learn independently Managing
operational costs with the independent Provincial RSJ in the management of
operational costs then the region fiscally benefits from the burden APBD will
automatically be reduced.
"There is authority given to the unit BLUD that so from the fund will be able
Reduce the load right, because if Acceptance increases then automatic APBD will
be reduced so ... logically Fore so right ". (E1)
Decrease of APBD budget allocation in 2012 and 2013 related to political
condition Where the regional fiscal policy for 2012 Focused on the completion of
the acceleration program Infrastructure and for the year 2013 is focused for
Pilkada implementation. This situation illustrates That the determination of APBD
allocations depends on The fiscal condition of the area at that time as well as what
the focus is The main government and how the leadership of the RSJ Provinces
are able to communicate needs Provincial RSJ funds to external stakeholders so
that They support for increased financing Operational Provincial RSJ through
APBD funds. Implementation of this policy is not maximal because In the first
years of policy implementation The social, political and economic conditions of
the government The province is not possible to make KDP BLUD's policy as one
of the programs Priorities of local governments. This happens because The
government's main program is the settlement Local superior program and
implementation program Pilkada. There are institutions and groups that are
Often have reasons and resources To counter change. As a result, it often happens
A kind of political or economic shock in the beginning The process of health
reform.

Resources and Organization Characteristics

Successful implementation of policy depending on the ability to utilize the source
Power available, both human and human resources Non human resources. Each
stage of implementation Policy requires resources Quality human beings in
accordance with the work Which is implied by the policy set. Disposition of the
implementor or the attitude of the implementers Directly related to availability
Quality and quantity of human resources at The implementing institution of the
policy. The attitude of policy implementers to receive Or refuse the
implementation of a very policy Affect the success or failure of implementation
Policy. Implementation of KDP policies BLUD in the first year is causing turmoil
Officials and financial managers in determining Patterns of use of funds.
Understanding the implementer to the content and mechanisms of the decisive
policy performance of a policy implementation. Understanding of financial
managers and officials In the provincial RSJ to the patterns of financial
management BLUD is still very lacking which results Implementation of BLUD
policy can not Run properly.
"First of ya that science we have not so perfect so there are doubts In executing
the budget, the second Availability of power ". (R1)
"There are still difficulties in shopping or Disbursement of funds because it was
still upset In finance "(R11)
In addition to less understanding then the response Its chief policy officer in
finance also very slow, communication between parts is not running smoothly,
some things are not complete related financial administration is often not
immediate informed to the procurement of goods services But only silenced.
The flexibility that exists in the KDP mechanism The BLUD is to cut the
bureaucratic chain Too long so with this flexibility RSJ Provinces can respond
more quickly to community needs To the ministry of the soul. So far flexibility
Finances conducted in provincial hospitals not yet Can run maximally as
mandated In Permendagri No. 61/2007. Mechanism disbursement of funds still
use the mechanism APBD with too long and bureaucratic channels long. The
financial management of the Provincial Hospital has not dare to disburse funds in
accordance with the mechanism KDP BLUD because the superiors of the
Financial managers are also still hesitant to do it. confusion the managers began to
overcome after facilitation from Australian Indonesia Partnership for
Decentralization (AIPD) and the Bureau Finance NTB Provincial Government in
the form of training BLUD financial management and technical guidance Direct
BLUD at Provincial Hospital. The emphasis of training and guidance is directing
how government in the management of BLUD more spirited enterpreneurship by
applying business concepts in a healthy manner and how to create financial
reports BLUD. In addition to understanding the content of the policy, attitude
The implementers of the policy are also determined by how large implementation
of the policy provides benefits for them. Direct benefits for employee in RSJ
Provinsi is to see how great division of the Services provided to them. The hope
with improvement the division of services will improve also performance of
employees at RSJ Provinsi. If we wanting civil servants to become income
conscious, we need encouraging incentives them to make money as they took it
out.
Limited number of personnel at RSJ Provinsi Also cause less maximal
implementation KDP-BLUD at the Provincial Hospital. Quality of service
Diminished due to community satisfaction index Decreased. The attitude of the
policy implementer is reflected from Behavior / habits of daily employees in
work. Survey on Minimum Service Standards (MSS) 2012 provides an illustration
that not all Service units that measured the value of the SPM reach Target value.
Some service units experience Decrease in achievement on the assessment
parameters. One reason is the officers are still Working with old, undisciplined
patterns And compliance with SOPs that have not been fully implemented
do. Indiscipline is not just in circles Regular employees but also still visible on
some Structural officials. Work hours compliance Still neglected. The employee
leaves the study During working hours without any information and The room
was left empty. Such is the tendency Employees at government institutions for
Resume their old habits despite the need To service has changed.
The availability of funds in the transformation process Provincial RSJ to PPK
BLUD is also very influential. Not easy to cooperate With a BLUD consultant at a
cost Was in the provincial hospital at that time. This is due to Because to hire the
services of a consultant It takes a huge cost. In addition to funding for the
transformation process, source Another power that also greatly affects success
Implementation of KDP BLUD year policy First in RSJ Province is the
availability of funds Start or start-up capital. Some activities experienced Delay of
a predetermined schedule Because the Provincial Hospital has no funds for
Finance the activity. Not just activities Which is funded by a delayed BLUD fund
but As well as activities sourced from APBD funds. Activities Of APBD funds
that should be implemented soon Participate pending because the provincial
hospital has No longer provided Money Inventory (UP). Already No facilities
Replace Money (GU) and Additional Money (TU) for less budget activities.
Implementation of activities must wait Once the revenue fund collected. This
condition of course Alone inhibits the fulfillment of needs in the service unit
And inhibit other program activities Such as trainings. Financial performance,
flexibility is felt Its benefits in the budgeting system and Financing activities.
Pattern of Financial Management Regional Public Service Board (PPK BLUD)
RSJ The province is no longer dependent on financing Operational activities on
APBD funds only but Can already use the funds directly from the results
Services. Budgeting system can be shifted Following urgent needs as needed
With the regulation of the level of procurement value Goods and forms of
administrative accountability Which is not as complicated as procurement from
APBD funds. System Procurement like this is mostly a necessity Logistics of
direct services and support services No longer have to be tendered so that the
process Procurement of goods can be accelerated. This shows that by applying
Mechanism of KDP BLUD, RSJ Province slowly Change management to
institution Government-oriented service Customers, because the customer-
oriented government Is the government that meets the needs Customers and not
bureaucratic needs. Determination of Provincial RSJ as KDP BLUD is not
Reduce local government intervention in terms of Management of management
and Human Resources (HR) due to the status of provincial hospitals that remain
as Regional Government Technical Institute (LTD) Provinces. Limitations on the
number of employees at the Provincial Hospital Increasingly exacerbated by the
existence of employee mutations Provincial RSJ to other agencies. Provincial RSJ
as Provincial government-owned LTD organizations must submit On the rules of
mutation made by the Agency Regional Personnel (BKD) Province. Civil Service
Agency Region (BKD) in the mutation does not Consider the condition of the
current Provincial RSJ This newly implemented a very BLUD KDP policy
Requires professionals to Improve the quality of service to the community.
This is of course very unfortunate because of personnel Is the most expensive and
most resource Important in the hectic health sector creation. This situation shows
that KDP status BLUD full of provincial RSJ has not made management RS
autonomy in full while system Which good management requires autonomy On
various aspects and needs. More and more Aspects of management that are then
automated The hospital will be easier to do Hospital management

CONCLUSIONS AND RECOMMENDATIONS

Conclusion
Implementation of Financial Management Policy Policy Regional Public Service
Agency as an Effort In Doing Change Management Not yet Maximum Running,
because: 1) The Coalition Team acts As the manager of less understanding
activities Implementation of the policy mechanism of PPK BLUD so that
Do not dare to act maximally in Financial management processes, 2) Absence
Assertiveness of the leaders at the Provincial Hospital for Enforce discipline
against existing rules, 3) Communication to external stakeholders Less actively
carried out by the coalition team so it raises Differences in perceptions among
stakeholders External, and 4) Understanding and support External stakeholders
are not all the same. Managing changes does not forever result Impact desired.
Initiative change In organizations often fail due to impact Which happened not as
we expected.

Suggestion
Mental Hospital (RSJ) strengthens the coalition team Through increased capacity
building so that the team More confident and daring to carry out Financial
management in accordance with flexibility which are given. Leader element in the
scope of Mental Hospital (RSJ) can act more firmly in enforcing Discipline
against existing rules. Mental Hospital (RSJ) should act More active to socialize
mechanism KDP-BLUD to external stakeholders.