Analysis of Hospital Service Management from the Perspective of Local Balinese Wisdom

This study aims to analyze the health service management of provincial hospitals (RSUDs) in Bali from the perspective of local wisdom, especially Tri Kaya Parisuda values and the integration of Tri Kaya Parisuda values with human capital theory (HCT). Structural equation modeling (SEM) was applied as the analysis technique in the study. The results showed that the management of health services at Bali’s provincial hospitals was considered satisfactory and in accordance with the existing health service standards, although there were certain staff members who had not provided maximum service. Intellectual intelligence to think properly ( manacika ), communication equivalent to correct sayings ( wacika ), and good employee behavior ( kayika ) contributed significant effects on the performance and service quality of RSUDs in Bali. This study discovered that the performance and quality of service were more dominantly affected by employee behavior than by intellectual intelligence or communication .


INTRODUCTION
Health development initiatives aim to increase public awareness, willingness and ability to promote a healthy lifestyle in order to achieve an optimal level of personal health. Article 1 of Law No. 44 of 2009 stipulates that a hospital is an institution that organizes comprehensive health services and provides inpatient, outpatient and emergency services. Health service performance is a parameter to measure a hospital's achievement as a basis for hospital management decision-making process (Muninjaya, 2012;Anis, 2014). Hospital services are appreciated by the public for the quality of health services provided. Enhancement of the quality of hospital services is increasingly needed in conjunction with the increasing knowledge and requirement of the community members as service recipients. However, it must be admitted that efforts to improve the quality of hospital services are not simple due to various challenges. The level of service quality is greatly influenced by the hospital's resources, namely medical/non-medical personnel, financing, facilities and technology. In addition, hospital management and board of management must have a high commitment in transforming a quality work culture for all staff members (Muninjaya, 2012). This is to avoid negative public view of the hospital image such as officers' ignorance, lack of attention to patients' complaints, slow service, unfriendliness, and the absence of quality management system (Muninjaya, 2012).
The paradigm shift in service standards began in 2012, focusing on patients, hospital management standards, patient safety goals, and the targets of Millennium Development Goals (MDGs). These service standards refer to the International Joint Commission (JCI) standard as well as the MDGs goals as a form of KARS commitment. The performance assessment is based on the community or public satisfaction index according to nine elements stated in Ministry of State Apparatus Empowerment Regulation No. 14 of 2017. The regulation issued by the Indonesian Ministry of Health No. 340/Menkes/Per/III /2010 states that a hospital classification is a grouping of hospital classes based on facilities and service capabilities. Standard Operating Procedures (SOP) are used as a reference in providing quality services to increase work efficiency and effectiveness (Ministry of Health, 2005). Primary health care is related to patient expectations and medical diagnosis results, while secondary health care is related to affordable service costs and the fulfillment of government and hospital regulations (Azwar, 1994;Alifin et al., 2011;Sundari et al., 2014).
The results of studies conducted by Iloh et al. (2012) at the National Health Insurance Scheme Clinic of a tertiary hospital in South-Eastern Nigeria; Sudarni (2009) at Cirebon Hospital; Suharmiati and Budijanto (2007) at the Government Hospital in Indonesia;and Nesa et al. (2012) at Menado Air Force Hospital show that good service quality has a significant effect on patient satisfaction. In contrast, the results of research by Ismiranto (2009) at Yogyakarta Hospital and Pratiwi (2010) at Cipto Mangunkusumo Hospital indicate that internal and external perspectives have a negative and significant effect on the quality of hospital services. These findings prove a research gap between the results of research by Iloh et al. (2012), Sudarni (2009), Suharmiati and Budijanto (2007), Ismiranto (2009) and Pratiwi (2010. The values of Tri Kaya Parisuda have been developing, are universally recognized, and are implemented in the life of the Hindu community in Bali (Sunariani et al, 2017). Tri Kaya Parisuda values present a significant effect in shaping the character of quality individuals in the life of the Hindu community. Therefore, these values are considered appropriate to be used as a measuring tool in assessing the quality of human resources. Present human quality should be assessed from the aspect of attitude or character, without ignoring other numerical aspects of assessment (Sunariani et al., 2016). From point of view of hospitality, the Tri Kaya Parisuda values are considered appropriate to be used as a philosophy for hospital employees in providing services (Peter S. G. & Andris N., 2012). Health services at hospital can be developed through the implementation of Tri Kaya Parisuda values for officers in serving patients and hospital service users (Muninjaya, 2009).
The province of Bali has nine regional general hospitals (RSUDs) located in nine cities/regencies, namely Wangaya Hospital in Denpasar City, Mangusada Hospital in Badung Regency, Sanjiwani Hospital in Gianyar Regency, Semarapura Hospital in Kelungkung Regency, Bangli Hospital in Bangli Regency, Amlapura Hospital in Karangasem Regency, Singaraja Hospital in Buleleng Regency, Tabanan Regional Hospital in Tabanan Regency, and Negara Hospital in Jembrana Regency. The vision of these hospitals is to become a teaching hospital with professional, innovative and cultured services towards internationally accredited standards. The management of health services at the hospitals is considered satisfactory and in accordance with health service standards. However, there are still human resources issues in providing services to patients and patients' families, such as communication style and less-empathetic and less-friendly behavior of officers in handling patients' complaints. Patient dissatisfaction with the image of hospital services is influenced by the quality of health service management according to existing standards. Therefore, a collaboration of local wisdom is needed between Tri Kaya Parisuda values, namely manacika, wacika, kayika, and human capital theory (HCT), such as intellectual intelligence, communication, and employee behavior to improve the performance and quality of hospital services. From the description above, the research problem was formulated as follows: How is hospital service management in the perception of local Balinese wisdom? The purpose of this research is to determine the management of hospital services in integrating Tri Kaya Parisuda values with the intellectual intelligence, communication and employee behavior variable to improve the performance and quality of hospital services.

LITERATURE REVIEW Local Wisdom of Tri Kaya Parisuda Values
Etymologically, local wisdom can be understood as values, views, teachings by the community (English-Indonesian dictionary by John M. Echols and Hassan Syadily, 2004). Local wisdom is a truth that has become a tradition in various regions in Indonesia, in addition to a combination of religious values and social and cultural values (Idrus, 2008). Among Hindus is also known local wisdom (local genius) which refers to the understanding of the essential teachings of Tri Kaya Parisuda values; that is, manacika, wacika, and kayika as a philosophy that has grown and developed to improve the self-quality of in the socialcultural life of the Hindu community in Bali (Sunariani et al, 2017). Even now, it has become a philosophical foundation for shaping the character of Hindu humans since they are still in the womb until they are born to be good children (anak suputra). According to Pustaka Suci Sarasamuccaya sloka 73 and 77, Tri Kaya Parisuda values are (1) positive thinking (manacika) meaning rationality, initiative, creativity, innovation and fostering and developing positive future-oriented creativity, (2) speaking honestly (wacika) that has an important role in shaping a good human being, and (3) good behavior (kayika) which means ability to improve good quality of personality (Gorda, 1999;Suhardana, 2007 andMangkunegara, 2005;Gibson, 2012). The values contained in Tri Kaya Parisuda have a significant effect in improving the performance and quality of service (Terja, 2016). Similarly, it is explained that local wisdom in one area may be different from local wisdom in other areas (Tia, 2004).

Service Management
Terry's management theory (1986) is a science and art of managing the process of utilizing human resources and other sources effectively and efficiently to achieve certain goals (Hasibuan, 2008). Health service management is the degree of fulfillment of community needs for health in accordance with good professional standards by fair, efficient, and effective utilization of resources within limitation for customer safety and satisfaction in accordance with good norms and ethics (Muninjaya, 2011). The quality of health services shows that the level of perfection in health services leads not only to satisfaction for patients but also to suitability with the established standards and professional code of ethics. Continuous, systematic, objective, and integrated efforts in identifying and determining problems and causes of problems based on established standards, establishment and implementation of problem solving according to the available capacity provide further suggestions to improve service quality called service quality management.
The concept of clinical governance was first introduced by the UK Department of Health (1997). Conceptually, there are four main components: (1) accountability; every medical effort must be scientifically, ethically and morally accountable; (2) continuous quality improvement, quality improvement efforts must be carried out systematically, comprehensively and continuously; (3) high quality standard of care, which implies that health service efforts are always based on the highest professional standards, facilitating and creating an environment that ensures the implementation of quality health services, (4) clinical governance, a new approach that aims to ensure the implementation of quality health services. The best service is given to all patients everywhere (Scally and Donalson, 1998). In practice, clinical governance is implemented in an effort to overcome and prevent side effects due to poor performance of health service workers. Implicitly, clinical governance is also expected to improve the better performance of health services (Dwiprahasto, 2001).

Quality of service
Kotler and Armstrong's theory (2008) says that service quality is a consumer's perspective of expected service and perceived service to create customer satisfaction. This theory assumes that service quality is said to be satisfactory if the service received is in accordance with customer expectation. Excellent service quality is labeled if the service received exceeds customer expectations. Service quality is a very important issue for every organization. Tjiptono (2008) points out that service quality can be defined simply as a measure of how well the level of service provided is in accordance with customer expectations. Dimensions to measure service quality are tangibility, reliability, responsiveness, assurance, and empathy (Parasuraman et al, 1988). The method of measuring service quality is by SERVQUAL (service quality) method with the term of gap analysis model Tjiptono and Chandra, 2005;Setianto, 2010;Mulyani, 2003).
In increasingly fierce competition, a service provider may use one strategy by improving service quality (Rudy & Wansley, 1985). This research was also conducted by Gunawan et al (2011) Based on Dessler's (2015) performance theory, a person's work performance can be measured by comparing work results with the set standards (Robbins, 2015). Furthermore, the performance indicators are quality, quantity, timeliness, effectiveness, independence, and commitment according to responsibility (Mangkunegara, 2002). Improving service quality means increasing customer satisfaction and ultimately improving performance Lupiyoadi, 2001;Diana and Harmawan, 2012;Artana, 2014;Ginting, 2012). Performance measurement indicators consist of input, process, output, outcome, benefit, and impact. Performance is a parameter measuring the hospital achievement, so that performance achievement is used as the basis for management decision making (Muninjaya, 2009;Anis, 2014).

Intellectual Intelligence
Robbins' (2001) theory of intellectual intelligence is designed to ensure mental, thinking, reasoning and problem-solving abilities to achieve goals. The ability to adapt to new needs by using thinking tools that fit the purpose is called intelligence (William Stern in Ngalim Purwanto, 2007: 52). Indicators of intellectual intelligence are concept understanding, ability to solve problems optimally, and ability to achieve goals (Stenberg in Arie 2009). To improve intellectual intelligence, someone needs to think sincerely and accept other people the way they are. This research has focused on mental abilities and good thinking as an intellectual intelligence and the measurement of service quality through intellectual intelligence of human resources (Rudy and Wansley, 1985;Gibson and Ivan, 2012;Griffin, 2002). One of the main factors that companies must pay attention in increasing customer satisfaction is improving service quality and performance Lupiyoadi, 2001;Diana and Harmawan, 2012;Artana, 2014;Ginting, 2012;Muninjaya, 2012). The results of research conducted by Choiriah (2013) suggest that performance will not be achieved if an employee does not have the ability to think correctly (rational and creative), and as a result, he cannot ignore the role of intellectual intelligence in improving performance (Sina and Noya, 2012). Communication Littlejohn's (2002) communication theory confirms that communication is difficult to define. It is the ability to communicate or negotiate to achieve organizational goals. Good communication indicators, according to Hutapea and Nurianna (2008), have knowledge to understand information correctly, skills, the ability to communicate clearly and well, and creative and innovative attitudes (Haryono, 2006;Lewis & Booms in Tjiptono, 2016). This study has focused on good communication skills which have a significant effect on service quality (Terja, 2016).

Employee Behavior
The perspective of Prawirosentono's (1999) behavioral theory shows the characteristics of a person's attitude and way of speaking personally (Sofyandi and Garniwa, 2007;Sobur, 2003: 287). Behavioral indicators are nativism, empiricism, naturalism, and convergence (Notoadmodjo, 2010: 5). This study has focused its attention on good behavior based on the results of studies by Furqoni et al (2014) at Lampung Province Hospital and Hafsyah (2012) at Pariaman Hospital. They show that the caring behavior of health workers has a significant effect on patient satisfaction.

METHOD
This research was conducted at nine hospitals in Bali Province, using quantitative research design with a background of research gaps and phenomena at the research location. In this study, the measurement of hospital service quality performance is focused on external performance (consumer perception and satisfaction), especially at the hospital, to integrate the values of Tri Kaya Parisuda with Resource Human Capital Theory. Therefore, the values of Tri Kaya Parisuda are proxied with the intellectual intelligence variable which is equivalent to good thinking (manacika), communication variable equivalent to good saying (wacika), and employee behavior variable equal to good behavior (kayika). Data collection techniques used questionnaires as the primary data source. The sampling method used nonprobability sampling method, namely quota sampling (Burkejohnson and Christensen, 2008;Ferdinand, 2006), involving a total sample of 110 outpatient respondents with the inner Cochran formula (Sugiyono, 2011). Data analysis techniques used Structural Equation Modeling (SEM) with the Analysis of Moment Structure (AMOS) program (Ferdinand, 2014).

FINDING AND DISCUSSION
Based on data normality test, there is no indicator of the intellectual intelligence variable which is equivalent to positive thinking (manacika), communication equivalent to good sayings (wacika), employee behavior equal to good behavior (kayika), performance and service quality which has a value of c.r. > 3.00. This means that the data distribution for all indicators is in a normal mode.
The results of the confirmatory factor analysis (CFA) on indicators of all variables of intellectual intelligence equal to positive thinking (manacika), communication equivalent to good sayings (wacika), employee behavior equal to good behavior (kayika), performance and service quality, are presented both in diagrams and in tabular form. It is known that the Standardized Regression Weight () for all indicators > 0.50 and the C.R. coefficient > 2.00 and the probability value of all indicators is less than 0.05. It means that all indicators are strong and can be included in further analysis. Based on the results of the processed data, Table 1 is presented below.

Structural Equation Model Analysis
Model testing is carried out using regression coefficients (regression weights) for intellectual intelligence equivalent to positive thinking (manacika), communication equivalent to good sayings (wacika), employee behavior equal to good behavior (kayika), performance and service quality. Based on the results of the processed data, the output were presented in the Table 2.

Analysis of Measurement Model with Determination
Square Multiple Correlation shows values of 0.632 and 0.864 respectively as shown in Table 3. According to Ferdinand (2002: 114), the value of Square Multiple Correlation for employee performance is identical to R2. Square Multiple Correlation for employee performance is 0.632, then the level of Determination of the Square Multiple Correlation value for employee performance times 100% is 63.2%. It can be stated that changes in To prove this hypothesis, the results of data processing are as shown in Figure  1 below.  Based on the test criteria, Chi-square (2), relative Chi-square (2 / df), RMSEA, GFI, AGFI, TLI and CFI above and the Goodness of Fit value of AMOS for Windows Version 22 processing as shown in Figure 1 and considering the value of cut-of-value and goodness of fit results of the model in Table 4, it can be seen that the eight criteria used have met the requirements, so that the above model can be declared good.

The Effect of Intellectual Intelligence Equavalent to Positive Thinking (Manacika) on Employee Performance
The results of the analysis show that intellectual intelligence equivalent to positive thinking (manacika) has a significant effect on employee performance by 2.07 organizationally. This study confirms that employee performance is influenced by the level of intellectual intelligence equivalent to positive thinking of medical/non-medical team. This study also confirms the acceptance of the view that the higher the level of intellectual   (2012), Terja (2016) that intellectual intelligence has a dominant effect on work results or performance. It also supports the results of research by Sunariani et al (2016) that the local wisdom of Tri Kaya Parisuda has a significant effect on the model of shaping the character of human resources based on the teachings of Hinduism in Bali. This research strengthens the expert's opinion (Gorda, 1999) which states that Tri Kaya Parisuda values can affect performance in the perspective of globalization era. Based on the point of view of Robbins' intellectual intelligence theory (2001) and Dessler's Theory of Performance (2000), a person's work performance can be measured by comparing work results with set standards. Performance achievement can be measured both in quality and quantity according to the responsibility and level of intellectual intelligence of employees according to opinion of Mangkunagara (2002) and Muninjaya (2009).

The Effect of Communication equivalent to Good Sayings (Wacika) on Employee Performance
Empirical test states that the communication variable equivalent to good saying (wacika) has a significant effect on employee performance by 3.47 organizationally. This study confirms that employee performance is affected by the correct communication carried out by the medical/non-medical team. This study also confirms the acceptance of the view that the better the communication the better the employee performance. This study supports the results of research by Terja (2016) that the results of communication equivalent to good sayings (wacika) have a significant effect on service quality. This study is strengthened by expert's opinion (Gorda, 1999) and there is consistency with Littlejohn's (2002) communication theory that communication is difficult to define, which means that the ability to communicate or negotiate can achieve organizational goals. The Effect of Employee Behavior Equivalent to Good Behavior (Kayika) on Employee Performance The result of the analysis shows that employee behavior equal with good behavior (kayika) has a significant effect on employee performance by 5.13 organizationally. This study confirms that employee performance is more dominantly influenced by the behavior of medical/non-medical team than that by intellectual intelligence and communication. This study also confirms the acceptance of the view that the better the employee behavior, the higher the employee performance. The results of this study support the research conducted by Furqoni et al (2014), Hafsyah (2012) which state that the caring behavior of health workers has a significant effect on the satisfaction of outpatients. This research is strengthened by expert's opinion (Gorda 1999). There is consistency in the perspective of Behavior Theories (Prawirosentono, 1999), (Sofyandi andGarniwa, 2007), and(Sobur, 2003) which show that the characteristics of attitude are creative and innovative personally. The Effect of Intellectual Intelligence Equivalent to Positive Thinking (Manacika) on Service Quality The results of the analysis show that intellectual intelligence equal to positive thinking (manacika) has a significant effect on service quality by 3.89 organizationally. This study confirms that the intellectual intelligence of employees has an effect on the service quality of medical/nonmedical team to outpatients. This study also confirms the acceptance of the view that the higher the level of intellectual intelligence, the better the quality of service organizationally. This study supports the results of the study by Terja (2016) that the results of intellectual intelligence have a significant effect on service quality. There is an inconsistency between the results of this study and the results of research conducted by Fitri (2007), Ismiranto (2009 indicating that internal and external perspectives have no significant effect on service quality. In contrast to the results of research developed by Parasuraman, et al (1988), this study shows that there is no significant difference between consumer expectations and management performance. It strengthens the theory put forward by Muninjaya (2009) that health services in hospital can be developed by the implementation of Tri Kaya Parisuda values for officers in serving patients and users of hospital services.

The Effect of Communication Equivalent to Good Sayings (Wacika) on Service Quality
The results of the analysis show that communication equivalent to good sayings (wacika) have a significant effect on service quality by 2.09 organizationally. This study confirms that the quality of service is influenced by good communication carried out by non-medical team to outpatients. This study confirms the acceptance of the view that the better the communication, the better the quality of service. The results of this study support the results of research by Terja (2016) that communication has a significant effect on service quality. This study differs from the results of research conducted by Fitri (2007) and Ismiranto (2009) that internal and external perspectives have no significant effect on the quality of hospital services. It is also different from the results of research developed by Parasuraman, et al (1988) that there is no significant difference between consumer expectations and management performance. This study strengthens the theory put forward by Muninjaya (2009) that health services in hospital can be developed by implementing of the values of Tri Kaya Parisuda for officers in serving patients and hospital service users. The Effect of Employee Behavior Equivalent to Good Behavior (Kayika) on Service Quality The results of the analysis show that the employee behavior equaivalent to good behavior (kayika) have a significant effect on service quality by 5.17 organizationally. This study confirms that the quality of service is more dominantly influenced by the behavior of medical/non-medical team than that by intellectual intelligence and communication. This study also confirms acceptance of the view that the better the employee behavior, the better the service quality of the medical/non-medical team. The results of this study support the studies conducted by Furqoni et al (2014), Hafsyah (2012) which state that the caring behavior of health workers has a significant effect on the satisfaction of outpatients. This study is different from the results of research conducted by Fitri (2007), Ismiranto (2009), and Pratiwi (2010) that internal and external perspectives have no significant effect on the quality of hospital services. This study strengthens the theory put forward by Prawirosentono (1999), Sofyandi and Garniwa (2007), and Sobur (2003). The characteristics of creative and innovative attitude personally can improve service quality.

Effect of Employee Performance on Service Quality
The results of the analysis show that employee performance has a significant effect on service quality by 4.02 organizationally. This study confirms the acceptance of the view that the better the employee performance, the better the service quality of the medical/nonmedical team. The results of this study support the studies conducted by Iloh et al (2012), Terja (2016), Gunawan et al (2011), andSundari et al. (2014) that good service quality has a significant effect on patient satisfaction. This research is different from the results of studies conducted by Fitri (2007), Ismiranto (2009), Lika (2012 showing that internal and external perspectives have a negative and significant effect on the quality of hospital services. This research strengthens the experts' opinions Lupiyoadi, 2001;Diana and Harmawan, 2012;Artana, 2014;Ginting, 2012) which state that improving service quality means increasing customer satisfaction. It also strengthens experts' opinions (Muninjaya, 2012 andAnis, 2014) which state that performance is a parameter measuring the hospital achievement, so that performance is used as the basis for management decision making. This study strengthens the theory put forward by Dessler (2000) and Mangkunegara (2002) that performance is the achievement of a person's work performance by comparing work results with the set standards.

CONCLUSION
Based on the analysis, the results of this study provide a number of new perspectives regarding the Human Capital Theory to build hospital service management in the perceptive of local wisdom as follows: (1) Health service management at Bali Provincial Hospitals is considered good enough in accordance with the existing health service standards, but there are still individual human resources who have not provided maximum service; (2) Intellectual intelligence equivalent to positive thinking (manacika), communication equivalent to good sayings (wacika), employee behavior equal with good behavior (kayika) has a significant effect on the performance and service quality of Bali Provincial Hospitals. This study shows that performance and service quality are more dominantly influenced by the behavior of employees as medical/non-medical team than that by intellectual intelligence and communication. This means that in providing services to outpatients, there should be a sense of empathy such as a touch of love, sincere, a sense of comfort and security.
It is suggested that Bali Provincial Government improve the quality of hospital services. In order to create a sense of empathy in the medical/non-medical team in providing services to patients, it is necessary to transform intellectual intelligence and digital-based health service communication systems in addition to local geniuses. The solution is that Bali Provincial Government needs to strengthen institutions to encourage innovative and disruptive policies to accelerate the professionalism of hospital management performance. In the future, it is necessary to set more detailed design of the brand activation program and the digitalization-based smart heritage Hospital program in Bali Province. Hospital service management enriches the concept of Resource Human Capital Theory with a social culture toward Smart Hospital digital services and KARS, in line with Regulation of State Apparatus Empowerment Minister Number 14 of 2017 concerning the assessment of the community service satisfaction index.