Factors Influencing The Implementation Of Health Service Quality Governance In Puskesmas: Systematic Review

Puskesmas is a health service facility that organizes public health efforts and individual health efforts at the first level, by prioritizing promotive and preventive efforts in their working areas. Puskesmas as health service providers for the community must provide excellent service that meets community expectations. Puskesmas need effective


INTRODUCTION
The quality of health services is strongly influenced by the quality of physical facilities, the types of personnel available, medicines, medical devices and other supporting facilities, the process of providing services, and the compensation received and the expectations of the user community (Andika & Hariyanto, 2017).Community Health Centers (Puskesmas) are health service facilities that organize public health efforts and individual health efforts at the first level, with more priority on promotive and preventive efforts in their working areas.The Puskesmas has the task of implementing health policies to achieve health development goals.(Permenkes RI no 43 of 2019).
Puskesmas as one of the health service providers for the community needs to have quality service quality in accordance with the expectations of the community to be able to maintain patient satisfaction and trust (Astari & Januraga, 2021).In the current era of Health transformation, Puskesmas as one of the First Level Health Facilities (FKTP), must carry out primary service transformation, namely comprehensive promotive and preventive efforts, expanding antigen types, immunization, strengthening capacity and expanding screening in primary services and increasing access, Human resources, medicine and service quality as well as strengthening laboratory services for the detection of diseases or risk factors that impact the community.In order for the Puskesmas to carry out optimal transformation of primary services, it is necessary to have good governance, both service performance, service processes, and the resources used.The community wants health services that are safe and of good quality, and can answer their needs, therefore efforts to improve service quality need to be implemented in the management of Puskesmas in providing comprehensive health services to the community through community and private empowerment efforts (Permenkes RI no 13 of 2022).
Quality Management of health services is a process of a series of activities carried out with a level of perfection of health services that are held in accordance with the established code of ethics and service standards (Naima et al., 2018).
Service quality is an important factor that can shape patient trust in the Puskesmas so as to create their loyalty as consumers of health services.Demands for quality are increasing day by day.This quality does not only exist in products or goods but also in services produced or offered by an industry/organization.Quality of service refers to the level of perfection of health services in meeting the needs of each patient.So, the quality of health services is what shows the level of perfection of health services in creating a feeling of satisfaction in each patient (Gde Muninjaya, 2015).
The concept of quality in the world was initially developed in industrial and corporate services, then the concept of quality developed further into various services, one of which was in health services (Aini et al., 2021).Many studies are used by experts in the field of quality to develop it in the field of health services.According to Bustami in (Aini et al., 2021), quality development in the health sector in Indonesia is carried out using various approaches, including through quality assurance of basic health services in puskesmas, quality control groups in various hospitals, both government and private, integrated quality control, integrated quality management (total quality management) abbreviated as TQM, and so on.
The quality of health services is strongly influenced by the quality of physical advice, the type of staff available, medicines, medical devices and other supporting facilities, the process of providing services, and the compensation received and the expectations of the user community.Various efforts have been made to improve the quality and performance of services, so that health services guarantee safety and satisfaction to patients and the user community (Andika & Hariyanto, 2017).
The definition of quality of health services has been widely expressed by experts including (Donabedian, 1980) who proposed a comprehensive approach to the quality of health services which includes Structure, Process and Outcome.Where the structure includes human resource facilities, infrastructure, finance, organization and management.In the process includes all activities carried out by health workers and their interactions with patients, the Outcome is a measure of the success of services and the degree of public health.As an effort to manage quality in the process of administering a health center, you can use the PDCA (Plan, do, Check, Action) method introduced by Edward Deming, known as the Deming cycle.The PDCA cycle emphasizes implementing changes and adherence to standards (Arnild, 2018).
It is necessary to carry out quality assurance of health services at puskesmas.One of the quality assurance measures implemented is the accreditation of the puskesmas.Accreditation is an acknowledgment of the quality of the puskesmas after an assessment is made that the puskesmas has met accreditation standards.(Permenkes RI no 34 of 2022).In an effort to improve the quality of service, the puskesmas must be accredited periodically, at least once every 5 (five) years.The target target for health service performance indicators for the Ministry of Health of the Republic of Indonesia is the number of sub-districts that have at least one accredited certified health center.To support the process of implementing accreditation at the puskesmas, the role of related stakeholders, such as the district/city Health Office, is very important in terms of the preparation stages for the accreditation of the puskesmas from the initial stage to post-survey assistance (Susilawati Susilawati, 2017).
In 2019, there were 9,153 Puskesmas that had been accredited or around 90.32% of the 10,134 Puskesmas.Provinces with a percentage of 100% accredited Puskesmas are Bengkulu Province, Bangka Belitung Islands, Bali, North Kalimantan and DI Yogyakarta.The province with the lowest percentage of accredited Puskesmas is Papua (28.57%) of the 10,134 Puskesmas that were accredited until 2019, the accreditation pass rate is still dominated by middle and basic graduation status.The distribution of the accreditation pass rate for Puskesmas is 5,068 (55.37%)Puskesmas accredited with intermediate graduation status, 2,177 (23.78%)Puskesmas accredited with basic graduation status, 1,669 (18.23%)Puskesmas accredited with primary graduation status, and 239 (2.61%) Community Health Centers accredited with plenary graduation status.There are 9 chapters for accreditation assessment.The achievement of plenary status is the lowest, and the evaluation in the lowest chapter is related to quality management or governance in chapters 3,6 and 9.
Based on the data mentioned above, it is necessary to examine further why this could happen, what factors influenced the implementation, both in terms of structure, process and outcome.These factors need to be discussed, so that obstacles in implementation can be anticipated, and supporting factors can be developed, so that the implementation of quality governance can run more optimally, and of course can meet patient expectations and satisfaction.This research was conducted through a literature review or literature review by collecting and analyzing research articles on various factors that influence the implementation of quality governance in puskesmas.

RESEARCH METHODS
This research uses a systematic literature review search design with a systematic method of collecting and synthesizing previous research (Snyder, 2019).The search strategy used in this study refers to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method through applicable research stages or protocols, using databases related to medical and academic topics, media publications, Google Scholar.With the 2017-2022 inclusion criteria, full text, journal articles, English and Indonesian with a focus on the factors that influence the implementation of Health Center Service Quality Governance, in terms of structure (facilities), processes and outcomes.Furthermore, with regard to writing ideas that use the words facilities, puskesmas, PDCA, accreditation and service quality, they are filtered until they find appropriate subject matter and can support analysis and writing plans.

RESULT AND DISCUSSION
Article search results used keywords and obtained 1,530 articles (all from Pubmed and Google Schoolar).The articles were then filtered using the format: Academic journals, last 5 years, with full text restrictions.After that, a screening was carried out for duplications and similarities to produce 103 articles.After that, abstracts and research results were read so that many were eliminated and produced 37 journals.Furthermore, an exception was made for the completeness of the contents of the journal and produced 19 journals.Then read the entire contents of the journal and obtained 15 appropriate journals.So the following results are obtained: Tabel  Lestari (2018), Human resource management is matters related to fostering the use and protection of human resources.Thus the task of human resource management is to manage human elements with all their potential so that human resources can be obtained that can achieve organizational goals.
Health workers are people in the health sector who can or become the object of a medical institution.As subjects, health workers, health workers are involved in planning, implementing, and monitoring evaluations.As an object, health workers are in the system that is the goal of the program.The facility has strict health care worker administrative controls for both permanent and temporary/contract workers.Through administrative management of health workers, facilities must be able to collect information about existing human resource systems (Lestari, 2018).
In his research, Lestari (2018) found that the quality of service at the puskesmas was relatively the same, because the activities of the puskesmas were still routine activities and based on established methods so that there were no differences from one another.rule.Even though its development tends to be static, the puskesmas has an obligation to innovate and respond to the dynamic needs of its community.
There is concern about the Puskesmas services as they do not have sufficient medical staff to handle volumes exceeding capacity.Staff shortages in the Puskesmas are largely due to their unequal distribution and failure to meet minimum human resource standards.The delivery of health services is the responsibility of the Human Resources Section of the Puskesmas.Officer discipline also affects the quality of puskesmas services, which is reflected in the timeliness of services provided, in the research of Fernandez1 et al, (2021) which was conducted at the Pasir Panjang Nusa Tenggara Health Center, a low level of patient satisfaction was obtained due to the low level of staff discipline.This is done to ensure that the responsibilities and main functions (tupoksi) of health workers are in accordance with their training and expertise.This is because Health Workers are a key component that supports other Health Subsystems, namely the Health Human Resources Subsystem.The quality of the Puskesmas health workers is also a reflection of the professionalism of the health workers who carry out the roles and functions of the Puskesmas.Based on Astari's research.N (2021) Constraints to limited human resources were found at the Kuta II health center, especially during the Covid-19 pandemic.The results showed that the strategy set by the Kuta II Health Center in maintaining and improving the quality of health services during the COVID-19 pandemic included all aspects contained in the 4 principles of quality assurance and 5 dimensions of quality with more emphasis on always meeting customer needs or expectations by trying to provide good facilities and provide services that are fast, precise, and safe.However, in the implementation of this strategy there are obstacles such as limited inadequate human resources.

Factors of the Leadership Role of the head of the Puskesmas
Quality-oriented leadership is a vital factor and has a strategic role in supporting the process of implementing quality governance at the Puskesmas, because implementing effective quality leadership will increase the competitiveness of services through innovative efforts to improve quality.The head of the Puskesmas as the driving force for changing the quality culture is an important key to success in creating changes in the work culture for the development of service quality.The Head of the Health Center must act as a facilitator, motivator, able to change the mindset of employees in a more positive direction and continue to innovate (Gde Muninjaya, 2015).
Referring to the research conducted by Zainuddin et al ( 2020), the statistical tests carried out showed that there was an influence between the leadership variable and the assessment of the accreditation status of the puskesmas, which meant that the majority of the health workers who served as a place thought that the leadership that had been implemented at work was at enough category.The majority of respondents who answered sufficient leadership had high work motivation, which consisted of intrinsic and extrinsic motivation.Health workers have harmonious relationships among colleagues, a comfortable work environment, and have leaders who can provide guidance and encouragement to work even better.Leaders here must be able to pay attention to employee motivation because motivation has an impact on employee performance.If the employee's performance increases, it will affect the achievement of organizational goals.This is supported by Andi Amir's research ( 2019), the role of the head of the Tanjung Jabung puskesmas in planning, decision making, commitment, communication, staff development is very influential in improving the quality of services at the puskesmas.
The head of the Puskesmas has an important role in the success of quality improvement in his work environment because he is the spearhead in carrying out his organizational activities.A leader must be able to develop a mature strategy to support the quality of service that will be provided to the community.As a leader, the Head of the Puskesmas must be able to master the dimensions in measuring service quality, namely, Reliability, responsiveness, assurance and empathy.The head of the Puskesmas must have this analytical ability so that he can determine the right strategy to improve the quality of his environment (Paramitha, 2020).A puskesmas head also plays a role in planning, decision making, commitment, communication, staff development which is very influential in improving the quality of services at puskesmas (Andi Amir, 2019).In Ahmed's research (2020) at Guanzitep Syria, in improving the quality of service, the commitment of leaders and staff who synergize with each other is needed.

Service Access
Puskesmas as primary health service providers have a role to support increasing access and quality of health services in the community, support the implementation of the National Health Insurance (JKN) and support the achievement of health indicators (Ministry of Health, 2012).Adequate health centers not only pay attention to the number or capacity of their services but also pay attention to the level of accessibility, which is one of the important things that need to be considered to improve the quality of services.
Access to health services is an opportunity to achieve and provide health services according to the situation and the perceived needs.Access means that health services are available whenever and wherever needed by the community.(Ainurrahmah, 2017).
Access is influenced by existing health policies both in terms of organization and in terms of finance (Ainurrahmah, 2017).Retnaningsih in Ainurrahmah (2017), emphasized that the factors that influence access to health services are individual factors and household factors.Individual factors that affect access, namely the needs felt by patients as individuals, level of education, age, employment and health insurance.Household factors that affect access are transportation from home to health facilities, family income, and number of family members.
To improve public health services, Ainurrahmah (2017) in his research proposed the use of information technology in the form of e-government to facilitate data collection and processing.Information technology is a technological device that can help humans in their work, by managing data in a maintained, fast, precise, and accurate manner.

Facility and Infrastructure Factors
Completeness of facilities and infrastructure at public health facilities is very basic to serve the community.Puskesmas which are the first level of health services must at least fulfill basic facilities to support health services to the community.However, in some cases there are still puskesmas that do not have adequate facilities and infrastructure.As stated by Susilawati (2017), in her research on the description of the implementation of puskesmas accreditation in districts/cities of North Sumatra Province, it was found that complete facilities and infrastructure as a basis for carrying out standardized services were not fully available.The accreditation assessment will be based on the facilities available to provide services.
The completeness of facilities and infrastructure also affects the level of patient satisfaction, as in research conducted by Naima et al, 2017 at the Sienjo Health Center, Moutong Regency, it was found that facilities and infrastructure at the Sienjo Health Center need to be added and improved because the lack of facilities will affect the quality of health services, because one of the the assessment of a public service is the availability of facilities and infrastructure that can help service owners and service users.Meanwhile, according to Aini R (2021) the inhibiting factors for implementing the quality of puskesmas services include: physical facilities, completeness of medicines, and inadequate internet networks affecting the level of patient satisfaction.

Budget
Regarding the budget, it is also a central factor in a health organization such as a health center to ensure the quality of health services.However, in some cases, such as in North Sumatra, it is still a concern.Budget Procurement for Accreditation of Community Health Centers, some District/City Health Offices in North Sumatra do not propose or prepare a budget for accreditation from both the APBD budget and the APBN budget.This budget is very important to support accreditation process activities from accreditation preparation to accreditation survey implementation.This can affect the performance of the puskesmas to serve public health.6. Factors in the PDCA Process (Plan, Do, Check, Action) The PDCA process is something that must always be carried out in puskesmas management.Quality program planning is a major component in quality governance that functions as a reference and program setting.The planning function is the most important function in the management process, if planning is not formulated correctly, then the management process does not run regularly.There are four aspects of planning boundary studies.First, planning will be effective if it is supported by relevant facts.Second, planning is the process of selecting alternative actions to achieve organizational goals.Third, planning is a strategic decision to make something happen in the future.Fourth, setting organizational long and short term goals based on situation analysis (Muninjaya, 2015).
The process of mobilizing and implementing quality programs at the puskesmas level is the responsibility of the puskesmas management team.Implementation of the quality program is an implementation step of the planning that has been prepared at the plan stage of the PDCA cycle.In Ainurrahmah.Y's research (2017) which was conducted at the Taronggong Health Center, it showed that the implementation of the management of the Puskesmas had sufficient criteria.The highest percentage is in the planning dimension, namely planning indicators at the Puskesmas level where employees prepare activity proposals by taking into account priority needs with sufficient criteria.The lowest percentage is found in the dimensions of mobilization and implementation, namely the indicator of teamwork in which Puskesmas employees carry out dynamic meetings once a week with the criteria of less than once.
Success in the PDCA process also depends on management's commitment to implementing quality, in Lailatul's research (2020) the Situbondo Health Center experienced problems in the PDCA cycle where comprehensive quality leadership documents were known to be incomplete.
Monitoring and evaluation is the next process after mobilization and implementation.A method is needed to do so, so that service quality can be assessed appropriately.The need to have a performance measurement tool, which combines operational level testing with strategy, to integrate organizational goals into operational performance themes and make estimates of its structure towards real management with quality.(Zadoud B et al, 2020).The evaluation process can be done by measuring customer satisfaction through feedback.Gage, A (2020) research in Haiti, most primary care facilities are of poor quality in Haiti.Elements of quality of service delivery that were found to be absent in nearly all Haitian primary care facilities, eg gathering client feedback and good provider communication, should be targeted for improvement and routine measurement.In Indonesia, the process of evaluating the implementation and mobilization of services at the Puskesmas uses a customer satisfaction survey that refers to the Regulation of the Minister of Empowerment and State Apparatus No. 14 of 2017, which is carried out routinely twice a year.

Output Measurement Factor
The output of the implementation of good health center quality governance is an increase in service level success and an increase in the community's health status.The success of the service level can be seen from the achievement of the National Quality Indicator (INM) targets.The Ministry of Health has determined that there are six INM that must be achieved by the Puskesmas, based on the Regulation of the Minister of Health of the Republic of Indonesia No. 30 of 2022, namely: a. Compliance with hand hygiene with a target of ≥ 85% b.Compliance with the use of Personal Protective Equipment (PPE) with a target of 100% c.Patient identification compliance with the target of 100% d.The success of treating Tuberculosis (TB) patients in all cases targets 90% e. Pregnant women receive antenatal care (ANC) health services according to the target standard of 100% f.Target patient satisfaction 76.61%.
The need for a strategy for precise measurement results, the puskesmas needs to have a performance measurement tool, which combines operational level trials with strategy, to integrate organizational goals into operational performance themes and make structural estimates towards real management with quality (Zaadoud, et al, 2020).

Accreditation Implementation
According to Fernandez et al ( 2021), the implementation of puskesmas accreditation has proven to be able to have an impact on the knowledge and skills of officers, so that in practice, officers are able to provide services in accordance with the applicable Standard Operating Procedures (SOP).Respondents considered that the skills of the puskesmas staff were good because the officers were able to treat and diagnose patients quickly, and did not repeat treatment actions.This is supported by the existence of technical guidance and training provided to puskesmas staff to improve the competence and capacity of officers which leads to increased performance.One of the criteria for accreditation of puskesmas based on Permenkes No. 46 of 2015 states that managers and implementers of puskesmas are able to meet the required competency standards and have development plans in accordance with predetermined standards.Therefore, in carrying out their duties, health workers who previously worked without following the SOP, after accreditation, the officers paid more attention to the applicable standards.Patients also feel that after accreditation, officers are quicker and more precise in determining diagnoses and treatment alternatives.In order for the quality of health services at the Puskesmas to run optimally, it is necessary to improve performance and continuous improvement.

CONCLUSION
Puskesmas is a health service facility that organizes community health efforts and individual health efforts at the first level, by prioritizing promotive and preventive efforts in their working areas.The Puskesmas has the task of implementing health policies to achieve health development goals.(Permenkes RI no 43 of 2019).
Puskesmas as one of the health service providers for the community needs to have quality service quality in accordance with the expectations of the community to be able to maintain patient satisfaction and trust (Astari and Januraga, 2021).The maintenance of public health status is very dependent on the health center.Community health centers are still often criticized for the quality of their services, so it is believed that they are not fully capable of carrying out their duties.Availability of health workers, infrastructure, budget, are just a few of the issues at the puskesmas that can have an impact on the quality of Puskesmas services.
Other resource problems at the Puskesmas that can impact service quality include: the not yet integrated system and practice of planning for the distribution of health workers; infrastructure, medicines; lack of effective communication between planning units and health care providers; and the lack of support from the leadership/head of the puskesmas.To deal with these various problems, continuous quality management is needed at the Puskesmas, starting from the planning, implementation, and evaluation processes.Choosing the right monitoring and evaluation method can effectively measure the quality of service at the puskesmas.Efforts to guarantee the quality of services at the Puskesmas through a survey on puskesmas accreditation.