Journal : JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit), 7 (x): x-xx, Date 201x

Website : http://journal.umy.ac.id/index.php/mrs
DOI : 10.18196/jmmr.6101

EXPLORATION CAUSING THE LOW ACHIEVEMENT OF

HOSPITAL BED OCCUPATION RATE: CASE STUDY
Umi Kulsum1, Gunawan2, Devita R 3
* Correspondence Author : umikulsumfuady@gmail.com
* Master’s Program in Hospital Management Brawijaya University, Malang, Indonesia
** Psychiatric Hospital of DR.Radjiman W, Malang, Indonesia
INDEXING A B S T R AC T
Keywords: Bed Occupancy Rate (BOR) in Psychiatric Hospital of DR.Radjiman W regency had low
BOR; percentage. In April 2022, it was 59,80%, May 50,55%, also June 48,84%. It may be
Hospital; pergub regulation and BPJS regulation, the development psychiatric in other health
Inpatient; services, the limited facilities and insfrastructure for non psychiatric patient, and lack
Reason for visit; information about non psychiatric services. This study focuses on analyzing factor the
Patient visits; low percentage of BOR (Bed Occupancy Rate). The sample were 4 respondents, those
are the head of inpatient, the head of outpatient, the head of emergency room, public
Kata kunci: relation. The main priority is to find solution of this research problem was using 5
BOR; WHY’s. Then, find an alternative solution by discussion method with all respondents.
Rumah Sakit; The result of this study showed the main factors that causing the low percentage of
Rawat Inap; BOR in RSJRW is an incomplete of facilities and infrastructure. It was suggested that
Alasan kunjungan ; RSJRW should be aware to be clean up and provide the less of facilities and
Kunjungan pasien ; infrastructure.

BOR (Bed Occupancy Rate) RSJ di Dr. Radjiman W masih belum memenuhi target
dimana capaian pada bulan April tahun 2022 sebesar 59,80% pada bulan Mei sebesar
50,55%, pada bulan Juni 48,84%. Kondisi tersebut kemungkinan di sebabkan oleh
regulasi BPJS, berkembangnya layanan psikiatri di fasilitas kesehatan lain, terbatasnya
sarana dan prasarana untuk pasien nonjiwa, kurangnya informasi mengenai pelayanan
kesehatan non jiwa. Penelitian ini merupakan penelitian kualitatif dengan pendekatan
studi kasus menggunakan teknik pengumpulan data laporan tahunan RSJRW,
wawancara, dokumentasi yang melibatkan 4 responden. Lokasi penelitian di RSJ Dr.
Radjiman W. Penentuan prioritas dilakukan melalui diskusi bersama menggunakan 5
WHY’s. Selanjutnya menentukan alternative solusi melalui diskusi bersama responden.
Hasil penelitian menunjukkan bahwa terdapat beberapa factor yang mempengaruhi
capaian target BOR RSJRW meliputi regulasi rujukan BPJS, berkembangnya layanan
psikiatri di fasilitas kesehatan lain, terbatasnya sarana dan prasarana untuk pasien
nonjiwa, kurangnya informasi mengenai pelayanan kesehatan non jiwa. Alternatif
solusi untuk mengatasi masalah tersebut yaitu dengan cara penyediaan sarana dan
prasarana yang belum lengkap, pengenalan layanan non psikiatri sehingga lebih
banyak di ketahui masyarakat. RSJRW harus segera berbenah dan melengkapi sarana
dan prasarana yang belum tersedia, meningkatkan promosi mengenai layanan
kesehatan non jiwa agar lebih banyak diketahui masyarakat.

© 2020 JMMR. All rights reserved

JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit), x (x), x-xxx |2|

INTRODUCTION
The hospital is a unique and complex organization both labor intensive, capital
intensive, knowledge intensive and human resources intensive. This complexity arises
because hospital services in the form of health services consist of various professions.
Based on Law No. 44 of 2009 hospitals are required to provide health services to every
individual to improve the degree of public health better (Njoto, 2011). To achieve this goal,
promotive, preventive, curative and rehabilitative health services are needed (Widiyanto &
Wijayanti, 2020). With the development of technology and the need from the community to
get comprehensive health services, the hospital has inpatient services to realize this goal
(Herawati, 2015).
The inpatient unit is one of the health services that can be an indicator of the quality
of services produced (Tomanyira et al., 2019). The quality of hospital services can be
determined through the BOR (Bed Occupancy Rate), BTO (Bed Turn Over), ALOS
(Average Long of Stay), TOI (Turn Over Interval). Indicators to determine the quality of
inpatient services can be evaluated through BOR and BTO (Sidiq & Afrina, 2017).
Information regarding the calculation of BOR, BTO, ALOS, TOI every month can assist in
determining efficiency targets that must be achieved each period (Rosita & Tanastasya,
2019). Apart from that, it can also evaluate the results of BOR achievements whether they
have met the standard targets from the Health Service (Riyanto, 2020).
BOR is the percentage of bed usage in a certain period of time. BOR itself can also
be used as an evaluation of efficiency in hospitals (Mahmud et al., 2021). A low BOR
achievement indicates a lack of efficiency in the use of beds in a hospital, as well as a high
BOR achievement indicates that efficiency in a hospital is running well. The low
achievement of BOR that has not met this target has a significant effect on hospital revenue.
The low BOR achievement means that there are not many patients who get inpatient health
services at the hospital. This causes hospital revenue to decrease along with the number of
patients who are hospitalized (Ambarwati, 2021) (Rahma et al., 2014). In addition, the
achievement of BOR is an indicator of the quality of hospital services. If the achievement
of BOR is low, this is very closely related to the quality of the hospital's services (Persadha
et al., 2019). Factors that influence the achievement of BOR include patient satisfaction,
high ALOS scores, and the completeness of hospital facilities and infrastructure. Several
studies of patient satisfaction are directly proportional to the number of patient visits, this is
according to 4 studies which state that 83% of the marketing mix has a significant influence
on patient satisfaction obtained from patient visits to hospitals (Safi & Sulistiadi, n.d.).
High ALOS can also affect BOR performance. Long ALOS has an impact on economic
value, patients require high treatment costs because the hospitalization period is quite long
(Lubis & Astuti, 2018). This is reinforced by other studies which state that a low ALOS
score can be caused by poor planning in providing services to patients or because policies
in the medical field and ALOS numbers are strongly influenced by the type of disease
suffered by patients (Meliala, 2018).
Health service infrastructure can be interpreted as a collaborative process of
utilizing all health facilities and infrastructure effectively and efficiently to provide
professional services in the field of facilities and infrastructure in an effective and efficient
|3| Author – title Articel…………………………………

health service process as well. Completeness of good infrastructure is influential in creating

customer satisfaction (Ida Yunari Ristiani, 2017).
RSJ Dr. Radjiman Wediodiningrat (RSJRW) Lawang is a type A psychiatric
hospital and a type B hospital for the general public. RSJRW has been established since
1926. As a health facility, it requires all parties working at RSJRW to be optimal in
providing health services with the hope that BOR achievements will meet the target every
year. According to the annual report, the performance achievements of RSJRW are shown
in table 1.

Table1. RSJRW Performance Achievements

STANDAR
Sem 1 D
NO INDICATOR 2021
2022
(DEPKES)

1. BED OCCUPANCY RATE (BOR) (%) 44.99% 55.89% 60-85

2. TURN OVER INTERVAL (TOI) (days) 20.31 14.79 1-3

3. AVERAGE LENGTH OF STAY (ALOS) 25.87 20.09 6-9

(days)

4. BED TURN OVER (BTO) (kali) 8.26 5.26 40-50

5. NETT DEATH RATE (NDR) (‰) 12.41 2.85 <0,025

6. GR0SS DEATH RATE (GDR) (‰) 19.98 4.75 <0,045

Source: Dr Radjiman psychiatric hospital annual report

According to the data obtained, the RSJRW BOR in 2021 reached 44.99% and in
2022 semester I reached 55.89%. This is not in accordance with the achievement of the
BOR according to the Ministry of Health standards, namely 60-85%. From table 1, the
ALOS achievement in 2021 was 20.31 and in 2022 it reached 14.79. Where the ALOS
standard according to the Ministry of Health is 1 to 3.
BOR achievements that have not met this target have encouraged researchers to
explore the low BOR achievements in RSJRW.

RESEARCH METHOD
The type of research used in this research is qualitative research with a case study
approach. The case study in this study is a detailed study of the exploration of low BOR
outcomes in RSJRW. The reason for the case study approach used in this research is to
obtain an overview of the causes of the overall low BOR achievement of the RSJRW. The
informants for this study were determined using a purposive sampling technique, that is,
informants were selected based on a consideration of personal abilities and were
responsible for the work unit to provide the right answers so that the data obtained was
more accurate, totaling 4 (four) people, namely the head of the inpatient unit. inpatient,
RSJRW Public Relations, head of the emergency unit, head of the outpatient unit (Campbell
JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit), x (x), x-xxx |4|

et al., 2020). The head of the first inpatient unit was chosen because he knew information
about the procedures of patients who were hospitalized at RSJRW. The head of the
outpatient unit was chosen because of his position and responsibility in managing
outpatient care. The head of the ER unit was chosen because the ER is the entry point for
patients who wish to be hospitalized at RSJRW. Public relations staff were chosen because
of their role as executors of marketing and public relations.

Data collection was carried out from August-October 2022. The data used in this
study were obtained from Focus Group Discussions (FGD) and secondary data. The
secondary data used in this research is the 2021 annual report and 2022 RSJRW annual
report. This qualitative data analysis activity is carried out continuously until completion.
To analyze the data in this study using data reduction, data display, conclusion
drawing/verification. The main category was determined as the final step in this study. The
main category in this study is according to the research objective, namely the exploration of
low BOR achievements in RSJRW.
RESULT AND DISCUSSION
RSJRW has a capacity of 400 TT (Beds), this number is much reduced due to the
conditions of the Covid 19 pandemic which initially reached 800 TT. With the vision of the
RSJRW, it is possible to improve the quality of life through comprehensive mental health
services. The achievements of BOR at RSJRW according to the 2021 report and the 2022
semester I report still have not met the target. According to the data obtained, the RSJRW
BOR in 2021 reached 44.99% and in 2022 semester I reached 55.89%. According to the
2022 report in semester I, inpatient visit data reached an average of 337 patients. This is not
in accordance with the achievement of the BOR according to the Ministry of Health
standards, namely 60-85%. For this reason, research was carried out on the causes of low
BOR achievements so that it would help RSJRW to improve better in the future. Based on
the results of interviews with informants, there are several causes that influence the
achievements of the RSJRW BOR. This is explained as follows:

BPJS Regulation Regarding Referrals

According to Law No. 40 of 2004 concerning the National Social Security
System (SJSN) in the health sector which is UHC (Universal Health Coverage). The
National Health Insurance is the government's effort to provide health services at affordable
prices but with good quality. According to BPJS Regulation No. 1 of 2014 concerning the
implementation of a tiered referral policy for BPJS participants. The implementation of a
tiered referral system for people who will seek treatment using BPJS must first go through a
level I health facility (Ambarwati, 2021). It is felt that the patient referral system is still
ineffective and efficient, many people are still unable to reach health services, as a result
there is an extraordinary accumulation of patients in certain large hospitals. The
community's understanding of the referral flow is very low so they do not get the services
they should. The following reads BPJS regulation No. 1 of 2014 regarding the referral
system: First level health services as referred to in paragraph (1) for medical services
include: a. medical cases that require initial treatment prior to referral; b. medical case
referral. Health facilities can make horizontal and vertical referrals. 29 (4) Horizontal
referrals are made between health services at one level if the referrer is unable to provide
|5| Author – title Articel…………………………………

health services according to the patient's needs due to limited facilities, equipment and/or
personnel which are temporary or permanent in nature. (5) Vertical referrals are made
between different levels of health services, it can be done from a lower level of service to a
higher level of service or vice versa.
"Since there is a BPJS regulation with tiered referrals... the patient
has to go to a hospital that is below the RSJRW first... so the patient
can't go straight to RSJRW" (Informant 1)(02:10-Oct:22).

".. So that makes the patient feel complicated because they have to
ask for repeated referrals to the FKTP and then referrals to other
hospitals and then to the RSJ doc…."(Informant 2)(02.18-Oct:22).

Incomplete Non-Psychiatric Facilities and Infrastructure

The RSJRW facilities and infrastructure for non-mental patients are still
incomplete. RSJRW still doesn't have an ICU or child inpatient room. With the lack of these
facilities, it has an impact on the less than optimal health services provided. Based on data
from RSJRW profile documents, RSJRW has 5 non-psychiatric specialist doctors and also
limited specialist doctors who treat non-psychiatric patients, as well as non-psychiatric
inpatient rooms with a total of 10 TT, and Covid 19 isolation inpatient rooms with a total of
40 TT. RSJRW is also equipped with 24-hour emergency room, laboratory, radiology
facilities which have CT Scan, XRay examination, Panoramic, 3D Ultrasound.

"The RSJRW has incomplete facilities for non-mental patients... we

still don't have an ICU for non-mental patients... nor do we have a
cardiologist... so if there is a heart patient... yes, we will refer them to
another hospital..."{informant 3 )(02:22-Oct:22).

"Yes, doc... the patient is disappointed, for example, when he comes

here but we have to refer him... so he wants to be treated here but
because the facilities are incomplete... finally he is referred"
(informant 2)(02.16-Oct:22).

Development of Psychiatric Services in other Health Facilities.

Based on search results from the websites of hospitals around Lawang district, it
was found that one hospital had opened psychiatric services, namely Lawang Medika
Hospital which had mental health specialists. Psychiatric health services at Lawang Medika
Hospital since 2018. Where competing hospitals have also opened psychiatric services, this
has become another option for the community to decide which hospital to get their health
services from.

"Nowadays many psychiatric services have been opened, both in

hospitals around Lawang or foundations... so if in the past they were
sent to the RSJ... now it's no longer... this also reduces hospital visits.

CONCLUSION
JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit), x (x), x-xxx |6|

Achievement of the 2022 BOR value at RSJRW is 55.89%. An overview of the

health service facilities at RSJRW for now such as the number of ready-to-use beds (TT)
available, the number of beds in all inpatient rooms is 400 TT. Non-psychiatric patient
facilities are in accordance with room standards and requirements. RSJRW already has a
radiology unit, laboratory unit, operating room, but RSJRW does not yet have a special
inpatient room for children and ICU, delivery room. Citra RSJRW is known to the public as
a hospital that only serves mental patients. This is an obstacle for non-psychiatric patients
who wish to obtain health services at RSJRW. Based on the description of the reasons for
the low achievement of the RSJRW BOR, the RSJRW needs to make improvements in
terms of equipping facilities and infrastructure for non-psychiatric patients, increasing
promotions related to non-mental health services so that they are better known by the
public, and making innovations that differentiate from competing hospitals. Based on the
research that has been done, this research has limitations. These limitations include:
1. This research requires further research regarding consumer decisions in
determining health services based on the marketing mix.
2. There are obstacles in finding patient visit data before the existence of BPJS and
after the existence of BPJS.

ACKNOWLEDGMENT
This research was supported/partially supported by Dr.Radjiman Wediodiningrat
Psychiatric of hospital. We thank our colleagues from Magister Management of Hospital
who provided insight and expertise that greatly assisted the research,

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REFERENCES

Disiplin ilmu / sub disiplin ilmu dari naskah yang Program Studi Magister Manajemen Rumah Sakit Universitas Brawijaya
dikirim

-- Magister Management Hospital Brawijaya University

Academic Discipline / Sub-Disciplines

Tipe / metode penelitian / pendekatan penelitian / Studi kasus/kualitatif/Studi Kasus

paradigma yang digunakan

--
Type / Method / approach / paradigm
Case study/kualitatif/Case study
Nama Instansi Penulis (dalam bahasa Inggris) 1. Program Studi Magister Manajemen Rumah Sakit Fakultas
* Bila lebih dari satu instansi gunakan numbering Kedokteran Universitas Brawijaya Malang
sesuai dengan urutan penulisnya 2. Rumah Sakit Jiwa DR. Radjiman W

--
Author’s Institution (in English)
* If there were more than one institution, please use
numbering in accordance with the order of authors 1. Master’s Program in Hospital Brawijaya University
2. Psychiatric Hospital of DR. Radjiman Wediodiningrat