A QUALITATIVE STUDY: HOSPITAL PATIENT COMPLAINT MANAGEMENT

A Qualitative Study... Abstract Background: Complaint management is vital for hospitals as patient complaints can be used to advance the quality of health services provided. Aims: This study analyzed patient complaint management at an X government hospital in Yogyakarta. Methods: The research used a descriptive-qualitative method and phenomenology, which was carried out through in-depth interviews, observation, and document review. It involved the head of the legal and public relations department, the head of the public relations sub-division, two staff of the legal and public relations department, two officers to outpatient and inpatient units, and two patients. This study used purposive sampling to select the samples. Data analysis referred to was from the concept of Miles and Huberman, which consists of data reduction, display, and verification. The accuracy of all data was checked using a triangulation method. Results: The hospital followed the patient complaint management procedures. Providing complaint reporting platforms is required to lodge patient complaints to the hospital. Moreover, the suggestion box should be managed properly, and thus the complaints on the box can be managed promptly. Conclusion: Overall, patient complaint management at the hospital has been carried out well and followed the standard operating procedures (SOP).


Introduction
According to the Regulation of the Indonesian Ministry of Health No 129/ Menskes/ SK / II / 2008, hospitals as one of the health facilities that provide health services to the community have a very strategic role in accelerating the community health status. Quality services at hospitals need to be following established standards and can reach all levels of society. Based on Law No. 44 of 2009 concerning hospitals, hospitals are obligatory to provide safe, quality, anti-discrimination, and effective health services by prioritizing patient interests under the hospital service standards, as well as respecting and protecting their rights.
Patients have rights to submit proposals and suggestions for improving the hospital's treatment, and to sue the hospital for being suspected of unstandardized services related to either civil or criminal matters. They primarily can complain about inappropriate hospital services through print and electronic media by statutory provisions.
Patients who are not satisfied with the service may complain and express negative responses to the hospital. Handling them quickly, precisely, and responsively will make patients feel calm. Therefore, complaint management is necessary to improve public service systems and to increase the legitimacy of service institutions to the public (Muzanil, 2016). Hospital complaint management is unsatisfying as hospitals only provide a suggestion box for manual complaint submission. Evidently, hospitals still implement slow complaint management and do not deliver complaint handling information from the hospital to patients. Otherwise, complaints that are not handled properly can impact the hospital's health care process (Irawan, Nawawi and Ahmad, 2016).
Complaint submission facilities are not appropriately provided according to the Decree of the Republic of Indonesia Law No. 25/2009 concerning Public Services.
Hospitals have incomplete stationery and complaint forms that prevent patients from submitting their complaints. Also, hospitals sometimes open the complaint submission once a week due to the limited staff in charge of taking the suggestion box.
Based on the interview with the Head of Legal and Public Relations Division, dr. Sardjito Central General Hospital has provided a patient complaint platform where patients can submit their complaints directly to the Law and Public Relations Office or indirectly to suggestion boxes, letters, or social media. Patient complaints can be resolved within three timeframes: 7x24 hours, 3x24 hours, and 1x24 hours. It is also categorized based on facilities used to submit the complaints. Based on the above background, this study aimed to analyze patient complaint management at an X government hospital in Yogyakarta.

Method
This study was qualitative and used phenomenology which was done through in-depth interviews, observation, and document review. It involved the head of the legal and public relations division, the head of the public relations subdivision, two staff of the legal and public relation division, two officers in charge of each inpatient and outpatient installation, and two patients. The research subjects should fulfill the following criteria: being officers in charge of complaint handling and management in the legal and public relations department, outpatient and inpatient units for at least two years.
A purposive sampling technique was performed to select the informants. Data analysis in this study referred to the concept of Miles and Huberman (2014). First, data reduction was carried out by simplifying and sorting the results according to needs, and data display was then carried out to present the data narratively. The last was concluding the results (verification) by comparing the results with existing theoretical studies. To maintain the validity of the data, this study used triangulation methods and sources. Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i1.2022  Training not only affects work efficiency and effectiveness but also benefits the hospital from performance improvement (Yuniarti and Lingga, 2019). With the training, officers can do their job properly. The Decree of the Director of RSUP Dr. Sardjito Number: 1647/ MENKES/PER/XII/2005 states that the legal and public relations department is responsible for providing information and communication services, reports, as well as managing public opinion or customer complaints quickly and accurately.
Feedback could be either negative or positive value. The positive feedback could be useful to evaluate shortcomings and improvements either for hospital management and image. Hospital pain has a character in response to complaints, namely with kinship and honesty (Ariadi, 2019). Patient complaints that are not handled properly will decline the quality of hospital services and cause dissatisfaction or disappointment. Consequently, that also can increase competition between these hospitals (Sujarwo and Subekti, 2019).

Funds
Based on the results, funding for patient complaint management at the hospital is managed by the legal and public relations department. That also involves budgeting to improve facilities/ infrastructures. However, the funding was inadequate because it was used to pay for the staff at the department. The budget is submitted to the Director-General of Operations. If it is approved, the Budget Planning (PEA) section will allocate funding for operational support and priority of goods. The results are shown in the following interview excerpt.
"Ourselves compile the budgeting, after that we will proceed it to the board of directors from there it will be processed again" (Informant A) "For the budget for repairing the facilities, yes, we propose that the budget must be under the government bureaucratic mechanism, and the financial accountability is tiered" (Informant B) Service resources include manpower, financing, infrastructure, facilities, and institutional arrangements. With adequate resources, the services will be run smoothly; otherwise, it is very difficult to provide quality service according to its objectives (Suhadi et al., 2019). Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia)

Original Research
Another study showed no budget for funds specifically allocated for customer complaint handling (Yonosari, Pawelas, and Kusumastuti, 2018). To meet the needs of complaint handling, budgeting goes to other units (mains). Sources of funds are allocated from the hospital's macro funding sources, namely the Regional Budget and BLUD.

Organizing
This study discovered that Human Resources (HR) involved in patient complaint handling come from different units. However, the availability of human resources was not adequate because there were only officers who are responsible for checking or collecting suggestion boxes. Meanwhile, staff in other units had their respective responsibilities in handling complaints.
It is highlighted that the front desk officers received five basic compulsory training besides the officers who handle complaints also refer to the Flow and SOP for handling complaints so that the ability to handle complaints is good enough. This is in line with Yulianti (2015) who states that training is a process of forming employees to obtain work effectiveness and of staff development. Also, it is useful to increase the capacity of human resources to be better at knowledge, work skills, and work professionalism in achieving the company goals (Aswad and Ferrial, 2016).

Implementation Standard Operational Procedures
Patient complaint management at the hospital already followed the Standard Operational Procedures (SOP). The SOP was formulated by the Head of the Legal and Public Relations Department in accordance with the organizational structure, main tasks, and functions. The standardized patient complaint handling starts from receiving incoming minor or major complaints. This result is extracted from the interview excerpt as follows.
"We establish SOPs by referring to the legal and community sections, then make the procedures of the complaint reporting mechanism. Lastly, we consider the complaint status either complete or closed"(Informant A) "So the complaint handling procedure that we have includes starting from the follow-up of complaints, the level of complaints, which means starting from minor, moderate and severe complaints. They are all included in one procedure" (Informant B) It is relevant to the research by  who found the officers received, recorded, confirmed, and resolved complaints based on its types: minor, moderate or major. According to Law Number 25 of 2009 concerning Public Services, a manager should create complaints management procedures, appoint an executor for handling the complaints, and determine which complaints are prioritized. Complaints from the suggestion box and social media must be resolved based on the SOP.

Complaint Handling Flow
The results showed several important activities of complaint handling had been run effectively. The first step performed was receiving and identifying both direct and indirect complaints. Second, incoming Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i1.2022 Original Research complaints would then be recorded and recapitulated by the officers. Next, the officers would find and propose the solutions by coordinating with the installation/work unit; afterwards, they would respond to customers with respect. Then the last one was providing feedback to the patient and gathering their responses.

Receiving and Identifying Complaints
The first step taken in handling complaints was receiving and identifying patient complaints. The officers dredged the data up and completed information needed for resolution discovery. The result is shown in the interview excerpt as follows.
" This is in line with previous research discovering direct and indirect methods in the complaint submission (Ariadi, 2019). Direct complaint submission has a positive effect on the hospital since both patients and officers can discuss what has happened directly. Previous research found organizations collected customer complaints in several ways, such as suggestion boxes, customer complaint forms, special telephone lines, websites, comment cards, customer satisfaction surveys, and customer exit surveys (Indriyani, S. Mardiana, 2016). Such complaint handling is known as the "Recovery Paradox".
From three types of complaints, the hospital refers minor complaints to administration and moderate complaints to doctors' and nurses' services. In addition to these types, serious complaints deal with errors in the administration of medical actions by officers and could be detrimental to patients. The following interview excerpt explains the results.
"Light is usually facilities such as dirty toilets, broken doors when it comes to the doctor himself, it is wrong to administer the medicine with weight" (Informant C) Research at A.M Parikesit Hospital found 3 types of complaints. First, minor complaints were resolved immediately after coordination with the relevant work units. Second, moderate complaints required further coordination than just resolving with the customer. Three, Serious complaints are complaints that are resolved through legal channels . Complaint handling at dr. Sardjito Central General Hospital was handed over to the legal and public relations department that determined the types and solution.

Complaint Documentation
The X government hospital recorded complaints using complaint forms. Complaints were recorded by type and submission method. The following is an interview excerpt to support the result.

Search and Submission of Solutions
Every officer who received complaints coordinated with the installation/work unit. The search for a solution depends on types of complaints and submission facilities. This is in accordance with the interview excerpt as follows. "

" (Informant A)
To handle customer complaints optimally, the hospital should improve several aspects; improving quality of customer service officers; providing call center/contact center available for disseminating information about the doctor's practice schedule, available rooms; providing the hospital's website for information update and a suggestion box where patients can lodge complaints privately (Sujarwo and Subekti, 2019).
Customer complaints can be responded directly by active listening and without taking sides (Yonosari, E. Pawelas, S. and Kusumastuti, 2018). The hospital currently researched had three time frames to solve patient complaints. According to Irawan et al. for minor and moderate complaints, the hospital needed no more than 1x24 hours. However, complaints submitted to the suggestion box require a longer time because checking was done once a week, and so did major complaints (Irawan, Nawawi and Ahmad, 2016).
A good and appropriate feedback method is required, and thus customers can understand the solutions offered. Good speaking skills are required for each officer. This further confirms that each officer and installation/unit has sufficient ability to Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i1.2022 Original Research handle complaints as seen from the following interview excerpt. "In handling complaints, the staff here is quite good, because, in PR itself, all officers must be able to handle it so they already understand". (Informant  A) "Enough, both the installation and the staff here already understand what the process should be." (Informant B) The problem of service complaints requires a little handling of the section head. Also, providing information on staff assigned to the patient is good and clear in handling complaints. Novitasari (2018) found in her research handling minor complaints only took ≤15 minutes.

Feedback
Feedback for patients aims to find out their response towards complaint handling. Based on the results, the officers approached the patients if the patient wanted to get information related to the service. This is in accordance with the interview excerpt as follows.
"When the patient is satisfied with the answer we give, we will ask again, maybe there is still something left unanswered. If the patient is satisfied and says enough and says thank you.

Yes, it means closed and finished". (Informant B)
Previous research showed officers who offered assistance with patient complaints could make patients satisfied with the services (Irawan, Nawawi, and Ahmad, 2016). The officers in charge provided other solutions by talking with the head of the department when the patient was not satisfied. Good feedback can also promote a good image for the hospital. If complaints are not addressed, it may cause a bad reputation that will decline patient visits and trust. Customer complaints are things that cannot be ignored (Marlinae et al., 2016).
Complaints are public expressions arising because of public dissatisfaction with a service product. However, not each dissatisfaction will be expressed with complaints. The public will lodge a complaint if they feel that the complaint submitted has not received a positive response (Hendramawan, 2016).

Facilities for Complaint Handling
The hospital has available facilities to accommodate complaints including a special room for direct complaint reporting, and telephone, suggestion box, email, and WhatsApp for indirect complaint submission. This is in accordance with the interview excerpt as follows.
" Whereas, complaints from the media were gathered every day during working hours. Problem solving should be undertaken through effective and assertive communication, especially in the information and customer service sections (Muhadi, 2016). Meriza (2018) defined oversight as the overall summary of supervising, checking, matching, and controlling all activities that follow the planned plans and desired results. Supervision is not solely intended to find and correct mistakes, but rather to prevent mistakes from occurring (Meriza, 2018).

Control Supervision of SOP
Supervision carried out at the hospital was related to the implementation of SOP, officers' work performance, and follow-up actions or reports of complaints. At the hospital, complaints handling started from the lowest level to the highest level, where the directors involved all relevant units. The results concerning the hospital supervision Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i1.2022  In addition to monitoring the applicability of the SOP for complaint handling, the legal and public relations department also supervised unresolved complaints by checking the complaint report book and contacting the patient from their registered identity. Major complaints posted on social media or suggestion box outside working hours were handled once the officers checked them out. Therefore, it is necessary to develop human resources, and thus productivity can encourage the company's progress.

Minimizing Complaints
Complaints are very useful as the experiences of service users at hospitals. Hospitals must respond positively to complaints without hesitancy to deal with them. Complaints can be used to improve hospital services (Ariadi, 2019) Using complaints, hospitals can find out their weaknesses of services and thus repair their future performance (Megawati, 2018).
Minimizing complaints could prevent further complaints from recurring. The results showed complaints could be minimized after the officers evaluated the meetings with directors and customer satisfaction surveys, as well as provided orientation to patients.
" The result accords with the interview excerpts that the officers took a good step in minimizing complaints. However, inaccuracy in complaint handling will be a restraint to patient satisfaction and quality service (Suhadi et al., 2019).

Evaluation
Evaluation is an examination of the implemented programs for better performance. The hospital conducted a more forward-looking evaluation to improve the success of the complaint management. Through evaluation, the hospital could find out the most recurrent complaints.
"Once a month there is an evaluation with management. Everyone is present at the meeting, both the board of directors, all divisions, and work units will be present. Evaluation is carried out to analyze the parts that always cause complaints." (Informant B) "The standard refers to the number of complaints each month, to see whether the complaints increase or decrease, and continue if the types of complaints are mild, moderate or severe. With the hope of complaints that no patient will return with the same complaint". (Informant C) This study found that the hospital conducted monthly meetings involving the board of directors, departments, and installations. In the evaluation, the hospital reviewed the number, topics, and types of complaints. Hastuti, Baginda, Aprianda Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i1.2022 Original Research The hospital leader significantly plays a role in complaint handling. Under current conditions, hospital leaders who lack the political relation will manage complaints effectively, leading to inadequate human resources in the complaint handling department (Jiang et al., 2014).

Conclusion
The analysis of patient complaints management at an X government hospital in Yogyakarta concluded that a complaint handling policy has been established by providing facilities where patients can submit their complaints and training to new officers/employees to participate in handling negative responses on social media. A person was already assigned to handle complaints in the law and public relations department and outpatient and inpatient installations. However, additional human resources are required to manage the suggestion box. Despite the implemented complaint management, the hospital had several obstacles for documenting the senders of the complaints as well as having inadequate stationery and complaint forms and mismatched schedule of complaint collection.
Complaints handling at the hospital was supervised and evaluated every month through meetings with the board of directors, departments and installations/ work units. The evaluation considered the number, topics, and types of complaints.
Abbreviations BLUD: regional public service agency, SOP: Standard Operating Procedure, PR: public relation.