Strategic Plan Development for the Implementation of Balanced Scorecard as a Performance Measuring Instrument at Gotong

The development of business, science and technology runs so quick, between institutions or organizations compete with each other and make changes and innovations to maintain the existence in the business world. According to Kotler et al. (2014) if the company wants to compete in the global market, one of them is to commit to creating and retaining customers and must be able to adapt to the changing market, by carrying out market-oriented strategic planning. Strategic planning allows companies to anticipate everchanging conditions, and provides a map of the journey and direction to go and how to achieve it (Jauch and Glueck, 2004). The implementation of National Health Insurance (JKN) that has been established by the government starting from January 1, 2014, hospitals in Indonesia must continue to improve in order to remain the hospital of choice for people who need health services. This can be realized if all leaders and staff in the organization are committed to improving the grade and quality of its services on a continous basis. Strategic plan is a series of activities aimed at obtaining the welfare of clarity of direction and objectives of an organization. Gotong Royong Hospital has a strategic plan for the period 2016-2020 with strategic direction and proritas at Gotong Royong Hospital that is to realize quality health services through mutual care that aims to improve optimal, orderly, comfortable hospital health services by always paying attention Abstract

to good quality and performance and respect the social values of professionalism and ethics so that the vision and mission of Gotong Royong Hospital can be fulfilled.
Balanced scorecard is a system mechanism that is able to translate the vision and strategy of the organization into real actions in the field. The implementation of balanced scorecard is very appropriate to be applied by non-profit organizations, because the measurement of the performance of non-profit organizations is not only financially centered but non-financial aspects are also the most important aspects. Through the evaluation of the implementation of balanced scorecards as a performance measuring instrument and the development of strategic plans, hospitals are expected to be able to provide quality services and provide satisfaction for those who use these services.
Some previous researches have done a lot of research on balanced scorecards. Such research done by Handayani (2011), Dewi (2014), Pamungkas (2014), Hadiyati (2014), Widhiyaningrat (2015). While research on the development of strategic plans such as research by Fahrianeta (2008) who compiled the development of strategic plans using the formulation of IFE Matrix and EFE Matrix and for alternative strategies using QSPM Matrix. Karmawan (2016) made strategic plan development by doing SWOT analysis and for decision making using Concensus Decision Making Group (CDMG) method. Aji and Tjahjono (2016) in their research analyzed the implementation of strategic plan using SWOT analysis, then the research by Lasyera et al. (2018) conducted research by analyzing strategic plans using IE Matrik.
The overview of the current performance of Gotong Royong Hospital has obtained the first accreditation status with class D hospital classification that has been established in November 2016 with a type of medical services consisting of 24-hour Emergency Services, Outpatient Services, Inpatient Services, Maternal Services, Operating Room Services (OK) and ICU Services, for supporting services consists of Laboratory Services, Radiology Services, Pharmacy Services, Nutrition Services, Medical Record Services and Instrument Sterilization Services, while for public services consists of Laundry, Maintenance facilities and medical and non-medical equipment, Waste Management, Environmental Sanitation, as well as procurement of Ambulances, Medical Gas Management and Clean Water Reservoirs.
Medical record data at Gotong Royong Hospital currently shows the presence of patient visits from various regions in Surabaya. The number of patient visits in 2016-2018, can be seen from the chart below. The performance of service aspects at Gotong Royong Hospital can be seen from patient visit data in 2016-2018. From the medical record of patient visits, it is known that there has been a decrease in patient visits from 2016-2018. Based on current data to support its services Gotong Royong Hospital has emergency facilities, outpatient units that have 18mpolyclinics, 37 inpatient rooms with 69 bed, maternity rooms, OK (operating rooms), medical check-ups, and equipped with ambulances. The number of Gotong Royong Hospital staff as many as 177 people consisting of 41 medical personnel, 63 nursing personnel, 37 medical support people and non-medical personnel as many as 35 people.
On the other side, data from BPS Surabaya, there are various health services centers consisting of 38 hospitals, 14 maternity place, 3 eye hospitals, 1 mental hospital, 1 cancer hospital, 1 surgical hospital, 1 internal disease hospital, 62 health centers, 69 medical laboratories, 99 optics, 762 pharmacies, and 59 herb stores.
This study aims to establish development of strategy plan from evaluation result implementation of balanced scorecard as a performance measuring instrument at Gotong Royong Hospital Surabaya. From several previous studies, data analysis of physical facilities, existing human resources, patient arrival data, and health care facilities in Surabaya, researchers made strategic plan development through the implementation of balanced scorecards as a performance measuring tool and can establish the development of a strategy plan in order to be an input for the Leadership of Gotong Royong Hospital related to the technical development of stategis plans that can be implemented into the activities of Gotong Royong hospital in accordance with its long-term goals.

II. Research Methods
This type of research uses interpretive paradigm with qualitative approach. The data source used in this study comes from the primary data, that is: data obtained directly from the source. The research subjects or respondents in this study are people who are seen as involved in planning the hospital's business strategy or can provide input for the development of the hospital's business strategy plan. The data source is obtained through direct observation with Interview / Indept Interview with related parts that is: Director of Gotong Royong Hospital Surabaya, Head of Marketing, Guarantor, SIR, General Vice Director Vice, Finance Vice Director, Head of HR Department, as well as requests for necessary documents include medical record data, financial statements and others.

III. Results and Discussion
Evaluation of the Implementation of Balanced Scorecard as a Performance Measuring Tool From the results of the ratio above shows that Gotong Royong Hospital experienced a decrease in costs in 2017 and while in 2018 again experienced an increase in costs. This shows that in 2017 Gotong Royong Hospital is able to reduce unnecessary expenditures, while in 2018 there is an increase in costs because Gotong Royong Hospital is still doing several stages of development. The results of the ratio of revenue growth and cost changes show that the performance of hospitals in terms of financial perspective is relatively good.

Perspective a. Customer Satisfaction
There has been no customer survey in 2016-2018 by Gotong Royong Hospital Surabaya. From the measurement results showed that Gotong Royong Hospital experienced a decrease in customer retention every year and the number of old patients also decreased from year to year. The decrease in the number of patients is also due to the "jamkesmas program" that is health BPJS which regulates regionalization and reference. This shows that Gotong Royong Hospital has not been able to maintain its customers. Based on the number of beds needs in accordance with BOR calculation standards, the ideal standard is 60-85% but the percentage of BOR at Gotong Royong Hospital is only 29.94% below the ideal standard. From the results showed that Gotong Royong Hospital has not been able the ideal standard of bed use. From the results showed that the average TOI value at Gotong Royong Hospital is 11.2 and has not reached the ideal standard value because it is still above 1-3 days while the ideal standard is in the range of 1-3 days. The results showed that the NDR value at Gotong Royong Hospital achieved an ideal value of 11.14 declared good the ideal standard of ranging < 25 per 1000 patients out.

Learning and Growth Perspectives
Measurement through learning and growth perspectives using the following benchmarks: From the measurement results showed that Gotong Royong Hospital experienced a decrease in employee capability every year and the number of employee training also decreased from year to year. The results of employee retention and training measurement show that the hospital's performance in terms of learning and growth perspective is quite good, this can be seen from the percentage of customer retention is above 100% even though the capability of employees has decreased.

Opportunities and Threats
After identifying internal factors for macro environmental data, an inventory of these variables and critical factors are opportunities and threats for Gotong Royong Hospital using Concencus Decision Making Group (CDMG). The consensus results are summarized in the Table as follows:  Source: Data processed by the author EFE Matrix results are used to summarize opportunities and threats to a business unit. From the results of EFE Matrix Analysis obtained an overview of the external condition of the company that the company's opportunities are greater than the threat. The existence of 24-Hour service 0,1 2 0,2 5

Strengths and Weaknesses
Financial performance is optimal 0,1 2 0,2 6 Hospital management information system is optimal 0,1 2 0,2 Source: Data processed by the author Matrix IFE results are used to summarize strengths and weaknesses in a business unit. From the results of the IFE Matrix Analysis obtained an overview of the internal condition of the company that the strength of the company is greater than the weakness.

Matching Stage Positioning 1. TOWS Matrix
Positioning by using TOWS Matrix is by combining strength and weakness factors against opportunity and threat factors. At the input stage, the element of strength (1.56) is greater than the element of weakness (1.12) and the opportunity element (1.88) is greater than the threat (1.48). The position of the TOWS Matrix can be seen in the table below. Source: Data processed by the author Thus, the results of the map in the TOWS Matrix show the position of Gotong Royong Hospital is in quadrant 4 (Future Quadran) that is, management must maximizing the srrenght they have and take advantage of external opportunities.

Matrix IE
In determining Matrix IE using the total score values EFE and IFE. The mapping result of the total EFE score is 3.36 and the total IFE score is 2.68. It shows the position of Gotong Royong Hospital in cells I and II in the picture below.  Cells I and II include quadrant Grow and Build strategy (growth and development) and the recommended strategies in these cells are intensive strategies. The first strategy is to find market share. The second strategy is market development. The third strategy is product development.

Stages of Strategic Alternative Determination
The results obtained at the matching stage using TOWS and IE Matrix resulted in several recommended alternative strategies, namely: From the table, it shows that the strategies selected and represented by the two existing matrix are product development and market penetration strategies. From the above results can be developed with increased product and market penetration. Both strategies can be used as input to the Gotong Royong Hospital to improve its performance.

TOWS Analysis
The results of TOWS analysis from internal and external analysis are the following. Hospital experienced a decrease in customer retention every year and the number of old patients also decreased, the decrease in customer retention is also due to BPJS health regulations.

Performance from an Internal Business Process Perspective
From some measurements of the effectiveness of hospital services shows that the performance of hospitals in terms of internal business process perspective is classified less good. Some indicators don't reach standards are: BOR, ALOS, TOI and BTO, while for GDR and NRD already reach standards.

Performance in Terms of Learning and Growth
The results of measurement of employee retention and training showed that the hospital's performance in terms of learning and growth perspective is rather good, this can be seen from the percentage of customer retention is above 100% although for the capability of employees decreased, for the decrease in employee capability is expected Gotong Royong Hospital to continue to improve the development of the quality of health services and human resources owned by adding training for employees to improve employee performance in the future.
After knowing the results of performance analysis on the implementation of balanced scorecard can be known in terms of customer perspective and internal business process perspective at Gotong Royong Hospital there needs to be a development of strategy plan.
The results of developing a strategyc plan at Gotong Royong Hospital from the analysis external environment and the internal environment by conducting Consensus DecisionnMaking Group (CDMG), and by using IFE Matrix and EFE Matrix known the ability of Gotong Royong Hospital that is a greater strength than weaknesses and opportunities of hospitals greater than threats. By using TOWS Matrix, the position of Gotong Royong Hospital is in the 4th quadrant namely Future Quadran while with IE Matrix in Cells I and II is included in the Grow and Build strategy. After matching stage in both matrix obtained alternative strategies arenproduct development and market penetration.
The development of the strategy plan from the results of the TOWS Analysis obtained several proposals for the development of strategic plans on strengths, opportunities, weaknesses and threats, namely:

Strategy (SO)
a. Creating good governance hospital, in accordance with the Hospital Law to create good governance hospitals must have an effective, efficient and accountable organization in accordance with UU Article 33 paragraph (1) UU No. 44/2009 and Article 36 of UU No. 44/2009 b. Making Geriatric Services as a superior service by improving services in the field of geriatric services. c. Improving human resources both in terms of quality and quantity, increasing the professionalism of human resources both medical, medical and administrative with the trainings n customized to the needs of hospitals. d. Optimizing networking systems and partnerships with suppliers, managing good relationships with suppliers who frequently interact with hospitals. Effective communication with suppliers will make inventory management better and improve the overall process of acquisition of goods.

Strategy (ST)
a. Measure customer satisfaction by creating questionnaires every year. b. Increasing hospital revenues by improving the quality of services, facilities and infrastructure and promoting hospitals to be better known to the public. c. Create MOU / cooperation agreement with private insurance, private clinics, schools and companies to increase hospital revenue.

Strategy (WO)
a. Realizing the hospital class into class C or B by participating in hospital accreditation. b. Improvement of Outpatient Services both in terms of service and service hours, improvement of outpatient services in terms of services can be supported by the timeliness of services, services in accordance with procedures and standards (SOP), implementation of zero error, completing number of human resources and supporting facilities. c. Building the effectiveness of education and excellent research centers by cooperation with educational institutions and realizing as an educational hospital.

Strategy (WT)
a. Development of Physical Facilities with the addition of several building constructions to support hospital services. b. Recruiting the marketing department by finding employees who are competent marketing in their sector and held training as needed. c. Optimizing research and development of Gotong Royong Hospital by making it as the Main Education Hospital, by cooperating with educational institutions and playing a role in conducting research and development of research and society service continously.

Suggestions
Based on the conclusion, the recommended strategy reformulation to be done is market penetration, and product development. In implementing the strategy, the things needed by Gotong Royong Hospital in achieving growth goals, researchers suggest: 1. Strategy development of strengths and opportunities a) Creating Governance Creates Good Hospital Governance; b) Making Geriatric Services as Excellent Services; c) Human resource improvement both in terms of quality and quantity customized needs. To improve the quality of human resources by providing opportunities to attend trainings and work shops and evaluations of the training activities; d) Optimizing networking systems and partnerships with suppliers 2. Strategy development of strengths and threats a) Measure customer satisfaction by making questionnaires on patient satisfaction. To improve the quality of hospital services and customer satisfaction the author recommends that the gotong royong hospital customer satisfaction survey be held from year to year; b) Increase hospital revenue; c) Create an MOU with private insurance, private clinics, schools and companies 3. Strategy development of opportunities and weaknesses a) Realizing the hospital class into class C or B, b) Improvement of Outpatient Services both in terms of service and service hours; c) The development of physical facilities, it is necessary for the management to make an annual work program or bussines plan of Gotong Royong Hospital from a choice of strategies; d) Building educational effectiveness and excellent research centers 4. Developing strategies for weaknesses and threats a) Development of physical facilities (operating rooms, ICU and parking facilities); b) Recruiting marketing. By recruiting employees in the field of marketing or marketing is expected to increase revenue from The Gotong Royong Hospital to increase and hold regular meetings to evaluate the implementation of hospital marketing; c) Optimizing the research and development of Gotong Royong Hospital by making it as the Main Education Hospital.