IMPLEMENTATION OF QUALITY MANAGEMENT BASED ON LOCAL WISDOM ON THE OUTPATIENT SERVICE IN THE SURYA HUSADHA HOSPITAL, NUSA DUA

This research aimed to observe the implementation of quality management of hospital’s health care service and to identified whether the service done by the hospital were related to the local wisdom in its quality management implementation. This research was designed using qualitative descriptive approach which was located in Surya Husadha Hospital, Nusa Dua. The data source in this research was a primary data which was collected through the research informant. The informants in this research were the head of polyclinic, the head of health care service division, health workers, and patients. The data validation testing was done using triangulation. The data were analysed using qualitative descriptive analysis technique. The result of this research showed that the quality management implementation on the health care service through the perspective from service users had been implemented properly, from the medical service to the non-medical service. The service which had been done related to the local wisdom on its implementation, based on Tat Twan Asi. Tat Twam Asi used as a guidance in giving service to the people. And also there were other local wisdoms, which were menyama braya and tri hita karana which consists of parahyangan, pawongan, and palemahan.


INTRODUCTION
The successfulness of quality management implementation in overall cannot be separated from local wisdom and culture where the company is located. The function of local wisdom, apart from education development, is also to develop the human resource. Local wisdom is a knowledge source which is done dynamically, developing and is continued by certain population. The certain population is integrated with a comprehension about nature and local culture. Local wisdom is also a foundation in policy making on the local level in medical field, agriculture field, education field, natural resource management and other activities in a population. Culture consists of two components, which are value and belief. Value refers to something which is believed by organization's members in knowing what is right and wrong, while belief refers to a behave on how they supposed to be working in an organization (Tika, 2006).
Quality is a perfection of a service product which obeys the established standard. The service quality, which is usually used in evaluating a quality of health care service, refers to five quality dimensions which are responsiveness, reliability, assurance, empathy and tangible. Those five quality dimensions can be used to create a satisfaction (Muninjaya, 2011). In several result of researches, service quality had a relationship between nursing service quality and patient's satisfaction escalation (Widyastuti, 2013). The implementation of integrated quality management, not only used by manufacture company, but also used by service company which operates in medical field. In this topic, hospitals also need to implement the quality management based on local wisdom. Hospital is one of the facilities which give health care service to the people. Hospital always tries to give the complete and high quality service with several superior services, and also prioritizing patient safety. There are some steps which done by the hospital in order to give a high quality service, such as, upgrading the professional hospital management, giving service through kind and faultless human resource, developing the human resource's qualified skills through continuous internal and external training, upgrading the service which focused on the patient's safety and satisfaction as well as providing modern medical facilities and infrastructure in order to support the health growth in Indonesia.
The development on the medical field in Indonesia, aims to attain a competent people in creating a healthy condition both physically and spiritually. According to that statement, the government had been trying to build a health care service which easy to reach and can be used by all levels of society both from the lower class until the upper class, without differentiates the economy status of someone in getting the fair and equitable health care service.
The fair and equitable service may causes a satisfaction since the people nowadays, are started to be critical in evaluating a service, especially in medical field. The Government Regulation of Republic of Indonesia No. 65 of 2005 concerning The Guideline of Preparation and Implementation of Minimum Service Standard, line I paragraph 6 stated that the implementation of government activities in the region, refers to the Minimum Service Standard (SPM) which will guarantee the community in obtaining good services from the government based on their needs.
With the quality service which based on the local wisdom concept in giving health care service, the nurse is hoped to work carefully and always based on reason. To work carefully does not mean to work hard. Otherwise, it means to work with paying attention to the quality which means to work more wisely using a good system, so the result will be better, but with less effort. The level of health care quality service will be determined by the balance level which happened between the three elements.

THEORETICAL FRAMEWORK The Concept of Quality
Quality is a full picture of characteristic of a product or service which related with its ability to give needs of satisfaction (American Society of Quality Control). Quality is a 'fitness for use' or the usage compatibility (Juran, 2016). Tappen (2015) explains that quality is an adjustment of the client's wish and suitable with the established standard and also it is an achievement of a desired goal. According to Supriono (2002), quality is a level of good or bad of something. Quality can be defined as a level of superior. Therefore, quality is a relative measurement of kindness. Operationally, good quality product is the products which fulfill the customer's expectation. Quality is a sustainable process, dynamic and involving all organization. Quality is each people's responsibility and not only the responsibility of quality department (Assaf, 2009).

Total Quality Management (TQM)
Total Quality Management (TQM) is a concept of improvement which is done continuously, which involves all elements and employees on the each organization level in order to attain the best quality on all organization aspects through management process. According to Hashmi (2014), TQM is a management philosophy which tries to integrate all organization function (marketing, finance, design, engineering, product, customer service, etc), and focuses to fulfill the consumer's expectation and the aim of organization.
According to Tjiptono and Diana (2015), TQM is an approach in increasing the organization productivity (quantitative performance), increasing quality (decreasing the fault and level of failure), increasing the affectivity on all activities, increasing efficiency (decreasing the resource through productivity escalation), and doing all things correctly in a right way. Dale (2013) defines TQM as a mutual cooperation among all people in an organization and it is linked with the business process to produce a value of product. It is a service which beyond the consumer's needs and expectation.
Moreover, Bhat and Cozzolino (2013) argue that TQM is a strategy and integration of management system to increase the consumer's satisfaction. It prioritizes the involvement from all managers and employees and also it uses quantitative method. Whereas, according to Directorate of Productivity Development or Direktorat Bina Produktivitas (2012) TQM is a management system to increase the quality and productivity with using the quality control in solving the problem. It includes the participation from all employees in order to give satisfaction to the customer.

Health Care Service
Based on Kasmir (2016), service is the ability of company/person in giving treatment which can give a satisfaction to the customer with the established standard. The ability is showed by their human resource, facility and infrastructure. The other opinion which delivers by Moenir (2016), service is the activity which is done by a person or some people with the foundation of material factor through certain system, procedure and method in order to try to fulfill other people' needs which appropriates to their right. Whereas, in the Law No 25 of 2009 concerning the public service, defines that public service is an activity or activities which happened in order to fulfill the service's needs which is consistent with the laws for each of the citizens and residents for product, service or administrative service which provided by public service provider.
Health care service is each people's right which guaranteed in 1945 Constitution of the Republic of Indonesia, in order to increase the health status, both for personal and overall society. The definition of health care service based on

Ministry of Health of Republic of Indonesia Year 2009 (Depkes RI) which states in
Health Laws about health, is each effort which is done individually or together in an organization to take care and increase health, prevent and heal an illness as well as health recovery, of an individual, family, group as well as citizen.

The Concept of Quality Management of Health Care Service
Law No 25 of 2009 concerning the public service, defines that public service is an activity or activities which happened in order to fulfill the service's needs which consistent with the laws for each of the citizens and residents for product, service or administrative service which provided by public service provider.
The quality of health care service is a level of service perfection of health care service which consistent with the profession standard and service standard by using resource potential which provided in the hospital or public health center (puskesmas). It is delivered properly, efficiently, and effectively. It is also given securely, and satisfied the norm, ethic, law and social culture with paying attention to the limitation and ability of government, citizen and consumer (Herlambang, 2016).
Bustami (2011) states that the quality of health care service is a level of the fulfillment of needs of citizen or a person to the health care which consistent with the proper profession standard by using the resource properly, efficiently, effectively in the limited ability of government and citizen. It also held securely and satisfied the customer according to the proper norm and ethic.

The Local Wisdom on Service
Local wisdom is everything as a characteristic of a community which consists of economic aspect, cultural aspect, information and communication technological aspect, ecological aspect, and many more. Another source states that local wisdom consists of crops, art creation, tradition, culture, service, natural resource, human resource and many more which becomes supremacy in a region (Dedidwitagama, 2007). Besides, local wisdom will still educate the citizen throughout the times (Hidayat & Vidjanarko, 2008). Local wisdom is a custom in a community as a symbol of culture values based on the outcome of local innovation, which can be used maximally and is directed positively in various forms and effort to solve the problem (Supadi, 2009).
A local wisdom is the identity of its community. The identity consists of vision, mission and values in their lives. Those values can be used in the effort to continue life, living together and also as an effort to increase the service based on local wisdom which has a universal meaning. The order (cosmos) in a system will send out the value of beauty that is supported and shaped by an order. The beauty saves much information. Therefore, the interaction patterns among the subsystem variety can be occurred proportionally, in balance and harmoniously (Sulistyo, dkk., 2010).

METHODOLOGY
This research was designed using qualitative descriptive approach which was located in Surya Husadha Hospital, Nusa Dua. The data source in this research was a primary data which was collected through the research informant. The informants in this research were the head of the polyclinic, the head of health care service division, health workers, and patients. The data validation testing was done using triangulation. The data were analyzed using qualitative descriptive analysis technique.

The Implementation of Quality Management of Health Care Service in Surya Husadha Hospital, Nusa Dua
Referring to the Laws of Republic of Indonesia No 44 of 2009 concerning hospital on line 1, states that hospital is a health care service intuition which held the health care service personally and faultless which provides patient service, outpatient service and emergency. To give a good quality service, it is important to do a management which manages a system, human resource, facility as well as infrastructure in order to run an integrated service. The quality management of health care service is a level of health care service perfection which is held based on ethical code and established service standard, therefore it creates a satisfaction from each patient (Kemenkes in Muninjaya, 2014).
The service user in Surya Husadha Hospital, Nusa Dua, which was external customer, consists of patient, patient's family, visitor, government, health insurance company, citizen, colleague, non-governmental organization and many more (Muninjaya, 2014). To give a high quality service as delivers by Kasmir (2016) which means, the ability of company/person to give a service that can satisfy the customer with the established standard. The ability is showed by their human resource, facility and infrastructure.
Surya Husadha Hospital, Nusa Dua had been giving a service based on the standard and was able to fulfill the customer's needs with the complete facility. Therefore, it can serve various types of patient with any types of illness and also was able to give recovery to its customer. There are five indicators of service quality, which are empathy, tangible, reliability, responsiveness, and assurance.
1. Empathy is giving a sincere attention and tends to be individually or personally.
It is given to the customer with the aims to understand the customer's expectation. A company is wished to have an understanding and knowledge about customer. For instance, understanding the customer's needs specifically and also having a comfortable operational time for the customer. Each of the service activities needs a comprehension and understanding in agreed assumption or importance of a thing which related to the service. The service will run smoothly and qualified if every side which related with the service has empathy in completing or taking care of service (Parasuraman, 2015). According to the interview result from the informants, the medical team had a quite high empathy feeling based on asking the patient's condition every morning and during they were hospitalized. Medical team also sometimes asked the patients regarding their illness which they felt and willingly provided care based on patient's needs. It was consistent with the empathy dimension which was done by arranging a sustainable training to teach how to give a proper and Journal of Business on Hospitality and Tourism PISSN 2527-9092 Vol 07 No 02, 2021: 213-223 EISSN 2527 218 https://jbhost.org/ https://creativecommons.org/licenses/by/4.0 right service, therefore the customer may feel comfortable and respected in the effort of understanding the specific needs of customer (Mardikanto, 2016).
2. Tangible is the ability of a company in showing their existence to the external side. The appearance and ability of facility and infrastructure of company and its surroundings are a real proof of a service which is given by the company. The physical proof of service quality is the real physically actualization form which used by the employee based on its usage which may can help to give a service to the people that want it. Therefore, the people satisfied with the service. It also shows the work performance for the service provided (Parasuraman, 2015). According to the statement from some of the informants, Surya Husadha Hospital in Nusa Dua had a quite decent building with a complete facility and infrastructure. The medical tools and other supported tools in determining diagnosis and therapy were complete and were able to serve all customer needs. The informants stated that Surya Husadha Hospital in Nusa Dua had a clean environment based on the observation that had been done. This made Surya Husadha Hospital in Nusa Dua became a high standard hospital for the citizen, in giving its service.
3. Reliability is an ability to give promised service immediately, accurately and satisfying. A performance must consistent with the customer's expectation. It means punctuality, the same service to all customers without any mistake, sympathetic behaviour and high accuracy. Every services need a proper form of service which means in giving a service, every employee are hoped to have an ability of knowledge, skill, independence, mastery and high work professionalism. Therefore, the work activity produces a form of satisfied service without any complaint and extreme impression of the service received by the citizen (Parasuraman, 2015). According to the research which was done, Surya Husadha Hospital in Nusa Dua as a hospital which is located in tourism area, was able to handle patient from foreign countries. Surya Husadha Hospital in Nusa Dua was forced to provide competent medical team and human resource in every field, in order to be able to give a maximum service to the citizen. With the intense activity in Surya Husadha Hospital, Nusa Dua, it forced all team to work faster, but still they received complaints from the service users. The informants stated that, with a great amount of patients that the medical team handled, not all patients got a fast response. This thing had become an issue of the service in Surya Husadha Hospital, Nusa Dua.
Based on the phenomenon above, it was consistent with the research that was done by the previous expert. It explained that the low level of customer satisfaction was found in the reliability dimension, especially about the lack of ability of the health worker in a hospital to give a promised service to the patient immediately, accurately, properly and quickly (Mardikanto, 2016). This phenomenon also showed that the service which was felt/received by patient was lower than the service that expected by the patient. If the customer's expectation is bigger than the reality, therefore the service quality that they