Date : March 2010

Name expert : Bert Aukema

Project number : 52304 M IE
Name applicant : Rumah Sakit Umum Cempaka Azzahra
Address applicant : Jl. Pocut Baren, Kel. Laksana, 23122 Banda Aceh
Contact person : Mr. Kamal Riza, riza.kamal@yahoo.co.id
Project dates : from March 4 till March 19 2010
Status of the report : draft.

A. Summary of the report

B. Problem description
1. Description of the company.
Rumah Sakit Cempaka Azzahra is a general hospital in Banda
Aceh, Indonesia. It is housed in a building that in the passed served
as an store/office. The start of the hospital was in 2008. Cempaka
Azzahra has 10 1-person bedrooms,1 emergency room,1 operation
theatre, 1 delivery room, 1 baby room ( max. 3 newborns). The
number of employees is 35. The year report of 2008 shows a total
of revenue of E 111.000, a total of costs of 115, a loss of E 4.000.
In 2009 the number of patients was 394. The total of nursing days
was 1.153, thus an occupancy rate of 26 %.
There are 5 general medical doctors, who cover 7 times 24 hours
duty. Medical specialists in the basic medical specializations like
internal diseases, surgery, gynecology, pediatrics and E.N.T. come
from outside the hospital as consultants. The nurses are working in
3 shifts, each shift has 2 nurses. In very busy times some extra are
on call. The emergency room has 3 shifts with 1 nurse. The overall
number of nurses is 14. The 4 midwifes also participate in the
shifts.

The building and the rooms have a fresh and clean appearance, a
good fit with Chempaka’s motto Clean, Comfortable and Cheap.
The OR looks quite well equipped.

The organization schema shows the director-owner Mr. Kamal on

top. There are 2 managers. Retired general surgeon Prof. Ridhwan
is responsible for the consultant-medical specialists, the general
doctors and Mrs. Rosmawati, the chief of the other care
departments: nursing ( incl. OR and deliveries), pharmacy, lab,
medical records, etc. The other manager is Mr. Kamal’s wife Mrs.
Yulia , who is responsible for administration, finance, security
housekeeping and maintenance.
The new activity Home care does not have a formal place in the
schema yet.
 2. Description of the problem
In the assistance request mr. Kamal states that he wants to
improve Cempaka in order to give the best services to the patient.
Also he wants to have / to maintain an own, special style that will
make Cempaka famous for the people of Banda Aceh.
By the time of filling in the assistance request Cempaka did not
face an acute problem. During the project an acute cash flow
problem occurred. In formulating the desired qualifications of the
expert, there is an other objective for this PUM project: “… a
creative person who can always suggest and has initiative and is as
a motivator to us.”

So the purpose of this project can be defined as: Give observations

of the actual functioning, what is necessary in the future and have a
creative and motivating attitude to (the employees of) the company

C. Project definition
In the first meeting with Mr. Kamal we discussed what would be the
agenda of my stay. I offered to be present for Mr. Kamal every day to
hear his views and to give my answers and suggestions in return. We
also planned interviews with the 2 managers, the chief of the are
departments, the consultant gynecologist, the pharmacist and the
homecare unit. Besides I would be in the clinic for”consulting by
walking around”. Also interactive lectures for the employees about
reputation and hospitality were scheduled. At the end of my stay I
planned to present a preliminary report with recommendations.

D.1. Analysis related to the problem definition

a. General
Any organization is different from any other. Ruma Sakit Umum
Cempaka Azzahra is a real family company. Director Kamal is a 32
years old ambitious businessman, always looking for opportunities. He
cooperates closely with Cempaka Lima, a combination of a pharmacy
and a 20 medical specialists outpatient company owned by his mother,
who is a pharmacist-businesswoman. She also is the president of
Aceh’s female entrepreneurs and the secretary-general of the
Indonesian organization. So entrepreneurship is in the family. Besides,
Mr. Kamal’s wife Yulia is 1 of the 2 managers. Mr.Kamal’s style is
very open and cordial to his employees.This style underlines the
informal atmosphere of Cempaka. After meeting the manager prof.
Ridhwan my conclusion was that Mr.Kamal is the boss, and prof.
Ridhwan is his medical advisor.

The open and direct attitude of mr. Kamal also showed when he
himself mentioned the may be problem that he being the translator in
interviews might influence the openess of the ones interviewed. I
 agreed, so for the interactive lecture with the employees we invited
receptionist Laila, who did a great job.

In all the meetings and contacts I stressed the importance of having a

good reputation, defined as “ How people think and talk about you,
especially when you are not there”. Also hospitality as Chempaka’s
specialty and to realize that a hospital is depending of the coming of
the patient were basic and central in my contacts. I combined these
ects in a lecture called REPUTATION (see annex 1).

I noticed that the director himself has a clear vision how to serve a
patient: “Like you wanted to be served yourself” he said, even before I
could mention my slogan: ”Treat the patient like she or he were your
own mother”.

His businesslike view also showed when we discussed his idea of a

bonus of Rph 25.000-50.000 for every employee who brings a new
patient. I told him it seemed an interesting idea to me. He will think it
over, consider possible problems and ethical aspects and then further
try to get the idea accepted in the staff.

b. The organization, efficiency and the quality of care

Cempaka is a small organization. And we know the saying:”Small is
beautiful”. Small, informal, short organizational lines, Cempaka
should keep these as organizational advantage, also when growing
bigger. But the small size makes it vulnerable, too. Both in quality and
in return on investment the size is a problem. When 5 on duty doctors
see less than 400 new patients a year, each will see average 80, that is
not even 2 a week. To keep or build up a good quality standard, this is
to little. Doubling the number of beds could be covered by the same
number of doctors, better both economically and quality like.
The nursing department will need more nurses. Administration and all
other departments most probably could cope with the patient increase

As to efficiency I noticed that the daily staffing is fixed and

Cempaka’s activity varies strongly: occupation of 9 beds occurred but
also 2 or 3. Taking the labor market in account, the cost of labor and
the necessity of building up a good and stable team I still do raise the
question whether a more variable staff would be possible.

Especialy in the nursing department Cempaka faces the inefficiency

related to the fact that in every shift you need a minimum staff. All
shifts have 1 nurse for the emergency room and 2 for the berooms. A
combination of the nurses for ER and patient rooms can be taken in
consideration, especially in the night shift. Average 8 new patients are
seen in one week. As nursing activity in the night is lower and always
 a general doctor is there, why not try out 2 nurses combined for ER
and patient rooms? If this reduction is too big, may be a reduction
between 23.00 h and 08.00 h might be possible. For sure in the project
period the nursing was overstaffed, related to the low number of
patients.

I observed that there is a quite big department of security. Though

knowing that security also takes some care for 24 h reception I wonder
whether the Banda’s safety situation demands that much security
function in Cempaka.

At the moment there is no patient elevator. The outside stairs have a

trail to carry a bed patient to the 1st floor. When in future the upper
floor also will be used, you will need an elevator.

I found it special to see that there is no radiology department. Again,

the scale of operating gives the answer. Inpatients now are carried to
an other hospital for radiology. As doubling of the capacity is in the
director’s mind, special attention is asked for radiology as a basic
hospital diagnostic facility. The investment costs for Chempaka would
be too high. So try to have a radiologist interested in starting a
radiology facility next door, and promise him your patients.

As the quality of care in general has both a technical and a human

aspect, try to emphasize on the human factor ( See annex 1,
Reputation”, making hospitality Chempaka’s specialty)

c. Human Resource Management

As the total of capacities of the employees, the so called human
capital, is the most precious capital of Cempaka, HRM deserves
structural attention.
Who are my key employees, how can I keep them, how can I attract
capable new employees, how can I heighten the average level of all
employees, f.i. by education, what is my reputation as an employer, do
I pay competitive wages, etc. etc.
To answer all these questions you need a good HRM policy. You will
need it even more when there will be an increase of employees when
expending. But also today, the 35 employees deserve good personnel
management.
That is why I wrote a paper to start basic HRM activity: prepare global
job descriptions, and start yearly, systematical evaluation meetings
between the individual employee and her/his chief. ( See annex 2)

When talking about education possibilities I point out especially at the

chief of most of the care departments, Mrs. Rose. In my opinion she is
the key employee in the care organization, the one who has by far the
 biggest number of employees reporting to her. Encourage her to make
time to create good working conditions for her employees. If necessary
let her diminish her direct patient care work. Offer her training courses
and other ”equipment”. She is worth it! And extension of the number
of employees will be in her department.

d. Financing.
In financing a sudden problem occurred during the project. Last year
and the 2008 year report show positive figures. A renovation is carried
out, without explicit financing, f.i. through an related loan. The
number of patient days in February dropped. There are no other
financial resources, neither is the bank willing temporally to enlarge
your paying capacity: there you have a classical cash flow problem.
Mr. Kamal and I discussed the situation several times. This month the
wages will be paid in 2 terms, which is not a good sign to the
employees and for your reputation as to employership. Contacts with
other banks are made, a guarantee by Cempaka Lima is an other
option, also looking for an investor to share profit and loss.

The lesson to learn: always make a global cash flow planning, and do
not start an activity (renovation) if it is not financed separately.

In a small company like Cempaka with a big variability in activity

(patients), thus a big variability in income one should look for ways to
heighten the minimum level of income.

At the end of my stay Mr. Kamal started discussions with the National
Insurance Organization. If Chempaka would enter this organization it
would be a good step to a higher minimum level of patients, thus of
income.

e. Home care.
A recently started activity of Chempaka is home care. It is a new
market. At the moment marketing of this product gets much attention.
By paying a yearly fee of Rp. 300.000 you are a member of Cempaka
home care. It guarantees that a Chempaka doctor or nurse will come to
your home once you need this care. In a system without family doctors
it will feel safe to have such a guarantee!
This week the first contract with a company is signed, a local hotel. If
one of the guests (employees?) needs home care Cempaka will be
there
Besides the members of Cempaka home care will
get discount in the
hotel.
So now Cempaka can market to companies that they
should promote
 their membership of Cempaka home care as a fringe
benefit for their
employees.
Next to primary conditions like salary fringe benefits
can be attractive
for the employees.

D.2. Analysis of the general situation including the position in the market
As an entrepreneur and businessman Mr. Kamal is eager to know his
position in the market. And of course, he knows the market better
than the expert, who is here for 2 weeks in an different culture with a
different system of healthcare. About the system an actual example:
Yesterday I had a meeting with the consultant gynecologist.
He had an emergency: an a term woman was in labor in the modern
newly built 400 beds governmental hospital (so called German hospital
after the founding after tsunami). Her first partus was through secarian
section. She was there for 3 days already, nothing was done, though all
signs pointed at a new sectio. The patient was sent in to Cempaka, had
her sectio in the less equipped OR, and the baby recovered within
24 hours, though the starting position before sectio was not good!
So what about market, big and too small hospitals, etc.?!

Nevertheless, the expert has made a SWOT analysis of Chempaka’ s

position. It is up to Mr. Kamal to improve it and to keep it actual.
The expert invites Mr. Kamal also to take advantage of the employees’
own opinions about the SWOT of Cempaka. Encourage them to tell!

As to the position in the market it is very important to keep close contact

with your stakeholders. Those are the organizations or individual persons
who are important for you, both in attracting patients, financing, licenses
to build, etc.
So we are talking about the government, banks, patient organizations,
press, individual rich people, etc.
They can all have decisive influence in times of important decisions.

E. Conclusions and recommendations

- Make hospitality Chempaka’s specialty.

Hospital care has a technical and a human aspect. As you cannot
compete with the big hospitals in techniques, emphasize the human
aspect
- Heighten efficiency and enlarge the scale of Cempaka.
In efficiency Cempaka meets the disadvantages of a 10-beds hospital.
Many various activities have to be done,but do not require fulltime jobs.
So try to make combination jobs or part time jobs.
In nursing, the biggest activity and department, it is difficult to say
what should be the minimum number of nurses in every shift. Though 2
seems reasonable, I would advise to try a combination with the ER in
in the night shift. 2 Nurses and 1 general doctor might do in the night.

Security seems to be an overstaffed department, so diminish.

- Keep the advantages of the small scale

The advantage of the small scale is in the informal atmosphere and in
the ready to (re)act. Try to keep these, no room for
bureaucracy!

- Install internet in the patient rooms.

The internet connections are already in the building.
As Cempaka’s clients are in the middle/higher market segment many
u use internet at home, surely at work. They will appreciate this tool.

- Though reputation goes from mouth to mouth, you can also

help it a little yourself, now a days count: Be good and tell it.
Good relations with the press profitable for the extern communication.

- Develop a basic HRM policy, start with yearly evaluation meetings.

Though in terms of hospital care 35 employees is limited, it is really
necessary to have a good HRM-policy, to keep your good employees
and to be able to attract new ones. It is about your reputation in the
labor market!

- Invest in Mrs.Rose
As Mrs. Rose is the key employee in the care sector, some 20 people
reporting to her, stimulate her to spend (more) time in creating the best
working conditions for her employees. That is her main job as a chief.
Give her the right “equipment” for this, f.i. by offering her specialized
education and training.

- Keep close contact with your stakeholders.

Those are the organizations and persons you are working with, working
for you, or have interest in you and who can be of importance, f.i. when
you need loans, need permits, or when you have to make important
decisions.

- Develop an own Cempaka house style for patient information.

It will be one of the ways “to show your face” to patient (groups)
 - A new “green” Cempaka Azzahra in 10 years from now requires a
substantial increase in patients in the actual housing first.

- Try to attract radiology facilities next door.

In diagnostics radiology is important and basic. An own department
does fit with the scale of Cempaka. So be smart and try to interest
a radiologist to settle a facility next door, and offer him your patients.

- Make a systematic ( 6 months) cash flow planning.

It does not take much time and it is quite simple to make a global
schedule of the money coming in and going out per month and per date.
The actual problem proves the need for it!

- Actualize the SWOT analysis yearly.

Yearly step back from day-to-day work and take some time to think
about the actual situation and the future of Cempaka. Both looking
inside (strength and weakness) and outside (opportunities and threats).
Invitate the employees to give their opinions and suggestions

- Make homecare a business unit directly reporting to the director

as long as the marketing aspect is dominant. -
Make good instruction for the doctors and nurses involved.

- Lower the even already low barriers to the public.

Invite the community of Banda to come in, they are welcome!
Have an opening of an exposition of paintings every 3 months.
Invite an important person to open, invite many guests, and
do not forget the press!
Also a small concert might be possible, at the same time or
even apart (school orchestra?)
So Cempaka Azzahra as a galery or concert room!

And remember: Always do the right things (effectiveness)

And do the things right (efficiency)

F. Follow up and action list

A revisit is to be taken in consideration next year, to evaluate the

implementation of the recommendations, especially
 - introduction of the yearly evaluation meetings, and other HRM activities

- heightening of the efficiency

- repeat of the interactive lectures with the employees.

- new developments in the ambitious world of Mr. Kamal’s Cempaka.

G. Final

The stay in Banda Aceh has been an impressive and unforgettable

period for me. I really felt that my presence did help Mr.Kamal in the
business of this still very young hospital Cempaka Azzahra.
We had intensive contact, both businesslike as private. He and his wife
showed real Aceh hospitality to me. I am very grateful for this to them, it
really was overwhelming.

Also the friendliness and laughs of the employees I will never forget and
I will take back with me to The Netherlands

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Annex 2

Yearly individual evaluation meeting of the employee and her/his chief.

Filosofie.
As the total of all the skills of all employees, the so called human capital, is the
most precious capital of the company, Human Resource Management (also
called personnel management) should get full attention.
From the employer’s point of view it is about how to attract and to keep the
best employees out of the labor market.
From the employee’s point of view it is about useful work, own competence,
responsibility, personal development, good salary and other benefits.

Employees want to contribute to the goal of the company.

Good information and communication about her/his functioning is essential.

Basic step.
 A basic and very practical step in developing the company’s HRM policy is to
have global job descriptions and to introduce so called yearly evaluation
meetings of the individual employee and her/his chief.
Of course, in weekly or monthly meetings the functioning of a department and
its individual employees will be discussed. But most probably not all the aspects
of each employee’s functioning will get attention enough, specially not the so
called “difficult things”.
If you make these evaluation meetings a systematic part of your HRM policy
the employee never can be amazed about the chief’s opinion.
And after all: the employee has the right to know how the chief things about
her/him!
An other advantage of systematical evaluation meetings is in the fact that both
good aspects and to be improved aspects of the functioning get attention. In non
y systematical meetings it is mostly about something that the employee did not
perform correctly.
Evaluation meetings take time: 0,5 h preparation, 1,0 h meeting, 0,5 h report,
all together 2 h per person per year. So if the chief has 10 employees it will cost
her/him 20 hours per year, let us say in the month of December.
But by doing so it will surely save her/him time in the other11 months!

Content of the yearly meeting.

The agenda of the yearly evaluation meeting can be ( and make a short report!).
- Evaluation of last year’s agreements
- Employee’s functioning
- Review
- Salary
- What does the employee need from the chief for good functioning
- Personal development plan
- New agreements.

Review document very poor poor moderate good excellent

Knowledge
- technical/professional
- general

Social skills
- attention, dedication
- affects atmosphere
- flexibility
- tact, f.i. in consolation of patient
- express oneself - verbal
- writing

Organizational skills
 - management of own work
- problem solving
- initiative
- making decisions
- productivity

Skills to handle
- automation equipment
- other equipment

Other skills
- persistency
- sense for systematic working
- sense for hygiene
- integrity
- reliability
- representative conduct

Others
………….
………….

Annex 3

SWOT analysis of Cempaka Azzahra.

Strength
- self conscious hospital
- entrepreneurship
- small, so ready to (re)act
- friendly, personal atmosphere: hospitality
- 7 times 24 h. medical doctor’s presence
- central geographic position
- relationship with Cempaka Lima

Weakness
- hospital is not built as such
- no radiology
- no elevator
- very small, as to quality, equipment and return on investment
- difficult to attract consultant-specialists and general doctors (?)
- limited financial resources
- small cash flow

Opportunities
- homecare market is growing
- middle/higher market segment healthcare is growing
- more people want privacy
- develop a website Cempaka
- develop own style Cempaka patient information

Threats
- medical technology development is very fast
- bigger hospitals are medical-technical more up-to-date
- growing quality of the government hospitals
- what if Aceh’s economy will fall back?