Knowledge-Based Performance Management Framework for Small Public Health Facility: A Case Study of Clinic T in City B, Indonesia

: The healthcare service system in Indonesia is divided into two levels, first-level healthcare services, and advanced-level healthcare services. One of the first-level healthcare services is the small public health facility or clinics. The healthcare system in Indonesia requires patients to seek treatment at a first-level health care system first and prohibits seeking treatment at an advanced-level healthcare system unless emergency or necessary. However, research on the performance management system for clinics is still very minimal. This research is intended to design a performance management framework using Clinic T in City B, Indonesia, as a case study. The flow of research methodology in this study is started with problem identification, continued with framework selection analysis. The selected framework in this study is the Knowledge-Based Performance Management System (KBPMS). Performance framework for Clinic T and the performance indicators are presented, along with the linkage between performance variables and one of the simple ways to show the clinic’s performance for easier evaluation. The proposed framework is expected to be suitable for other clinics in Indonesia and can be used as a foundation for other clinics in designing their own performance management framework. The Performance Prism is a performance management system developed by A. Neely in 2002 as one of the improvements for BSC 10. One area that Neely criticizes about BSC is it only covers two stakeholders, namely the shareholders and the customers, while the Performance Prism framework is built upon considering the satisfaction of all stakeholders, such as the customers, employees, interrelated suppliers, governments, community, as well as activists. The Performance Prism framework is also developed under the basis of five fundamental questions 10, which is: Stakeholder Satisfaction (who are the important stakeholders? what are their needs and wants?), Stakeholder Contribution (what contribution from the stakeholder that the organization needs?), Strategies (what are the strategies to satisfy the stakeholder’s wants and needs?), Processes (what important process that the organization must have to achieve its strategy?), and Capabilities (what are the capabilities that the organization needs in order to improve itself?). Although the Performance Prism provide a wide range of performance indicators, it also become its shortcoming. There are several critics for criticize the Performance Prism. The first point is that the Performance Prism concept is very complicated and hard to understand because it views performance from five different perspective that mutually related. The Performance Prism also didn’t provide a step-by-step example on how to implement the performance management system in the real-world case. Another point is that the benchmarking system and procedure is not explained explicitly in the framework 6. The Knowledge-Based Performance Management System (KBPMS) by D. Wibisono can be viewed as the refinement of both the Balanced Scorecard and the Performance Prism. The KBPMS combines the simplicity of design from the BSC and the stakeholder satisfaction aspect from the Performance Prism. The KBPMS also built on the expectation that the framework would be especially


INTRODUCTION
The healthcare service system in Indonesia is divided into two levels, namely first-level healthcare services and advanced-level healthcare services. One of the first-level healthcare services is the small public health facility or clinics, while one of the advancedlevel healthcare service is the regional general hospitals (RSUD). The healthcare system in Indonesia requires patients to seek treatment at a first-level health care system first. To be able to seek treatment at an advanced-level healthcare system, it is necessary for the patient to have a referral from a doctor stating that the patient requires further treatment or cannot be handled by in a first-level healthcare system. However, this provision is excluded in certain cases, such as when a medical emergency occurs or when the patient is outside the area where the first-level health care facility is located. One of the clinics in City B, Indonesia was taken as a case in this study. To maintain confidentiality, this clinic will hereinafter be referred to as "Clinic T". Initially, this clinic only served general patients, but after the rename and rebranding, Clinic T then also accepted BPJS patients. General patients are patients who are not an insurance participant, or do not use insurance. BPJS patients, on the other hand, are patients who use Healthcare BPJS, the health insurance program from the Indonesian government. The Social Security Administrator for Health issued a BPJS rating system for a clinic in order to make sure the fairness of service for all BPJS participants. Clinics with low BPJS rating could be removed from the list of clinics that can accept BPJS participants and are prohibited from accepting BPJS participants. This could actually massively affect the clinic's income. Clinic T further expanded its services by adding laboratory test services, such as general blood tests and cholesterol tests. In the era of the Covid-19 pandemic, it also serves covid tests such as antigen and PCR tests. Recently, Clinic T has also expanded its services by adding a beauty clinic. Broadly speaking, the flow of services at Clinic T can be observed in the following figure The flow started with Patient Arrival. This is when the patient first arrived to the clinic. Because of the Covid-19 pandemic, Clinic T require all entrants to the clinic to do Covid procedure, which is washing hands. The Administration section is when the patient registers for treatment and wait until called in for treatment. For a more service-specific procedure, there are slight differences for the Action and Patient Discharge sections. For general practitioners and dentists, the action taken is an evaluation and diagnosis by a doctor. For laboratory services, the actions taken are sample collection and inspection. For beauty clinics, the actions taken are evaluation and diagnosis, or skincare treatment. For general practitioners and dentists, the Patient Discharge section is usually started by administrating needed medicine to the patient. For beauty clinics, however, drug administration is also carried out, but only for patients who needed it. To assess the current condition of Clinic T, an SWOT analysis was carried out. SWOT analysis can be used to identify the unique competencies possessed by a company and to show opportunities that may have not yet been exploited by the company due to limited resources 1. The results of the SWOT analysis of the Clinic T are as follows. Table 1. SWOT Analysis of Clinic T

Strength Opportunity
 Has a doctor who graduated from the prestigious Faculty of Medicine, University of Indonesia which has "A" accreditation  Has a high customer satisfaction rating  Provide Covid-19 tests, namely the Antigen and PCR  Provide beauty care services, which are rarely found in clinics in general  Has a good BPJS rating  Prices for the clinic's drugs and services follow the price marketed by the government. If the price from the government goes up, the price from the clinic would also goes up, resulted in higher income  There is a need for cooperation between the clinic and manufacturing companies within the region, for the clinic to be a reference for BPJS clinics for its workers. This could increase the number of BPJS patient registered to Clinic T  There is no other clinic in the area of operation that can provide beauty care services

Weakness Threat
 The number of registered BPJS patients can be considered small  The number of rooms the clinic has are actually still lacking according to BPJS standards  Still does not have adequate space for birth delivery  Its BPJS rating is actually classified as standard when compared with other clinics  Prices for the clinic's drugs and services follow the price marketed by the government. If the price from the government goes down, the price from the clinic would also goes down, resulted in lower income  Changes from BPJS's regulation for clinics  Other clinics could copy Clinic T's business strategy The Performance Prism is a performance management system developed by A. Neely in 2002 as one of the improvements for BSC 10. One area that Neely criticizes about BSC is it only covers two stakeholders, namely the shareholders and the customers, while the Performance Prism framework is built upon considering the satisfaction of all stakeholders, such as the customers, employees, interrelated suppliers, governments, community, as well as activists. The Performance Prism framework is also developed under the basis of five fundamental questions 10, which is: Stakeholder Satisfaction (who are the important stakeholders? what are their needs and wants?), Stakeholder Contribution (what contribution from the stakeholder that the organization needs?), Strategies (what are the strategies to satisfy the stakeholder's wants and needs?), Processes (what important process that the organization must have to achieve its strategy?), and Capabilities (what are the capabilities that the organization needs in order to improve itself?). Although the Performance Prism provide a wide range of performance indicators, it also become its shortcoming. There are several critics for criticize the Performance Prism. The first point is that the Performance Prism concept is very complicated and hard to understand because it views performance from five different perspective that mutually related. The Performance Prism also didn't provide a step-by-step example on how to implement the performance management system in the real-world case. Another point is that the benchmarking system and procedure is not explained explicitly in the framework 6. The Knowledge-Based Performance Management System (KBPMS) by D. Wibisono can be viewed as the refinement of both the Balanced Scorecard and the Performance Prism. The KBPMS combines the simplicity of design from the BSC and the stakeholder satisfaction aspect from the Performance Prism. The KBPMS also built on the expectation that the framework would be especially applied to companies in Indonesia. The KBPMS is much simpler compared to the BSC and the Performance Prism because it simplifies the performance perspective into three perspectives: Organization Output, Internal Process, and Resource Capability. It also can be considered to be very complete and easy to understand because it explains the design process from start to finish: from establishing how the foundation of a performance management system should be, the method for analyzing the business environment, how to connect the company's strategy with the performance management system, the high-level view of the performance measurement framework, the steps for implementing the The next step in this study is the Framework Selection Analysis. In this step, the author present, describes, and analyses several, very well-known, performance management frameworks that have been widely used in various types of industry. From the results of this framework analysis, it is concluded that the Knowledge-Based Performance Management System (KBPMS) will be chosen as the reference framework for this study. The next step is a literature study to understand more about the steps in designing a performance management system based on the KBPMS framework. It is discovered that in the KBPMS framework, there are five stages in designing a performance management system, namely the Foundation, Basic Information, Design and Planning, Implementation, and Review and Update. From the literature study, several suggested performance indicators in the KBPMS are identified, which include indicators to measure Organization Output, Internal Process, and Resource Capability. From these indicators, several will be selected and adjusted to match the needs of the clinic that being studied. The next step is to conduct data gathering and data formulation. From this process, two types of data are obtained, the first one is primary data and the second one is secondary data. Primary data is obtained through interviews conducted with Clinic T's management. From this interview, Clinic T's business processes are determined and its needs are formulated. Secondary data is obtained via literature study on journal or books that is relevant to performance management or healthcare system, especially in Indonesia. Throughout these results, the data will be used as the basis for the selection of indicators in the KBPMS. The last step is to design performance management with the KBPMS based on the information obtained and conduct discussions and determine the conclusions about the conceptual framework that has been designed.

KBPMS-BASED FRAMEWORK DESIGN
The KBPMS Framework is divided into stages. The first stage is the Foundation. This stage explains the principles and rules that must be used as a foundation for designing a performance management system. The second stage is Basic Information where basic information about the company, such as the forces that could affect the company's operation, are determined. The third stage is Design and Planning where variables that could be chosen as a performance indicator are designed and planned. The fourth stage is Implementation which explains about aspects that needs to be considered when implementing the KBPMS framework. The last stage is about the Review and Update of the KBPMS in order to maintain the suitability of the framework to the company's performance and maintain the relevancy of the framework.
A. Foundation In designing a performance management system, there are four foundational principle that must be used as a guideline: 1. Comprehensive partnership between management, employees, and customers. It is hoped that from this partnership, there will be a thorough understanding between the stakeholders on the importance of a performance management system. Each party would also need to take part in determining the performance indicators 2. Empowerment from the company leaders to all levels of employees. This aspect needs to be carried out in order to ensure awareness and activeness for all employees in improving the company's performance 3. Integrated performance improvement, where linkages exist between the performance variables for each of the company's division. It is hoped that from this integration, employee's sense of belonging would grow and view the company's performance improvement process as something that needs to be maintained and cared for 4. Independent performance team are needed. This would be the team that responsible for the design, review, and maintain the company's performance management framework. The role of this team is to organize and determine the key performance indicator for all of the company's division. Therefore, they must be given the opportunity and trust from all aspect of the company There are also five important rules that must be considered in designing a performance management system: 1. The KISS (Keep It Stupid Simple), where the designed performance management system must able to be easily understand and must be easily applied by all levels of the company 2. Long Term Oriented, where the performance management system must be designed to support the company's performance in a long term so that the company can continue to compete 3. Realtime Basis with as-soon-as-possible Feedback, where the performance variables must reflect what the company needs at real time. If a performance deviation occurs, which are not in accordance with the company's performance guidelines, it must be followed up immediately 4. Focus on Continuous Improvement, where the designed performance management system must be able to accommodate continuous improvement process, such as benchmarking and learning from other company's best practice 5. Use Quantitative Approach, where the variables of the performance management system should be quantitative variables. This is because quantitative variables are easier to be checked and maintain, and deviating performance variable could also be easily identified B. Basic Information Basic information is needed as an input to design the performance management system based on the environment condition of the organization. The business environment analysis is carried out using a modified Porter Competitive Forces concept and the result can be observed in the figure below.  From the Porter Competitive Forces analysis, it can be concluded that the major force in the small public health facility is the industry regulation. The regulation is issued by the Ministry of Health and it must be strict since its concerned with the patient's well-being. The threat from rivals/competitors could also be considered as high since the score is at second-highest on the scale. Even though the industry growth is small, the number of competitors is quite large. However, Clinic T has an advantage in terms of the number of services it featured. Threat from New Entrants is average because, while customers switching costs is low and the access to customer and labor is easy, the capital and the experience required in order to establish the business is high. The Buyer power is also average because there are many potential buyers and Clinic T could provide its service at a little bit lower price compared to the average, even though the cost for the customer to switch clinic is low. The Supplier power and the Threat from Substitute Products can be considered as low, with later to score the lowest on the scale. The profit and cost contributed the supplier is average, but there are many numbers of supplier. This aspect lessens the supplier's power in the industry. For substitute products, its availability is low from the start, making it to be the weakest competitive force.

C. Design and Planning
In this stage, the performance indicators for the three KBPMS perspective is formulated, based on the characteristic of Clinic T and it needs. The linkage between these performance indicators is also established.

1) Vision, Mission, and Strategy
Just like any business, Clinic T has Vision and Mission for its reason for being. The vision of Clinic T is "To become a clinic that can create a healthy community, supported by a good and quality health service system with adequate health facilities and infrastructure, while increasing public awareness about health", and its missions are: 1. Provide adequate health facilities and infrastructure in accordance with the continuous needs and progress of medical technology 2. Stay up-to-date with the developments in medical science and technology, by engaging in various medical scientific activities at local, national, or international levels 3. Involve in social activities in the community, either unilaterally or through collaboration with existing community institutions or organizations 4. Implement a quality and affordable health care system for the whole community 5. Establish good cooperation with other health institutions or organizations Its business strategy could be considered as the mix of Low-Cost strategy and Differentiation Strategy. Clinic T's pricing strategy is to provide its service, whether its medical check-up or lab test, with the same price or slightly cheaper than the market price. Clinic T also expand its service, not only providing medical service from general practitioners and dentists, it also has laboratory to do medical tests and beauty clinic.
2) Performance Indicators Determining performance indicator in KBPMS can be viewed in three perspective, Organization Output, Internal Process, and Resource Capability. Each of these perspectives can be expanded into more detailed aspects. From these aspects, more detailed performance indicators for every perspective will be identified, based on the company's vision, mission, strategy, and needs. a) Organization Output The Organization Output perspective of the KBPMS consists of two aspects: Financial and Non-Financial. The financial aspect is an important aspect for the company in relation to maintaining and fulfilling the wishes and needs of investors. Non-financial aspects, on the other hand, are closely related to the level of customer satisfaction. These two things are very important aspects that needs be considered. For companies whose performance cannot be directly assessed from the Financial aspect, the Non-financial aspect becomes a more important aspect of performance appraisal. In the Financial aspect, indicators regarding the financial performance of the clinic are identified. For the Non-Financial aspect, indicators regarding the performance of the clinic's output beside that related to financial performance are explained. Below are the performance indicators for financial aspect. Table 3. Financial Aspect Performance Indicators, Description, and Formula.

Operating Profit Margin
To determine the operating profit margin of the clinic. Could also determine the reduction percentage of revenue due to operating expenses (Operating Profit/Revenue) x 100%

Profit Growth
To determine the profit growth on current period compared to the previous period

(Current Period Operating Profit/ Previous Period Operating Profit) -1 Current Ratio
To determine the ability for the clinic to pay its current obligations Current Asset/Current Liabilities Return on Asset To determine the clinic's asset utilization level for gaining profit Operating Profit/Total Assets

Market Share
To determine the clinic's market position compared to its competitors in the same industry (Clinic's Revenue/Total Industry Revenue) x 100% Below are the performance indicators for non-financial aspect.

BPJS Rating
Rating from BPJS concerning the overall quality of the clinic Rating from BPJS b) Internal Process The Internal Process perspective consist of four aspects: Innovation, Operating Process, Marketing, and After-sales. Internal Process is the perspective that concerned with day-to-day operation of the company, or in this case, the clinic. Based on the information obtained regarding Clinic T's business process, the Internal Process aspect selected are Innovation, Operating Process, and Marketing. Innovation is an important aspect for the clinic to stay competitive in the industry. This is because new products or services that enter the market earlier will have the opportunity to sell more than those that enter the market later 12. Operational Process can be defined as the process of converting materials, energy, and information into products or services at a certain scale to meet customer needs 13. This aspect is one of the most crucial components in organizational strategy. The concept of marketing in the business approach should not be something that only marketing people can master, but it is the task of everyone in the organization within the company 14. Performance indicators that related to Clinic T's internal process performance are as follows Table 5. Innovation Aspect Performance Indicators, Description, and Formula

Indicator
Description Formula

Medical Scientific Activity Attended
The number of medical scientific activity attended in order to keep up with the latest medical science and technology Medical scientific activity attendance count

Clinic Capacity Utilization
The number of patients that the clinic could serve Clinic Capacity Count

Operating Medical Devices
The number of medical devices that still operable Number of Operating Medical Device

Accurate Inventory Counting
The accuracy of the inventory count especially for drugs availability %missed count on inventory availability Table 7. Marketing Aspect Performance Indicators, Description, and Formula

Indicator
Description Formula

Marketing to Industry Count
The number of time marketing campaign done to industrial companies

Industry Campaign Effectivity
The number of patients gained from industry campaign New Patient from Industry Campaign/Total New Patient

Marketing Medium
The number of medium for marketing that the clinic have

Social Activity Attendence
The number of social activity that the clinic organize or participate in Social Activity Count

Advertising Effectivity
The effectivity of paid advertising to the profit of the clinic (Advertising Cost/Revenue) x 100%

Promotion Effectivity
The effectivity of promotion to the profit of the clinic (Promotion Cost/Revenue) x 100% This perspective assesses how the company's performance is in utilizing its assets, both tangible and intangible. In this study, based on the information obtained regarding Clinic T's business process, the Resource Capability aspect selected are Human Resource and Technological Resource. Human Resource is the most important resource for a company to stay competitive because it could be considered as the backbone of the designed system. This Human Resource capability can be assisted by Technological Resources. Investment in technology, to increase the level of competitiveness of the company, is an important element for achieving long-term success of the company 15. Performance indicators that related to Clinic T's Resource Capability performance are as follows Table 8. Human Resource Aspect Performance Indicators, Description, and Formula

Indicator
Description Formula

Employee Attendence
To determine the attendence rate of the employee Number of employee absent days compared to total working days Employee Satisfaction To determine the satisfaction level of the employees Employee satisfaction survey

Doctor Attendence
To determine the attendence of doctors and their availability at their on-duty hours

Number of doctor absent hours compared to total working hours per period Doctor Qualification
The number of doctors graduated from "A" accredited universities High qualification doctor count

Availability of Experties
The number of available employee based on their jobdesc and experties Available experties compared to the needs

Employee Productivity
To determine the productivity of the employee based on the delivery of their task

Employee Participation
The number of employee participating in various clinic activities Employee participation count Table 9. Technological Resource Aspect Performance Indicators, Description, and Formula

Indicator Description Formula Supporting Technologies
The number of technology that can be utilize to improve and support the HR process or operating activity

3) Variable Linkages
In general, there are four levels in a company's organizational structure related to performance management: the Corporate level, Business Unit level, Operations Management level, and Day-to-day Operations level. Between these levels, there is a need for identifying the relationship between performance variables. By determining the relationship between performance variables, the improvement process on variables that do not reach the required standard will be easy to implement. In addition, the interrelationships between performance variables may involve cross-sectoral inter-departments that are not vertically related. By identifying the variable linkage, the connection of performance variable from the Resource Capability perspective to the Organizational Output can be observed. Improvement on the Resource Capability could affect the improvement of the Internal Process and, in the end, will resulted in the improvement of the Organizational Output. The performance variable linkage for Clinic T's performance indicators is presented below

D. Implementation, Review, and Update
The implementation aspect of the KBPMS follows four cyclical steps: Measurement, Evaluation, Diagnosis, and Follow-up. Measurement needs to be done to determine how the company's performance, after the performance management system is implemented. The results of these measurements can then be used as a basis for evaluation. Evaluation is where the measured performance is evaluated to determine its alignment with the established standards. From the results of this evaluation, deviant performances are identified and then diagnosed. The purpose of the Diagnosis step is to diagnose deviant performances and determine its cause. Later, Follow-Up will be carried out to re-align these performances with the standards set in the performance management system. Another important aspect in implementing performance management system is to communicate the results to the employees. Publishing the company's performance measurement results, especially those that summarize how teams or individuals in the company are performing, can increase overall motivation in the company and create a supportive environment. As previously discussed in the Foundation section, quantitative data will be easier to display and understand, even though the context of the data may only be understood by the concerned teams or individuals. One of the simplest ways to communicate performance is to use Display graphic. The main rule in designing it is that the graphic must be easy to read and attract attention. Display graphic with various color and large text can help to attract attention. In addition, these graphics must also be easy to design, update, access, and interpret.  Continuing the implementation aspect of the KBPMS are the Review and Update of the performance management system. The purpose of this is to keep the performance management system dynamic and in accordance with the needs or problems faced by the company. One way is to maintain the sustainability of the company's characteristics that were previously good, such as leadership, commitment, stakeholder involvement, and others.

DISCUSSIONS AND CONCLUSIONS
Performance management framework for Clinic T based on the Knowledge-Based Performance Management System (KBPMS) has been presented. The performance indicators are categorized in KBPMS's three main perspective: Organization Output, Internal Process, and Resource Capability. The Organization Output perspective consist of two aspect, Financial and Non-Financial, and each of these aspects has five performance indicators. For Internal Process perspective, there are one performance indicator for Innovation aspect, seven (7) indicators for Internal Process aspect, and six (6) indicators for Marketing aspect. For the Resource Capability perspective, there are seven (7) indicators for the Human Resource aspect and one indicator for the Technological Resource aspect. The linkage between variables has also been shown to make it easier to see the cause-and-effect relationships between indicators. Display graphic example for showing and communicating Clinic T's performance is also presented. The regulation of the Indonesian Ministry of Health Number 9 of 2014 is a regulation regarding clinics that must be followed by all clinics running in Indonesia. Additionally, the BPJS rating system is also applied to all clinic that can accept BPJS patients. Based on these considerations, it is hypothesized that most clinics in Indonesia will face the same problem as the Clinic T. However, this hypothesis requires further evidence by testing this performance management framework in other clinics. By benchmarking with various clinics, performance variables for clinics that can be applied generally can be obtained, with slight changes for special cases or certain clinics. In addition, the author admits that there are still limitations to the correlation analysis between performance variables. Further studies can be carried out by taking the topic of improvements to the correlation analysis between these variables by using more concrete correlation analysis methods.