Internal and External Factors That Influence Behaviour of

Physicians in Charge of Service (DPJP) within Completeness of JKN

Inpatient Discharge Summary in St. Carolus Hospital

Demi Sahhan

, Syefira Salsabila

and Witri Zuama Qomarania

Study Program Master of Public Health, Department of Health Information Management,

Esa Unggul University, Indonesia

Study Program Master of Epidemiology, Department of Health Information Management, Esa Unggul University,

North Arjuna Street 9, Duri Kepa, Kebon Jeruk District, East Jakarta, 11510, Indonesia

Keywords: DPJP’s Behavior, Discharge Summary, JKN, Internal, External, Personality.

Abstract: The incomplete discharge summary can allow inaccuracies in the diagnosis code and affect the INA-CBGs

payment rates, thereby impacting the JKN patient claim process. Completeness of filling discharge summaries

is the responsibility of Physicians in Charge of Services (DPJP) as a direct implementer of services in

hospitals. This study aims to analyze the influence of internal and external factors on DPJP’s behavior within

completeness JKN inpatient discharge summaries. This research is a quantitative study with a cross-sectional

research design. The population in this study is DPJP as many as 46. The sample used a saturated sample.

Based on the results of multiple linear regression analysis, internal factors (gender, personality) and external

factors (education, work environment) simultaneously have no significant effect on DPJP’s behavior in

completeness JKN inpatient discharge summaries (p-value 0.070). While partially internal factors

(personality) significantly influence DPJP’s behavior in filling JKN discharge summaries (p.value 0.033) and

other variables do not. In conclusion, there is no influence between internal and external factors

simultaneously on DPJP's behavior in filling out discharge summaries. While partially internal factors

(personality) significantly influence the behavior of DPJP in filling JKN discharge summaries at Carolus

Hospital.

1 INTRODUCTION

In early 2014, government had implemented health

insurance for the public called JKN. The National

Health Insurance (JKN) is carried out using a

mandatory social health insurance mechanism based

on Law Number 40 of 2004 concerning the National

Social Security System with the aim of fulfilling the

basic needs of adequate public health provided to

everyone who has paid their contributions or

contributions paid by the Government. The National

Health Insurance (JKN) is organized by the Health

Insurance Administering Agency or called BPJS

(SJSN Advocacy, 2011).

The problems that occur at this time in the JKN

claim process are inseparable from the

incompleteness of discharge summaries. The

incompleteness of this discharge summary can allow

inaccuracies in the diagnosis code and affect the INA-

CBGs payment rates, thereby impacting the

obstruction of the JKN patient claim process. In the

implementation, the completeness of discharge

summaries is the responsibility of the Physicians in

Charge of Services (DPJP) as the direct executor of

services in hospitals, the compliance behavior in

filling out discharge summaries in full is the

responsibility of physicians and other health

professionals (Menkes, 2014).

Based on previous research related to the

completeness of inpatient discharge summary carried

out by Ardhika at Mulia Hati Wonogiri Hospital in

2014, it showed that the complete review of reporting

information filled in the incoming diagnosis items as

many as 58 (70%) resumes filled in, final diagnostic

items were 58 (70%), surgery items 53 (64%),

historical summary items 35 (42%), examination

results and supporting items 28 (34%), development

items during treatment 23 (28%), and patient

condition items by 50 (60%). The completeness of the

authentication review filled in the items date was 32

152

Sahhan, D., Salsabila, S. and Qomarania, W.

Internal and External Factors That Inﬂuence Behaviour of Physicians in Charge of Service (DPJP) within Completeness of JKN Inpatient Discharge Summary in St. Carolus Hospital.

DOI: 10.5220/0009570201520158

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 152-158

ISBN: 978-989-758-454-1

(38%), the physicians signature item was 33 (40%),

and the physicians' name item was 47 (57%)

(Ardhika, 2014)

This was also at Fatmawati General Hospital in

2015 by Apriyantini, obtained from 100 documents,

98% were obtained for complete primary diagnosis,

39% for incomplete secondary diagnosis, 95% for the

complete primary procedure (Apriyantini, 2016).

Problems related to completing discharge

summary form filling also still occur in 2017,

conducted by Elvisa at Prof. Orthopedic Hospital Dr.

Soeharso Surakarta, showed the completeness of

important reports on JKN patient discharge summary

forms on the final diagnosis items by 77% and on the

history items of disease by 76%, completeness of

authentication on JKN patient discharge summary

forms on physician's name items by 77%, physicians's

signature 71% and date items 75% (Elvisa, 2017).

Some of the previous studies above prove that the

problem of incomplete inpatient discharge summary

still occurs in several hospitals every year. In

implementing this discharge summary form must be

filled out by physicians/ dentists who carry out

medical practice in accordance with Permenkes No.

269 / MENKES / PER / III / 2008. Thus, problems

related to the incompleteness of this discharge

summary can be directly influenced by the behavior

of the Physicians in Charge of Services (DPJP) in

terms of filling out (Permenkes, 2008).

The behavior of physicians in filling out inpatient

discharge summaries is influenced by various factors.

Internal and external factors become one of the most

fundamental factors in influencing behavior that

explains the development of behavior from inside and

outside the individual. One of internal factor that

influences behavior is gender, this is reinforced in

research conducted by Puspito at Hermina Hospital

Depok in 2011, the results of the analysis showed that

physicians with female gender tended to complete

higher discharge summary completion with an

average completeness by 84.4% compared to men

with an average of 74.4%

(Puspitosari, 2011).

This is supported by research conducted by Rina

in 2016 at Queen Latifa General Hospital. The results

show that there is a significant correlation between

gender variables and physician behavior in filling out

discharge summaries (p.value = 0.02), alpha 5%

(Rina, 2016).

Internal factors that can also influence behavior

are personality. Based on research conducted by

Nasyroh in 2017, the Pearson correlation between

personality (Big Five Personality) and employee

performance behavior is 0.362 with a significance

score (p.value = 0.049), alpha 5%. It states that there

is a correlation between personality (big five

personalities) with employee performance behavior

(Nasyroh,2017).

In addition, external factors can also influence the

behavior of physicians in filling out discharge

summaries, in this case, explained by variables of

education and work environment. Based on the

results of previous studies conducted by Warsi in

RSUD dr. Soeratno Gemolong Sragen in 2012

obtained the results of a statistical test of the

correlation between the type of education with the

behavior of filling out the discharge summary,

showing a significance value (p.value = 0.047), alpha

5%. Therefore, there is a correlation between the type

of education with the behavior of filling out discharge

summaries (Warsi, 2012).

Then, work environment factors/ work conditions

on physicians' behavior, it was proven in previous

research conducted by Nelfiyanti at Haji Hospital

Medan in 2009 with the results of statistical tests

showing significance values (p.value = 0.01), alpha

5%. This shows that there is a correlation between the

work environment/ working conditions and

physicians' behavior within the completeness JKN

discharge summary (Nelfiyanti, 2009).

Based on observations related to completing JKN

inpatient discharge summaries in Sint Carolus

Hospital in the 2018 period, with an average of 424

JKN inpatient visits each month, in fact, there are still

incomplete discharge summaries with an average

monthly 31.8% or 135 files for the DPJP category

(Specialist), while around 3.3% or as many as 14 files

for General Physicians (Carolus, 2018).

Based on the description above, the researcher

interested in conducting research with the title

"Internal and External Factors That Influence the

Behavior of Physicians in Charge of Services (DPJP)

in Completeness JKN Inpatient Discharge Summary

in St. Carolus Hospital".

2 RESEARCH METHOD

This research is a quantitative study with a

crosssectional research design. The population in this

study is DPJP as many as 46. The sample used a

saturated sample. The research hypothesis was tested

using multiple regression analysis.

The approach taken in this study is a quantitative

approach to the research design using observational

descriptive-analytic studies. Describing the internal

factors (gender, personality) and external factors

(education, work environment), from other aspects,

Internal and External Factors That Inﬂuence Behaviour of Physicians in Charge of Service (DPJP) within Completeness of JKN Inpatient

Discharge Summary in St. Carolus Hospital

153

are analytic because researchers want to know the

effect of internal and external factors on DPJP’s

behavior within completeness JKN inpatient

discharge summary in St. Carolus Hospital

(Notoatmodjo, 2017).

3 RESULT AND DISCUSSION

3.1 Univariate Analysis of Internal

Factors (Gender, Personality) and

External (Education, Work

Environment)

3.1.1 Internal Factors (Gender and

Personality)

Table 1: Gender and Age.

Characteristic N Percentage

(%)

Gender Male

Female

63,0

37,0

Age 28-49 years

50-60 years

61-71 years

76,1

15,2

8,7

Source: Primary Data Analysis, 2019

Based on table 1, a total of 29 (63.0%) respondents

were male and 17 (37.0%) female. The majority of

respondents have an age range of 28-49 years by

76.1% (35 respondents), 15.2% (7 respondents) aged

50-60 years and 8.7% (4 respondents) aged 61-71

years.

It can be concluded that 46 respondents in St.

Carolus are mostly 29 (63%) men and most have an

age range of 28-49 years with a total of 35

respondents (76.1%).

The distribution of respondents' answers based on

statement items related to Personality variables is

described in the following table:

Table 2: Distribution of Respondents' answers related to

Personality (item 1).

Statement item 1 Highly

Agree

I like to be in groups

when I have free time

at work

(28,3%)

33 (71,7%)

Source: Primary Data Analysis, 2019

Based on item statement 1, out of 46 respondents

there were 33 (71.7%) respondents answered Agree

and 13 (28.3%) answered Highly Agree.

Table 3: Distribution of Respondents' answers related to

Personality (item 2).

Statement item 2 Highly

Agree

I can quickly make a

decision if needed

(17,4%)

(82,6%)

Source: Primary Data Analysis, 2019

Based on item statement 2, out of 46 respondents

there were 38 (82.6%) respondents answered Agree

and 8 (17.4%) answered Highly Agree.

Table 4: Distribution of Respondents' answers related to

Personality (item 3).

Statement item 3 Highly

Agree

Agree Less

Agree

I enjoy working

with friends to do

work

(26,1%)

(71,7%)

1 (2,2%)

Source: Primary Data Analysis, 2019

Based on item statement 3, out of 46 respondents

there were 33 (71.7%) respondents answered Agree,

12 (26.1%) answered Highly Agree and 1 (2.2%)

answered Less Agree.

Table 5: Distribution of Respondents' answers related to

Personality (item 4).

Statement item 4 Highly

Agree

Agree Less

Agree

Disagree

I always

friendly to my

co-workers

(23,9%)

(54,3%)

(19,6%)

1 (2,2%)

Source: Primary Data Analysis, 2019

Based on item statement 4, out of 46 respondents,

there were 25 (54.3%) respondents answered Agree,

11 (23.9%) answered Highly Agree, 9 (19.6%)

answered Less Agree and 1 (2.2%) answered

Disagree.

Table 6: Distribution of Respondents' answers related to

Personality (item 5).

Statement item 5 Highly

Agree

I am responsible for

what I do

(58,7%)

(41,3%)

Source: Primary Data Analysis, 2019

Based on item statement 5 out of 46 respondents

there were 19 (41.3%) respondents answered Agree

and 27 (58.7%) answered Highly Agree.

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154

Table 7: Distribution of Respondents' answers related to

Personality (item 6).

Statement item 6 Highly

Agree

I do every job well as

expected by the

organization

(41,3%)

(58,7%)

Source: Primary Data Analysis, 2019

Based on item statement 6, out of 46 respondents,

there were 27 (58.7%) respondents answered Agree,

19 (41.3%) answered Highly Agree.

Table 8: Distribution of Respondents' answers related to

Personality (item 7).

Statement item 7 Highly

Agree

I always careful in

completing every job

(23,9%)

(76,1%)

Source: Primary Data Analysis, 2019

Based on item statement 7, out of 46 respondents,

there were 35 (76.1%) answered Agree and 11

(23.9%) answered Highly Agree.

Table 9: Distribution of Respondents' answers related to

Personality (item 8).

Statement

item 8

Highly

Agree

Agree Less

Agree

Disagree

I am calm in

dealing with

everything that

happens at

work

(19,6%)

(58,7%)

(15,2%)

3 (6,5%)

Source: Primary Data Analysis, 2019

Based on item statement 8, of the 46 respondents

there were 27 (58.7%) respondents answered Agree,

9 (19.6%) answered Highly Agree, 7 (15.2%)

answered Less Agree and 3 (6.5%) answered

Disagree.

Table 10: Distribution of Respondents' answers related to

Personality (item 9).

Statement

item 9

Highly

Agree

Agree Less

Agree

Disagree

I able to

control

emotions

well

(37,0%)

(45,7%)

(10,9%)

(6,5%)

Source: Primary Data Analysis, 2019

Based on item statement 9, out of 46 respondents,

there were 21 (45.7%) respondents answered Agree,

17 (37.0%) answered Highly Agree, 5 (10.9%)

answered Less Agree and 3 (6.5%) answered

Disagree.

Table 11: Distribution of Respondents' answers related to

Personality (item 10).

Statement item 10 Highly

Agree

I easily accepted the new

rules set by the

organization

7 (15,2%) 39

(84,8%)

Source: Primary Data Analysis, 2019

Based on item statement 10, out of 46 respondents

there were 39 (84.8%) respondents answered Agree

and 7 (15.2%) answered Highly Agree.

Table 12: Distribution of Respondents' answers related to

Personality (item 11).

Statement item 11 Highly

Agree

I am actively looking for

information that fits with my

work

(43,5%)

(56,5%)

Source: Primary Data Analysis, 2019

Based on item statement 11 (I am actively looking

for information that fits with my work), of the 46

respondents there were 26 (56.5%) respondents

answered Agree and 20 (43.5%) answered Highly

Agree.

Conclusions can be drawn from all items related

to personality statement, showing that the highest

percentage of answers is in item 10 (I easily accepted

the new rules set by the organization) with alternative

answers Agree of 84.8%. This shows that respondents

tend to more easily accept new rules set by the

organization, and can be categorized into personality

types Openness to a new experience.

3.1.2 External Factors (Education and

Work Environment)

Table 13: Distribution of Physician Education in St.

Carolus Hospital.

Type of education Total Percent %

Spesialist 41 89,1

Subspesialist 5 10,9

Total 46 100

Source: Primary Data Analysis, 2019

Internal and External Factors That Inﬂuence Behaviour of Physicians in Charge of Service (DPJP) within Completeness of JKN Inpatient

Discharge Summary in St. Carolus Hospital

155

Table 13 shows that of the 46 DPJP respondents in St.

Carolus, the number of respondents in the type of

specialist education had 41 (89.1%), while the

number of respondents in the type of subspecialty

education was 5 (10.9%). So, it can be concluded that

respondents with the type of specialist education in

St. Carolus is more than subspecialist respondents.

The distribution of respondents' answers based on

statement items related to work environment

variables is described in the following table:

Table 14: Distribution of Respondents' answers related to

Work Environment (item 1).

Statement item 1 Highly

Agree

Agree Less

Agree

The hospital

environment

supports the carrying

out of discharge

summary filling work

(30,4%)

(67,4%)

(2,2%)

Source: Primary Data Analysis, 2019

Based on item statement 1, out of 46 respondents

there were 31 (67.4%) respondents answered Agree,

14 (30.4%) answered Highly Agree and 1 (2.2%)

answered Less Agree.

Table 15: Distribution of Respondents' answers related to

Work Environment (item 2).

Statement item 2 Highly

Agree

Agree Less

Agree

Facilities which available

at the hospital supporting

the implementation of

completeness discharge

summary

(32,6%)

(65,2%)

(2,2%)

Source: Primary Data Analysis, 2019

Based on item statement 2, out of 46 respondents

there were 30 (65.2%) respondents answered Agree,

15 (32.6%) answered Highly Agree and 1 (2.2%)

respondent answered Less Agree.

Table 16: Distribution of Respondents' answers related to

Work Environment (item 3).

Statement item 3 Highly

Agree

Agree Less

Agree

Disagree

Physicians office is

uncomfortable in

carrying out discharge

summary filling

(21,7%)

(58,7%)

(17,4%)

(2,2%)

Source: Primary Data Analysis, 2019

Based on item statement 3 (Physicians' workspace

settings are less comfortable in carrying out medical

resume filling), from 46 respondents there are 27

(58.7%) respondents answered Agree, 10 (21.7%)

answered Highly Agree and 8 (17.4%) answered Less

Agree and 1 (2.2%) answered

Disagree.

Table 17: Distribution of Respondents' answers related to

Work Environment (item 4).

Statement item 4 Agree Less

Agree

Disagree Strongly

Disagree

Workflow in the

hospital causes the

implementation of

completeness

discharge

summary not

optimal yet

(8,7%)

(10,9%)

(67,4%)

(13,0%)

Source: Primary Data Analysis, 2019

Based on item statement 4, of the 46 respondents

there were 4 (8.7%) respondents answered Agree, 5

(10.9%) answered Less Agree, 31 (67.4%) answered

Disagree and 6 (13.0%) answered Strongly

Disagree.

Table 18: Distribution of Respondents' answers related to

Work Environment (item 5).

Statement

item 2

Highly

Agree

Agree Less

Agree

Disagree Strongly

Disagree

Hospital

Management

had been

monitoring the

completeness

of filling out

discharge

summary

documentation

(2,2%)

(19,6%)

(10,9%)

(54,3%)

(13,0%)

Source: Primary Data Analysis, 2019

Based on item statement 5, from 46 respondents

there were 9 (19.6%) respondents answered Agree

and 1 (2.2%) answered Highly Agree, 5 (10.9%)

answered Less Agree, 25 (54.3%) answered Disagree

and 6 (13.0%) answered Strongly

Disagree.

The respondents' distribution above shows the

highest percentage is in item 1 (The hospital

environment supports in carrying out of discharge

summary filling work) with alternative answers

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Agree of 67.4%. It can be concluded that 46

respondents tended to agree that the hospital

environment was supportive in carrying out of

discharge summary filling work.

The highest percentage for alternative answers

Disagree is in item 4 (Workflow in the hospital causes

the implementation of completeness discharge

summary not optimal yet) of 67.4%. It can be

concluded that about 31 (67.4%) of respondents

disagreed that the workflow in the hospital causes the

implementation of completeness discharge summary

not optimal yet.

The statement of Disagreement is also found in

item 5 (Hospital Management had been monitoring

the completeness of filling out discharge summary

documentation) by 25 (54.3%). It can be concluded

that 46 respondents tended to disagree that hospital

management monitored the completeness of filling

out discharge summary documentation.

3.2 Regression Model of Internal

Factors and External on DPJP’s

Behavior within Completeness JKN

Discharge Summary

Regression analysis was performed using multiple

linear regression analysis. This analysis was

conducted to see the predictions and effects of each

independent variable on DPJP’s behavior within the

completeness JKN discharge summary

simultaneously. The best model selection is chosen by

the backward method.

Based on the selection for multivariate modeling,

there are several variables that enter the regression

model as follows:

Table 19: Multiple Regression Linear Model.

Variable B Sig

Constant 38,571 0,000

Gender 1,559 0,204

Personality 0,400 0,033

Source: SPSS Output, 2019

Interpretation on Table 19. above, the value (a) =

38,571 and regression coefficient value (b1) = 1,559,

regression coefficient (b2) = 0,400.

Y = a + b

+ b

Based on the results above, the equation can

predict DPJP’s behavior within the completeness

discharge summary by using gender and personality

variables. The meaning of the coefficient, as follows:

1. Gender does not significantly influence

DPJP’s behavior within the completeness JKN

discharge summary, with a significance of

0.204. So, there is no contribution of the

influence given by gender to DPJP's behavior.

2. Personality has a significant effect on DPJP’s

behavior within the completeness JKN

discharge summary, with a significance of

0.033. Each personality value increases by 1

point and other variables are considered fixed,

then the DPJP’s behavior within the

completeness discharge summary will increase

by 0,400.

It can be concluded that personality variables have

the biggest influence on DPJP’s behavior within the

completeness JKN discharge summary with a value

of B = 0,400.

Table 20: Anova.

Model F Sig.

2,832 0,070

Based on Table 20. F test results (simultaneously)

it can be seen that the significance value (P-value) is

equal to = 0.070. P-value is 0.070 > 0.05, it can be

concluded that there is no significant effect between

internal and external factors simultaneously on

DPJP’s behavior within completeness JKN inpatient

discharge summary.

4 CONCLUSIONS

Characteristics of respondents with male gender in

St.Carolus Hospital were more in number with 29

(63.0%) compared to 17 (37.0%) women. The

majority of respondents work in St. Hospital. Carolus

in the age range of 28-49 years, amounting to 35

(76.1%).

Based on the distribution of respondents' answers

related to Personality. This shows that most of DPJP

in St. Carolus Hospital has the personality type of

Openness to new experience as many as 39 (84,8%).

The type of education at St Carolus Hospital tends

to be dominated by a specialist with a total of 41

(89.1%) compared to subspecialists who only amount

to 5 (10.9%).

Based on the distribution of respondents' answers

related to the Work Environment, most respondents

at St. Carolus Hospital agreed that the work

Internal and External Factors That Inﬂuence Behaviour of Physicians in Charge of Service (DPJP) within Completeness of JKN Inpatient

Discharge Summary in St. Carolus Hospital

157

environment of the hospital was supportive in

carrying out discharge summary filling work with a

percentage of 67.4%.

However, this has not been supported by the

hospital management in monitoring the completeness

of filling out discharge summary documentation, as

many as 25 (54.3%) of 46 respondents answered

Disagree.

The conclusion from the results of multiple linear

regression test shows that there is no simultaneous

influence of internal factors (gender, personality) and

external factors (education, work environment) on

DPJP’s behavior within completeness JKN discharge

summary in St. Carolus Hospital with a significance

value of 0.070. While partially Personality variables

have a significant effect on DPJP’s behavior within

completeness JKN inpatient discharge summary with

a significance value of 0.033.

5 SUGGESTION

In improving the performance of health practitioners,

especially the Physicians in Charge of Services

(DPJP) related to the completeness of clinical

documentation, especially discharge summary, it

needs a process of monitoring and evaluation as well

as improving workflow so that it can launch a clinical

documentation implementation system at St. Carolus

Hospital.

A strict policy is given regarding discipline and

physicians' compliance in filling out discharge

summary, both in the form of reward/punishment.

This will be easy because it is supported by the

personality type of DPJP’s behavior in St. Carolus

Hospital who tends to easily accept the new rules set

by the organization.

It was expected that further research development,

should be focusing more on the influence of behavior

which affects the performance.

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