Analysis of the Application of Pharmaceutical Service Standards and Patient Satisfaction with Accreditation Status and Types of Services

Accreditation is a method to improve the quality of health services, so that it is expected that the services provided are in accordance with established regulations. This study aims the implementation of Pharmaceutical Service Standards (PCSs) and patient satisfaction on accreditation status and types of PHCs in Deli Serdang Regency, Sumatera Utara. This descriptive analytical cross-sectional study was conducted to analyze pharmacy services at PHCs (n=34) in Deli Serdang Regency. The reference used is the Checklist for PCSs based on direct observations and interviews with the person in charge of pharmacy and the Patient Satisfaction Questionnaire. The data obtained were analyzed using SPSS version 22. The results on the value of a total score PCSs showed 41-90, with the highest level of patient satisfaction is the very satisfied category is 65.90%.The correlation test was analyzed using the Chi-Square test with a significance limit of p<0.05, the correlation of accreditation status to the implementation of PCSs showed a value of p=0.304, the correlation of the type of service to the implementation of PCSs showed a value of p=0.591, the correlation of the accreditation status of PHCs to the level of satisfaction patient value showed a value of p=0.000. This study concluded that the accreditation status of the PHCs does not affect implementation of PCSs, the type of PHCs service does not affect implementation of PCSs and the accreditation status of the PHCs has an effect on the level of patient satisfaction in Deli Serdang Region, Sumatera Utara.


Introduction
Pharmaceutical services are an integral part of the implementation of health efforts at community health centers, which play a major role in improving the quality of health services for the community.Public and patient demands for increasing the quality of pharmaceutical services require a broad paradigm with patient orientation through a pharmaceutical service philosophy from the old product-oriented paradigm (Minister of Health, 2016).
Indicators that can be used to measure the level of success of pharmaceutical services include knowing the level of patient satisfaction.Users of health services at community health centers, namely patients, require quality services, not only for their health to improve or related to the recovery of physical illnesses, but also related to the availability of adequate facilities, satisfaction with attitudes and comfort in the physical environment (Supriyanto and Ernawaty, 2010 ).For this reason, there needs to be further research that confirms the relationship between the type of health center service, patient satisfaction and the accreditation status of the health center.Characteristics: Deli Serdang Regency, with an area of 2,497.72 km2, ranks second in North Sumatra Province in terms of population distribution (1.93 million people).It has 34 community health centers with 7 outpatient health centers and 27 inpatient health centers spread across 22 sub-districts with staff.There are 34 pharmacists (Dinkes, 2020).

Accreditation of Community Health Centers
Public health center must be accredited periodically at least every three years, which is also a requirement for credentials as a first-level health service facility that partners with BPJS (Social Security Administering Agency).Public health center accreditation aims to improve performance and quality in service and program delivery systems, quality management systems, implementation of risk management through continuous improvement and not just assessment to obtain an accreditation certificate (Minister of Health, 2015).(Dinkes, 2020).

Level of Accreditation of
Accredited health facilities tend to have employees dedicated to improving environmental safety, quality, and risk management (Braun, 2008).Accreditation standards that influence the quality of service in health facilities consist of patient and family education standards, community integration standards, management and organization standards, patient safety, and sustainable patient care standards (Diab, 2015).The accreditation process involves the assessment of a given set of standards, an on-site survey by a team from an external organization guided by the assessment, a written report with or without recommendation and rejection as well as the granting of accreditation status and an assessment of the level of compliance with the standards (O'Beirne, 2013).

Types of Services at the Deli Serdang District Health Center
In accordance with service capabilities, the Public health center categories are as follows:

Non-inpatient health center
Community health centers that provide emergency services, outpatient services and home care.

Inpatient health center
Public health center are given additional human resources based on consideration of health service needs in carrying out inpatient services and others.Inpatient health centers also have a function as referral centers, namely referrals between non-inpatient health centers and others, before being referred to referral health facilities (Minister of Health, 2019a).Public health center in Deli Serdang Regency has 7 non-inpatient and 27 inpatient health centers with a bed capacity of 336 units spread across 22 sub-districts in Deli Serdang Regency (Dinkes, 2020).

Standards of Pharmaceutical Services at Community Health Centers
In accordance with PMK No. 74 of 2016, SPK is a benchmark in providing pharmaceutical services which is used as a guide for pharmaceutical personnel.Pharmaceutical services are direct and responsible services to patients related to pharmaceutical preparations which aim to produce clear results in developing the patient's quality of life (Minister of Health, 2016).Pharmaceutical services are integrated activities which aim to resolve, identify and prevent drug problems and health-related problems.The demands of society and patients in improving the quality of pharmaceutical services require an expansion from the old paradigm which refers to products to a new paradigm which refers to patients through the philosophy of pharmaceutical services.

Patient Satisfaction
Patient satisfaction is a level of patient feelings that arise as a result of the performance of health services that they get after the patient compares them to something they expected.The main problem encountered is that satisfaction is subjective in nature.Each person, depending on their satisfaction, can also have a different level of satisfaction with the same health service.Furthermore, there are also many health services that, even though they are considered to have provided patient satisfaction, when viewed based on the code of ethics and professional service standards, their performance is still not met (Yewen, 2018).In terms of successful implementation of SPK in community health centers, cooperation and commitment from all relevant health workers is needed.This can make pharmaceutical services at community health centers more optimal and their benefits can be enjoyed by the community and patients, which in general can develop community or patient satisfaction and the image of the community health center (Minister of Health, 2016).Quality health services are a reference for satisfaction which has an impact on patients' desire to return to effective health service providers (Umniyati, 2010).

Methods
This research is a survey design analytical cross-sectional study, using instruments taken from the TOT Pharmaceutical Services  1, it can be seen that the average number of prescription services per month at primary accreditation health centers with the highest visits being at 18 health centers with inpatient services (2,974 prescriptions) and the lowest visits being at 14 health centers with inpatient services (674 prescriptions).In community health centers with intermediate accreditation, the average number of prescription services per month with the highest visits was at community health center 13 with inpatient services (3,488 prescriptions) and the lowest visits were at community health center 9 with non-inpatient services (197 prescriptions).In community health centers with basic accreditation, the average number of prescription services per month with the highest visits was at community health center 4 with inpatient services (4,601 prescriptions) and the lowest visits were at community health center 26 with inpatient services (301 prescriptions).The number of patient visits is influenced by the quality of service which includes comfort, cleanliness and neatness of the staff which can make the patient's family and patients feel satisfied thereby increasing interest in returning visits (Solikhah, 2008).
Consumer satisfaction with all services can have a big and positive influence on interest in using the same service, if customers feel that the service is of high quality, that is, the service they receive is higher or equal to expectations.The behavior of someone who repeats a service that has been experienced shows that there is a response that is influenced by knowledge, attitudes and beliefs regarding how to utilize a condition to realize a goal (Kotler, 1995).

Implementation of Pharmaceutical Service Standards in District Health Centers Deli Serdang
Pharmaceutical service standards at community health centers are in accordance with PMK No. 74 of 2016 is intended to develop pharmaceutical services, ensure legal certainty for pharmaceutical personnel and provide protection for the public and patients from illogical use of drugs for patient safety, and also becomes a form of centralized regulation from the central level starting from the Ministry of Health to the Health Service City/Regency and Provincial Health Services, then continue at the lower level, namely the Public health center, where the policy administrator is the Public health center drug manager.

Calculation Results for the Implementation of Pharmaceutical Service Standards at Community Health Centers
The value of SPK implementation at the Deli Serdang Regency health center is calculated according to the total score of human resources, facilities and infrastructure, management of pharmaceutical preparations and BMHP, clinical pharmacy services and quality control of pharmaceutical services.The value of implementing SPK at the Deli Serdang Regency health center is calculated according to the total score of human resources, facilities and infrastructure, management of pharmaceutical preparations and BMHP, clinical pharmacy services and quality control of pharmaceutical services.2 It can be seen that the SPK implementation value for category I/good is found in 3 community health centers (8.82%) with basic accreditation status of 2 community health centers and primary accreditation of 1 community health center with inpatient service types in 3 community health centers.for category II/medium, there are 24 community health centers (70.59%) with basic accreditation status for 10 community health centers.intermediate accreditation of 11 health centers.Main accreditation of 3 health centers with 19 inpatient services and 5 non-inpatient health centers.for category III/less, there are 7 health centers (20.59%) with basic accreditation status for 5 health centers.intermediate accreditation of 2 health centers with inpatient services at 5 health centers and 2 non-inpatient health centers.25) 3 ( 75) 0 Based on Table 3. Chi-square correlation analysis of community health center accreditation status on the implementation of pharmaceutical service standards was shown with a value of p=0.304 (p>0.05).This shows that there is no correlation between the accreditation status of community health centers and the implementation of SPK.Based on table 5 the correlation analysis of accreditation status with the level of patient satisfaction is shown with a value of p=0.000 (p<0.05).This shows that there is a correlation between accreditation status and the level of patient satisfaction.

Relationship between types of health center services and the implementation of pharmaceutical standards
Guaranteeing the quality of community health services as the first level health service facility in Indonesia still has limitations in terms of complete equipment and types of services.Apart from that, the community considers that the performance of the staff at the community health center is still less than professional.All of these conditions are related to the low incentives received by community health center staff, weak leadership and managerial skills of community health center leaders and staff as well as the lack of guidance at community health centers by the district/city health service.(Sulaeman, 2011).Public health center, in accordance with its function, is obliged to strive for, provide and administer quality services to meet the community's needs for quality health services.Providing quality public services that are able to provide satisfaction to the community is an obligation that must be carried out by the government.Including the community health center as the spearhead and also the benchmark for public services in the health sector, is one of the pillars in meeting demands for bureaucratic reform.Assessment of the quality of health services at community health centers shows results that do not meet quality standards.
Community health centers can carry out their functions optimally if they are managed well through service performance, service processes and the resources used.The community wants health services that are safe, of good quality and meet their needs so that quality improvement, risk management and patient safety are maintained in the management of community health centers in providing comprehensive health services.Quality improvement is carried out by increasing performance and implementing risk management on an ongoing basis in community health centers which can be seen from the results of accreditation.Accreditation is very necessary because it is carried out by external parties using standards set according to the accreditation mechanism.Community Health Centers are required to be regularly accredited at least once every three years.Likewise, accreditation is one of the credential requirements as a first-level health service facility that collaborates with the Health Social Security Administering Agency (BPJS).
According to Rustandi, the benefits of community health center accreditation in detail are; (1) Provide a competitive advantage; (2) Strengthen public trust in health service facilities; (3) Ensure the provision of primary health services to patients and the community; (4) Improve the education of primary health care facility staff to provide the best service for the community; (5) Improving risk management in patient services both at Community Health Centers and other primary health facilities as well as the implementation of community health center efforts; (6) Build and improve teamwork among primary health facility staff; (7) Increase reliability in service, orderliness in documentation, and consistency in work; (8) Increase safety at work.
The vision for health development organized by the Community Health Center is to achieve a Healthy District towards the realization of a Healthy Indonesia.A healthy sub-district is a picture of the future sub-district community that we want to achieve through health development, namely a community that lives in an environment and with healthy behavior, has the ability to reach quality health services fairly and evenly, and has the highest level of health.
Community health centers still encounter many obstacles in implementing accreditation according to the research results of Farzana et al ( 2016), including several stages such as differences in information regarding post-failure actions in previous accreditation assessments, the presence of community health center staff who still do not understand document preparation, lack of special resources in terms of staff availability, and the application and assessment process was carried out suddenly by the accreditation commission without prior coordination with the accompanying team or the Semarang City Health Service.

Conclusion
The conclusion of this research is that the accreditation status of the Public health center and the type of Public health center service do not influence the implementation of pharmaceutical Deli Serdang District Health Center Public health center accreditation has been carried out in Deli Serdang Regency since 2017 and until 2019 all Public health center have been accredited with 17 Public health center in the basic category, 13 in the intermediate category, and 4 in the main category.Public health center in Deli Serdang Regency that were accredited in 2020 increased to 34 Public health center from 32 Public health center in 2019.The addition of 2 Public health center that received accreditation in the basic category, namely Gunung Meriah Public health center and Petumbukan Public health center.The percentage of community health centers that have been accredited can be seen from Figure 1.
1215 (Print), ISSN 2721-1231 (Online) Copyright © 2023, Journal La Medihealtico, Under the license CC BY-SA 4.0 79 ISSN 2721-1215 (Print), ISSN 2721-1231 (Online) Copyright © 2023, Journal La Medihealtico, Under the license CC BY-SA 4.0 84 Correlation of Community Health Center Accreditation Status with the Implementation of Pharmaceutical Implementation Standards Module and the Patient Satisfaction Questionnaire Form accessed from PMK No. 74 of 2016.This research was conducted in all community health centers (n=34) in Deli Serdang district in September-December 2021.Respondents in this study were all those in charge of pharmacy and patients who received medication at the District Health Center.Deli Serdang, where the number of respondents was obtained based on Slovin's calculations with a margin of error of 10%.The independent variables in this study are the accreditation status of the Public health center and the type of Public health center services.The dependent variable in this research is the Value of the PMK Implementation Category No. 74 of 2016.(Human resources, facilities and infrastructure, management of pharmaceutical preparations and BMHP, clinical pharmacy services, quality control of pharmaceutical Characteristics of the Pharmaceutical Service Observation Unit at the Deli Serdang District Health Center services) and level of patient satisfaction.The assessment for each variable in the PMK implementation category is given a value based on the TOT Module for pharmaceutical services at the community health center.Then categorized into categories according to range.Table 1 ISSN 2721-1215 (Print), ISSN 2721-1231 (Online) Copyright © 2023, Journal La Medihealtico, Under the license CC BY-SA 4.0 81

Table 2 .
Results of Calculation of Pharmaceutical Service Standard Checklist at Public health center Deli Serdang Regency ISSN 2721-1215 (Print), ISSN 2721-1231 (Online) Copyright © 2023, Journal La Medihealtico, Under the license CC BY-SA 4.0 83

Table 3 .
Correlation of Community Health Center Accreditation Status with the Implementation of Pharmaceutical Implementation Standards

Table 4 .
Correlation of Types of Community Health Center Services with the Implementation of Pharmaceutical Implementation Standards

Correlation of Patient Satisfaction Level with Pharmaceutical ServicesTable 5 .
Correlation of accreditation status to patient satisfaction levels The functions of the Public health center include 85 the implementation of first level Community Health Efforts (UKM), and the implementation of first level Individual Health Efforts (UKP) in its work area.Law of the Republic of Indonesia No. 36 of 2009 concerning health states that the provision of health services is carried out responsibly, safely, of quality, evenly and non-discriminatorily.Likewise, Presidential Regulation of the Republic of Indonesia No. 72 of 2012 concerning the National Health System states that in administering Health Insurance, health services to participants must pay attention to service quality, be oriented towards aspects of patient safety, effectiveness of actions, suitability to patient needs and cost efficiency.