Balanced Scorecard Approach in Strategic Decision Making in Development of Executive Clinic Universitas Trisakti Academic Dental Hospital 2023

: Strategic planning enables hospitals to anticipate various ever-changing conditions and provides a roadmap, direction, and means to achieve their goals. The Executive Clinic at RSGM-P FKG USAKTI is a comprehensive and professional healthcare provider offering specialized and public services. However, its role as a profit center has experienced a decline during the two-year pandemic. This research aims to revitalize the Executive Clinic as a profit center for RSGM-P FKG USAKTI. The research methodology employed is operational research. The strategic plan development involves three stages: input, matching, and decision stages. The findings from the research indicate that the input stage resulted in the Internal Factor Evaluation (IFE) and External Factor Evaluation (EFE) matrices with scores of 2.81 and 2.69, respectively. The matching stage utilized the SWOT matrix and IE matrix, recommending the "Hold and Maintain" strategy. The decision stage includes the prioritized strategies, namely, increasing operational hours and enhancing front office services. The identified strategic objectives are


Introduction
Ensuring optimal oral health is paramount in evaluating one's overall health and wellness (Yimenu et al, 2021).According to the 2018 Indonesian National Institute of Health Research and Development, about 57.6% of Indonesians experience oral health problems (Susilawati et al., 2018).Addressing this issue requires access to quality oral health services.Dental and Oral Hospital is a specialized healthcare institution that provides services for individual oral health issues (Indonesian Ministry of Health, 2020).
To thrive in the face of globalization, hospitals need to implement strategic management.The modern business world is often confronted with the VUCA (Volatility, Uncertainty, Complexity, and Ambiguity) environment, which describes rapid, unpredictable, and volatile change.To thrive in this environment, hospital management must shift from a fragile management approach to agile management (Meri, 2021).Balanced Scorecard is a useful tool for organizations seeking to navigate the volatile, uncertain, complex, and ambiguous (VUCA) environment.Balanced Scorecard provides a framework for organizations to measure their performance toward strategic objectives and provide a comprehensive overview of progress toward achieving desired outcomes.Organizations can better understand their performance and identify areas for improvement and development (Fransisren & Gani, 2021).
Dental Academic Hospital of the Faculty of Dentistry at Universitas Trisakti is a medical facility owned and operated by Universitas Trisakti.The Executive Clinic within Universitas Trisakti Academic Dental Hospital (RSGM-P FKG USAKTI) is a specialized oral healthcare facility renowned for providing comprehensive and expert services.Established in 1995, this clinic has effectively addressed various oral health issues through a team of general dentists, specialists, and sub-specialists.Serving as a revenue-generating entity for Universitas Trisakti, the executive clinic has faced significant challenges for the last two years, during the COVID-19 pandemic.To overcome the challenges and navigate the situation, strategic management of the executive clinic is imperative to re-establish its status as a revenue-generating center.Given this context, it is worthwhile to delve deeper into the business strategy management processes employed by the Executive Clinic of RSGM-P FKG USAKTI in response to the competitive challenges and the influence of globalization with BSC approach.

Literature Review
Strategic management is the combination of knowledge and the art of formulating, implementing, and evaluating cross-functional decisions that enable an organization to achieve its goals (Djordjevic, 2021.)The focus of strategic management is to integrate management, marketing, finance and accounting, production and operations, research and development, and information systems to achieve organizational success (Ayuningtyas, 2020).Strategic management formulation consists of three phases of analysis that include the Input Stage, Matching Stage and Decision Stage (David, 2017).
Successful healthcare organizations are typically led by individuals who are able to understand the nature and implications of external change, develop effective strategies to direct change, and have the will and ability to manage the momentum of the organization actively (Ginter et al., 2018).Without planning, individuals and departments within an organization or company can have different goal (Rusniati & Haq, 2014).
According to Fred R. David, strategy formulation consists of three stages which are the Input Stage, Matching Stage, and Decision Stage (David, 2017).Input Stage is a stage that aims to obtain information about the position of the organization by conducting situation analysis.Situation analysis is carried out by identifying external and internal environmental variables.Fred R. David states that there are two matrices that can be used in the input stage, namely the External Factor Evaluation (EFE) Matrix and the Internal Factor Evaluation (IFE) Matrix (Ayuningtyas, 2020).The EFE Matrix is used to evaluate the external factors of a company or organization, while the IFE is used to evaluate internal factors.At this stage, each Critical Success Factor is given a weight and score to calculate the total EFE and IFE scores (Karmawan, 2016).
The Matching Stage is the adjustment stage between critical external and internal factors, and then analysis is carried out using quantitative models to produce alternative strategy formulations.Several models that can be used for this analysis are the SWOT matrix (Strengths, Weaknesses, Opportunities, Threats) and the IE Matrix (Internal-External) (Yus & Widodo, 2018).The SWOT matrix is used as an advanced analysis tool in determining and developing appropriate alternative strategies.From the SWOT matrix analysis, various alternative strategies are produced, namely Strength-Opportunities (SO), Strength-Threat (ST), Weakness-Opportunities (WO), and Weakness-Threat (WT) strategies (Putra, 2014) namely the total score from the EFE Matrix on the X axis and the total score from the IFE Matrix on the Y axis (Nourlette & Hati, 2017).
The final stage is the Decision Stage which evaluates alternative strategies using the Quantitative Strategic Planning Matrix (QSPM).The QSPM matrix makes it possible to sort various existing strategies to form a priority scale for strategy implementation (Qanita, 2020).
The Balanced Scorecard (BSC) method is an effective tool for hospitals to improve their strategic management by measuring performance.With this method, hospitals are expected to be able to conduct strategic management more effectively and efficiently (Jaber & Nashwan, 2022).Developed by Kaplan and Norton, the Balanced Scorecard is a strategic planning and management system approach that helps monitor business activities as well as vision and organization strategy through performance monitoring toward strategic objectives (Pathuri & Wang, 2017;Coskun & Senyigit, 2010).The Balanced Scorecard approach measures performance seen from the financial and non-financial aspects.BSC is divided into four perspectives, namely financial performance, customer satisfaction, internal business process, and growth and development (Akbarzadeh, 2012).Subjects of this study were the Dental Hospital Director of RSGM-P FKG USAKTI as an informant for research purposes and 100 patients who visited the Executive Clinic of RSGM-P FKG USAKTI to measure patient's satisfaction using the Patient's Satisfaction Questionnaire-18 (PSQ-18).The research investigation spanned the period from February to March 2023.This study was carried out in the Executive Clinic of RSGM-P FKG USAKTI, Jakarta.

Figure 1. Flow of the Research Methods
Variables in this study are divided into external and internal environment analysis.External environment consists of politics and policy, economy, social, demography, customer, and competitor variables.Internal environment analysis consists of organizational management, vision and mission, marketing, human resources, information systems, and infrastructure.All these variables will be used in the formulation and implementation of strategic management of the executive clinic.
Within the context of this study, the collection of both primary and secondary data are done.Primary data is obtained quantitatively with the use of Patient's

Satisfaction
Questionnaire-18.Primary qualitative data is obtained through in-depth interview with the hospital director, and a consensus decision making group with the hospital board.Secondary data is obtained quantitatively through internal hospital data collection and data from the National Central Bureau of Statistic.
Internal and external hospital data obtained through primary and secondary data that influence Executive Clinic of RSGM-P FKG USAKTI.All data collection are then processed to be presented at the CDMG meeting with the hospital board.Situation Analysis phase entails the gathering of data and the comprehensive examination of internal and external factors.The data analysis process encompass a range of strategic tools and frameworks, including SWOT analysis in BSC perspective, Internal Factor Evaluation (IFE) analysis, External Factor Evaluation (EFE) analysis, SWOT Matrix, Internal-External (IE) Matrix analysis, Quantitative Strategic Planning Matrix (QSPM) analysis, the elaboration of alternative strategies into strategic objectives, alignment of strategic objective with the Balanced Scorecard (BSC),  1.
During the first meeting of the CDMG, researchers delivered a comprehensive presentation encompassing the analysis of primary and secondary data followed by the hospital board engaged in a discussion to fill out a SWOT analysis with Balanced Scorecard perspective on VUCA environment.The second CDMG meeting proceeded with the completion of the Internal Factor Evaluation (IFE), External Factor Evaluation (EFE), and Internal-External (IE) matrices.During the final CDMG meeting, the Quantitative Strategic Planning Matrix (QSPM) was utilized to determine and prioritize strategic alternatives.

Swot Analysis with BSC Perspective
The SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis is conducted through a comprehensive examination of both the internal and external environments, aiming to identify the specific Strengths, Weaknesses, Opportunities, and Threats pertinent to the Executive Clinic of RSGM-P FKG USAKTI.These findings are subsequently integrated into the Balanced Scorecard framework can be seen in Table 1.

IFE and EFE Analysis
The Input Stage involves the categorization of Critical Success Factors that have been identified through the collaborative efforts of the Consensus Decision Making Group.(CDMG).These factors are then incorporated into both the External Factor Evaluation Matrix (EFE) Matrix and the Internal Factor Evaluation Matrix (IFE) Matrix.
Table 2 show the result of the EFE matrix analysis indicate that the cumulative opportunity factor score stands at 1.46, whereas the cumulative threats factor score is recorded at 1.23.A comparison between these two scores reveals an advantageous margin of Note: Weight 0.0 -1.0 → unimportant -very important Rating 1 -4 → 4 = a superior response, 3 = above average response, 2 = average response, and 1 = poor response Total Weighted Score 1 -4 → A score of 4.0 indicates that the organization is responding in an extraordinary way to opportunities that exist and also to avoid threats.Score > 2.5 indicates a greater opportunity, if < 2.5 indicates a greater threat.A score of 1.0 indicates the organization does not take advantage of existing opportunities or does not avoid external threats 0.23 in favor of the opportunity factor, resulting in a total score of 2.69.This signifies that the Executive Clinic of RSGM-P FKG USAKTI exhibits a relatively robust capacity to capitalize on opportunities and effectively mitigate external threats.

SWOT Matrix
The SWOT matrix shown in Table 4 is analyzed from the outcomes of both the EFE Matrix and the IFE Matrix.The EFE Matrix reveals a higher total score for opportunities compared to threats, and the IFE Matrix indicates a greater total strength score in comparison to weaknesses.

IE Matrix
Upon evaluating the IFE and EFE matrices, it is discerned that the Executive Clinic of RSGM-P FKG USAKTI has IFE score of 2.69 and an EFE score of 2.81.These values collectively position the Executive Clinic in the middle of the Strategic Business Unit cells within the matrix, specifically falling within cell V.This placement suggests that the recommended strategy is to "Hold and Maintain."Commonly employed strategies in this context often involve market penetration and product development can be seen in Figure 2.
After evaluating the IFE and EFE matrices, it was found that the Executive Clinic of RSGM-P FKG USAKTI had a total IFE of 2.69 and an EFE of 2.81.Based on these values, it can be concluded that the Executive Clinic of RSGM-P FKG USAKTI is in the middle position in the matrix and is located in cell V.This means that the recommended strategy is Hold and Maintain.Commonly used strategies are market penetration and product development.

QSPM Matrix
In the final phase of the strategy analysis process, the selection of the most appropriate strategy is a pivotal step that paves the way for its implementation within the organization.This strategic decision-making can be systematically executed through the use of the Quantitative Strategic Planning Matrix (QSPM).
Based on the last CDMG results, a strategic plan has been endorsed for implementation at the Executive Clinic of RSGM-P FKG USAKTI.This plan can be seen in Table 5 revolves around the adoption of the Market Penetration strategy and encompasses the following key initiatives which are Actively promoting the Executive Clinic's specialized services on social media and establishing a dedicated marketing team focused on social media engagement, Expand collaborative arrangements with various health insurance companies to broaden accessibility and coverage, Extending the operational hours of the Executive Clinic so that patients are more flexible in determining appointment schedules and Create a membership system wherein patients can collect points with each treatment, enabling them to redeem these points for discounts on future medical The alternative strategies employed in the implementation of the Product Development strategy shown in Table 6 encompass the following Establishment of an online reservation system accessible through a website or a mobile application, aimed at simplifying the process of appointment scheduling for patients, Improvement of front office services with a primary focus on creating a patientcentric environment, Implementation of a protocol to ensure that patients are provided with an estimated maximum waiting time of 10 minutes.This initiative is intended to elevate patient satisfaction levels with the services and create multidisciplinary dental care packages that are tailored to patient needs.
In accordance with the outcomes from the QSPM matrix analysis, the alternative strategy that has the highest Total Attractiveness Score (TAS) will be recommended as the chosen strategy.The market penetration strategy, with the highest TAS value of 4.45, entails the extension of the operating hours of the Executive Clinic.Furthermore, the product development strategy with the highest TAS of 4.9 pertains to the improvement of front-office services.

Selected Strategic Alternatives into Strategic Objectives
After obtaining a priority strategy, this alternative priority strategy is translated into strategic objectives.For market penetration, strategic objectives encompassed increasing revenue, seizing market opportunities, and upgrading operator competencies.Product development strategic objectives include increasing revenue, increasing patient satisfaction levels, cultivating favorable brand images, enhancing service quality, and enhancing staff performance standards.

Alignment of Strategic Objective with the Balanced Scorecard
The strategic objectives obtained are subsequently mapped into the four key perspectives of the Balanced Scorecard framework that can be seen in Table 7.

Formulation of Strategic Map
The strategic objectives are then mapped onto the four perspectives of the Balanced Scorecard framework shown in Table 8.

Program Implementation
Following the comprehensive establishment of performance targets and work programs for all Key Performance Indicators (KPIs), the subsequent phase entails the implementation of these programs.During this program implementation stage, active participation is sought from all hospital staff, fostering their direct involvement in the program's execution.

Conclusion
The Executive Clinic of RSGM-P FKG USAKTI exhibits a predominance of strengths over weaknesses, as evidenced by the results of the Internal Factor Evaluation (IFE) Matrix.Additionally, the Executive Clinic has greater array of opportunities than threats, as revealed by the External Factor Evaluation (EFE) Matrix.SWOT Matrix reveals the combination of all SO, WO, ST, and WT strategies are the recommended course of action.In the IE (Internal-External) Matrix analysis, the Executive Clinic of RSGM-P FKG USAKTI occupies cell V, thereby recommending a "Hold and Maintain" strategy.Conventional strategies of market penetration and product development are commonly employed.The Quantitative Strategic Planning Matrix (QSPM) delineates alternative priority strategies, designating the extension of the Executive Clinic's operational hours as the principal priority within the market penetration strategy.Conversely, for product development, the primary priority strategy is the improvement of front-office services within the RSGM-P FKG USAKTI Executive Clinic.
Alignment of strategic objectives with the Balanced Scorecard framework reveals that those strategic objectives exhibit relevance to all four key of Balanced Scorecard perspectives.From strategic map, we could see that The Balanced Scorecard framework commences with a foundational focus on the Growth and Learning perspective, as it is the foundation for long-term success, with a focus on innovation and employee development.Subsequently, the framework shifts towards the Internal Business Processes perspective, emphasizing the necessity of operational efficiency and effectiveness to deliver value to customers.Following the internal processes, attention then shifts to customers, because customer satisfaction is the key to revenue.Satisfied customers are instrumental in driving financial success.Lastly, a financial perspective is used to measure the end result of all these efforts, reflecting the overall performance of the organization.This helps organizations to understand and maximize their long-term value, rather than just focusing on current financial numbers.

MethodA
descriptive study with qualitative and quantitative approaches (mixed methods) is used for this study.The scope of this research focuses on the analysis of the internal and external environment of the Executive Clinic of RSGM-P FKG USAKTI in formulating strategic management.The research protocol received ethical approval from the Health Research Ethics Committee, Faculty of Dentistry, Universitas Trisakti with ethical clearance number 621/S2/KEPK/FKG/10/2022.All enrolled patients participated by providing informed consent, explicitly authorizing the utilization of their anonymized data for research purposes.

Note:
Weight 0,0 -1,0 → unimportant -very important Rating 1 -4 → 4 = major strength, 3 = minor strength, 2 = minor weakness, and 1 = major weakness.Total Weighted Score 1 -4 → A value of 4.0 indicates that the organization has great strength.A score > 2.5 indicates greater strength, if < 2.5 indicates greater weakness.A score of 1.0 indicates the organization has many weaknesses or a low internal position Balanced Scorecard Approach in Strategic Decision Making in Development of Executive Clinic Uni….| 51

Figure 2 .
Figure 2. Internal -External Matrix . The IE Matrix is used to analyze the hospital's position by comparing the data obtained from the previous stage into the nine cells in the matrix, taking into account the total value of the EFE and IFE Matrices.The IE Matrix has two dimensions, Balanced Scorecard Approach in Strategic Decision Making in Development of Executive Clinic Uni….| 47

Table 5 . Quantitative Strategic Planning Matrix (Market Penetration) Critical Success Factor Weight Strategic Alternative (Market Penetration)
Balanced Scorecard Approach in Strategic Decision Making in Development of Executive Clinic Uni….| 53