A Critical Evaluation of National Quality Indicators

Institutional Quality and Implementation Challenges at Level III “X” Hospital Bogor

Abstract

This study aims to critically evaluate the performance of National Quality Indicators (INM) in the first quarter of 2025 at Level III “X” Hospital, focusing on the gap between administrative compliance and substantive patient experience. Using an evaluative-comparative approach and the SERVQUAL framework, the study examines 15 national quality indicators through Donabedian’s model and clinical governance theory. Results show strong performance in structurally controlled indicators such as patient identification (100%), critical lab result reporting (100%), and compliance with the National Formulary (98.53%). However, systemic weaknesses emerge in indicators requiring inter-unit coordination, such as outpatient waiting time (63.29%) and specialist visit compliance (70.6%). These findings reflect an epistemic transition from compliance-based to learning-based quality governance. The study recommends repositioning quality strategies by promoting collective reflection, patient involvement, clinical data integration, and transformational leadership. The findings contribute to developing a hospital quality system that is more humanistic, value-driven, and sustainable.