RJOAS September 2025
by Hermawati Heri, Imam S. Sentot, Ambarika Rahmania (Strada Indonesia University, Kediri, East Java, Indonesia)
The reclassification of hospitals from Class B to Class A is part of Indonesia’s national strategy to improve service capacity, expand access to specialized care, and strengthen the effectiveness of the referral system. This study aims to analyze the impact of the class upgrade of RSUD R.T. Notopuro Sidoarjo on the number of referral patients using a quantitative approach. Secondary data were collected from the hospital’s official reports for 2022 (before the upgrade) and 2023 (after the upgrade). The analysis employed descriptive statistics and a paired t-test to measure the significance of changes in referral patient volume between the two periods. The results indicate that the average number of monthly referral patients increased from 300 to 450 after the class upgrade (p < 0.05), representing a significant rise in service demand. This growth is linked to several factors, including the availability of subspecialty services, improved medical infrastructure, and an increase in the number and competencies of healthcare personnel. Furthermore, the hospital’s transformation has enhanced public trust, making it a preferred referral center for complex cases within Sidoarjo and neighboring areas. These findings suggest that upgrading a hospital’s classification can have a direct positive effect on referral patterns, patient access to specialized services, and overall healthcare system performance. However, the rising patient volume also presents challenges that require proportional increases in human resources, digitalization of referral pathways, and improved hospital management practices. The study recommends strengthening referral governance, investing in advanced medical technology, and ensuring sustainable human resource development to support long-term positive impacts of hospital reclassification.
Studies examining the impact of reclassifying regional hospitals from Class B to Class A remain limited. RSUD R.T. Notopuro is the first district-level regional hospital to successfully achieve Class A status, making it a strategic case study for quantitative analysis. This research aims to assess the impact of hospital reclassification on the number of referral patients, the adequacy of human resources, and the feasibility of infrastructure as a foundation for policy evaluation and future strategic planning for the hospital.
In addition, accreditation serves as an important strategy to ensure quality and patient safety. Hussein et al. (2021) indicate that accreditation plays a key role in promoting a culture of safety and managerial efficiency within hospitals, although its implementation is not always consistent. RSUD R.T. Notopuro was granted full accreditation in July 2024, which is expected to strengthen public trust in the services of this regional hospital.
Disparities between the hospital’s designated status and its actual capacity in terms of human resources and facilities pose a risk of reducing efficiency and service quality. In terms of financing, the Performance-Based Financing (PBF) model, which has begun to be implemented in the National Health Insurance (JKN) system, demands measurable performance and service effectiveness as the basis for budget allocation. According to Setiawan et al. (2022), the application of PBF directly affects budgeting patterns and necessitates reforms in hospital governance.
On the other hand, the demand for handling complex cases has increased, yet this has not been matched by adequate growth in the number and competencies of medical personnel, particularly specialists and subspecialists. Based on an analysis by the Ministry of Health (2023), the uneven distribution of subspecialist physicians is a barrier to meeting Class A hospital service standards outside metropolitan areas.
Nevertheless, challenges have emerged during the implementation of this change. Based on RSUD R.T. Notopuro’s data, a decline in the number of outpatient referrals occurred following the class upgrade. This phenomenon can be attributed to the rigid BPJS tiered referral system, patient preference for private hospitals with direct access, and limited promotion of flagship services offered by public hospitals. Hussein et al. (2021) also noted that public trust in government hospitals remains lower than in private hospitals in several regions.
RSUD R.T. Notopuro Sidoarjo, a public health facility owned by the Sidoarjo District Government, underwent a significant transformation with its upgrade from Class B to Class A in October 2023, as stipulated in Operational License No. 9120009850961000. With a capacity of 700 beds, the hospital now serves as a referral center for specialized medical services in the southern part of East Java. This class upgrade marks a major milestone in improving healthcare quality, responding to the growing public demand for faster, more accurate, and higher-standard services.
Hospitals are vital components of the healthcare system, responsible for providing comprehensive promotive, preventive, curative, rehabilitative, and palliative services. In Indonesia, hospital classification is regulated under Law No. 44 of 2009 and reinforced by Minister of Health Regulation No. 3 of 2020, which categorizes general hospitals into four classes based on their capacity, types of services, and availability of medical personnel: Classes A, B, C, and D (Ministry of Health RI, 2020; Law RI No. 44 of 2009). Class A hospitals are equipped to provide complete specialist and subspecialist medical services and function as regional referral centers.
This study employs a descriptive quantitative approach aimed at identifying and measuring the impact of the reclassification of RSUD R.T. Notopuro Sidoarjo on the number of referral patients. This approach was chosen because it can provide an objective representation through statistical figures related to the changes occurring before and after the hospital's class upgrade. The research design is retrospective and comparative, comparing two sets of data from different periods for the same subject, namely RSUD R.T. Notopuro. This method enables the researcher to assess whether the hospital class upgrade had a significant influence on quantitative parameters such as the monthly number of referral patients, based on historical data and factual events. This approach is also deemed suitable for the nature of the phenomenon under study, which cannot be manipulated experimentally.
The study was conducted at RSUD R.T. Notopuro Sidoarjo, located in East Java Province. This hospital is a government-owned healthcare institution that underwent a class transformation from Type B to Type A at the end of 2023. The location was selected because it is one of the few district-level hospitals that successfully upgraded its classification, making it an interesting case study. The research was carried out between January and March 2024, encompassing data identification, processing, and statistical analysis. The timing coincided with the post-implementation phase of the class change policy, thus providing an ideal evaluative momentum to assess its empirical impact.
The type of data used in this study is secondary data sourced from the hospital's official documents. These data include reports on the number of outpatient and inpatient referrals, profiles of medical and non-medical personnel, and supporting medical facilities such as inpatient rooms, laboratories, and other ancillary installations. Data were obtained from internal hospital documentation, including the medical records department, human resources, and facilities divisions. The data collection was categorized into two periods: 2022 as the representation before the class change and 2023 as the representation after the class change. Secondary data were considered relevant as they are objective, well-documented, and had undergone internal administrative verification processes.
The data collection process was conducted through document analysis of official hospital records directly related to the research indicators. In addition, informal interviews were held with hospital staff, such as personnel from medical records, human resources, and unit heads, to ensure the validity of the information obtained. A triangulation technique was employed to enhance the reliability and validity of the data by cross-checking information across departments or sources to verify consistency (Sugiyono, 2019). This approach helped avoid errors due to recording mistakes or biases in internal reports and ensured that the analyzed data accurately reflected the actual conditions in the field.
The collected data were then statistically analyzed using IBM SPSS Statistics
version 26. The analysis was conducted in three main stages. First, descriptive statistics were applied to describe the data profile, such as the average number of referral patients per month, patient age distribution, and patterns of fluctuation throughout the year. Second, a paired t-test was conducted to determine whether there was a statistically significant difference in the mean number of referral patients before and after the hospital's class upgrade. This test was relevant as it involved two related data groups for the same subject in different periods. Third, a simple linear regression analysis was performed to evaluate the influence of demographic variables, such as age and gender, on the number of referrals to the hospital. This analysis aimed to identify whether patient demographic characteristics also affected the number of referrals. All analyses were carried out with a 5% significance level (α = 0.05). The interpretation of results was based on p-values, with p < 0.05 considered statistically significant (Field, 2018), indicating sufficient evidence that the observed differences or relationships were unlikely to have occurred by chance.
This section presents the findings of the data analysis on the impact of RSUD R.T. Notopuro Sidoarjo’s class upgrade on the number of referral patients. Data were collected from the hospital’s annual reports for 2023, representing the period before the upgrade, and 2024, representing the period after the upgrade. Both descriptive and inferential statistical methods were applied to assess variations in referral patient volumes over time. The analysis provides a comparative overview of monthly referral trends, highlighting changes in patient flow patterns and evaluating whether the reclassification to Class A had a statistically significant influence on referral rates.
The data indicate that the average number of monthly referral patients prior to the hospital’s class upgrade in 2023 was approximately 300 patients, whereas following the upgrade in 2024, this figure rose significantly to 450 patients per month. This increase occurred gradually and consistently throughout the 12-month observation period. The finding is supported by a univariate analysis of medical records and internal hospital statistical reports, which clearly demonstrate a notable rise in referral volume after RSUD R.T. Notopuro’s reclassification to Class A status.
The study analyzed a total of 800 referral patients, evenly distributed across the pre- and post-upgrade periods. The majority of patients fell within the productive age range of 30–50 years, with a relatively balanced gender distribution. This indicates that the hospital’s transition to Class A not only contributed to an overall increase in patient numbers but also expanded its demographic reach, attracting a wider population segment for specialized healthcare services.
This growth is strongly associated with enhanced public trust in the hospital’s capabilities following significant improvements in service quality. Key contributing factors include the availability of subspecialty services, modernization of medical equipment and infrastructure, and upgrades to hospital information systems and administrative procedures, which collectively improved efficiency and patient experience.
According to findings in Hermawati’s thesis (2024), the reclassification enabled the hospital to handle a greater number of complex cases while referrals for general and less severe conditions declined due to the structured, tiered referral system implemented by BPJS. Additionally, the strengthening of human resource capacity, including the recruitment and training of specialized medical personnel, and the introduction of flagship services such as the Integrated Cancer Care Installation (IPKT), which saw nearly a twofold increase in visits from 2023 to 2024, further underline the success of the hospital’s service transformation following its class upgrade.
Table 1 illustrates the comparison of the average number of monthly referral patients before and after the reclassification of RSUD R.T. Notopuro into a Class A hospital. In 2023 (prior to the class upgrade), the average number of referral patients was recorded at 300 patients per month, with a standard deviation of 35, indicating relatively moderate variation in monthly visits. Following the class upgrade in 2024, the average significantly increased to 450 patients per month, with a standard deviation of 42, suggesting that in addition to the rise in patient volume, the fluctuations in monthly visits also became slightly higher.
This increase reflects a surge in service demand as a result of the hospital’s enhanced appeal as a regional referral center for specialized medical services in Sidoarjo and its surrounding areas. Moreover, the growth aligns with the strengthening of service capacity and the addition of subspecialists implemented after the class upgrade. This pattern demonstrates a positive correlation between the hospital’s upgraded status and the confidence of primary healthcare facilities in referring patients to RSUD R.T. Notopuro.
The figure below illustrates the trend in the number of referral patients from January to December for the years 2023 and 2024.
According to a comparative study by Nugroho et al. (2021), Class A hospitals in district-level areas tend to experience a 32% increase in patient load within one year after a class upgrade. However, this increase is not always accompanied by an improved doctor-to-patient ratio, leading to service system overload. A similar situation was observed in the 2022 policy evaluation by the West Java Regional Government, which indicated that the success of hospital class upgrades largely depends on the readiness of supporting systems, including financing, human resource management, and digitalization of services.
Therefore, RSUD R.T. Notopuro must formulate a comprehensive long-term strategy to maintain and strengthen its role as a leading regional referral hospital. Sustaining this position requires continuous improvements in service capacity, infrastructure, and human resources. To support this analysis, the following table provides quantitative data on the monthly number of outpatient referral patients, offering a clearer view of referral patterns before and after the hospital’s class upgrade.
Based on the graph and table, the upward trend in the number of referral patients in 2023 was progressive, with a sharper increase occurring particularly between July and December. This phenomenon indicates a shift in public perception regarding the quality of services at RSUD R.T. Notopuro following the class upgrade. The presence of subspecialty services, increased bed capacity, and improvements in administrative and scheduling systems encouraged the public to choose this hospital as their primary referral center. In addition, better institutional communication and the achievement of full accreditation further strengthened the hospital's image as a trusted referral facility. In other words, this upward trend is not only due to technical capacity improvements but also the hospital's success in building its reputation and expanding access to information for the community.
The study by Nugroho et al. (2021) shows that Class A hospitals in district areas experience an average increase in service load of around 32% within one year of a class upgrade. This finding aligns with the pattern observed at RSUD R.T. Notopuro, which recorded a significant surge in referral patient volume after the upgrade. However, from a managerial perspective, this increased load presents its own challenges, as not all regional hospitals have optimal readiness in terms of organizational structure, service flow speed, or internal monitoring systems. Without proper mitigation strategies, the surge in patient visits may lead to overcapacity in inpatient wards, long queues in specialist clinics, and burnout among medical personnel handling complex cases continuously. Therefore, it is important for the hospital to develop a medium-term plan that includes demand forecasting and optimization of referral pathways.
Upgrading hospital classification is indeed an affirmative policy to expand access to quality healthcare services. However, if not accompanied by management restructuring, modernization of medical equipment, and proportional human resource fulfillment, the risk of systemic pressure on services becomes high. Emergency departments, hemodialysis units, and subspecialty services are usually critical points due to direct contact with complex referrals and high dependency care. Additionally, a non-integrated digital referral system between primary and secondary facilities increases administrative burdens and slows down service flow. Hence, RSUD R.T. Notopuro needs to develop a strategy for strengthening human resources through tiered training schemes and subspecialist recruitment, expanding physical infrastructure and service spaces, and optimizing hospital information technology to support data interoperability across healthcare facilities. This approach would ensure that the hospital's transformation to a higher class remains sustainable and adaptive to modern service challenges.
Statistical analysis using a paired t-test was performed to compare the average number of monthly referral patients before and after the upgrade of RSUD R.T. Notopuro from Class B to Class A. The results yielded a p-value of 0.001 (p < 0.05), indicating a statistically significant difference between the two periods. This demonstrates that the observed increase in referral patients was not random but a direct consequence of the hospital’s reclassification.
The increase reflects a positive response from both primary healthcare facilities and patients toward the hospital’s enhanced status as a specialized referral center. Several factors contributed to this growth, including improved service quality, the availability of subspecialty care, expanded medical infrastructure, and better administrative processes. These enhancements increased public trust and strengthened referral linkages from lower-level health facilities.
The findings support the argument that upgrading a hospital’s classification has a tangible and measurable effect on referral system effectiveness, improving access for patients with complex conditions. This result aligns with the literature (Field, 2018), which indicates that institutional capacity building in healthcare facilities significantly impacts both patient volumes and the complexity of cases handled, emphasizing the importance of strategic investments in hospital service upgrades.
These findings indicate that upgrading to Class A status has a direct and significant impact on patient volume, particularly referrals from primary healthcare facilities. According to Hussein et al. (2021), public confidence in hospital services increases when subspecialty care, full accreditation, and adequate medical infrastructure are in place. However, a rise in patient numbers must be matched with system readiness, including sufficient medical personnel, reasonable waiting times, and supporting facilities to maintain service quality. The Indonesian Ministry of Health (2023) highlighted that Class A hospitals outside metropolitan areas often experience service load pressures that exceed their human resource capacity, potentially leading to overcrowding and reduced service efficiency. Therefore, RSUD R.T. Notopuro’s management must implement measures to ensure that the increase in patient visits is supported by proportional enhancements in staffing, infrastructure, and service flow management to maintain high-quality care and avoid systemic strain.
The reclassification of RSUD R.T. Notopuro Sidoarjo from Class B to Class A had a significant impact on increasing the number of referral patients. The average monthly referral patient volume rose from 300 to 450 patients, with the paired t-test showing a p-value of 0.001 (p < 0.05), indicating a statistically significant difference. The upward trend remained stable throughout 2024, reflecting increased public trust in service quality. The availability of subspecialists, improved infrastructure, and better management were the main factors driving this surge in referrals. However, the increased service load also poses systemic challenges, requiring strengthened hospital capacity to ensure optimal functioning as a regional referral center. As a follow-up, RSUD R.T. Notopuro is advised to strengthen its human resource capacity through the recruitment and training of subspecialist medical personnel, expand critical service infrastructure such as emergency departments and inpatient units, and optimize its digital hospital information system integrated with the national referral system. In addition, promoting flagship services and establishing strategic collaborations with primary healthcare facilities should be intensified to increase the hospital’s visibility and utilization, thereby supporting the effectiveness of the referral system in Sidoarjo and surrounding regions.
Original paper, i.e. Figures, Tables, References, and Authors' Contacts available at http://rjoas.com/issue-2025-09/article_05.pdf