What are the Appropriate Leadership Styles for Class C Hospital in National Health Insurance (JKN) Era?

The form of leadership is able to determine the success of an organization including hospitals, so a leader needs to think about the right leadership style, especially in the JKN era. This study aims to explore the appropriate leadership style in X General Hospital so that it can get full accreditation and the hospital’s existence is still maintained until now. The study used a qualitative study design with a case study approach (case study) which was conducted at one of the Class C General Hospitals in Malang Regency which has collaborated with BPJS Kesehatan (Healthcare and Social Security Agency). The study involved employees who worked at General Hospital X and experienced hospital leadership during the JKN era during February-March 2020. Data collection techniques used three methods including interviews, observation, and document review. The results showed three major themes of leadership style including leadership style transformational, democratic leadership style, and moralist leadership style. The transformational leadership style is the core of the existence of General Hospital X in the JKN era, while the democratic and moral leadership style supports the existence of General Hospital X in the JKN era.

pISSN 1858-1196 eISSN 2355-3596 behavior of hospital management and services (Rahmadani et al., 2019). One of the indicators to assess the quality of human resources is a form of leadership. The form of leadership is able to determine the success of an organization, including hospitals. So that a leader needs to think about the appropriate leadership style in achieving organizational goals (Dele et al., 2015). Leadership style is a method used by a leader to influence the behavior of others. Empirically, the transformational leadership style has a significant positive effect on employee job satisfaction so that leadership support is needed in shaping the work climate (Rahmadani et al., 2019). In 2018 East Java had the highest number of class C hospitals, namely 176 hospitals, 7 of which are located in Malang Regency. Based on BPJS Kesehatan data in 2019, the number of hospitals that have

Introduction
In early 2014 the Indonesian Government implemented the National Health Insurance (JKN) program with the aim of providing guarantees to all Indonesians so they can access health services without being constrained by costs. (Irwandy and Sjaaf, 2018). The existence of the JKN policy in Indonesia has an impact on increasing access to public health services which is directly proportional to the increase in patient visits to health facilities including hospitals. The increase in the number of patient visits resulted in less than optimal service as evidenced by patient dissatisfaction, meanwhile, health services in the JKN era were demanded to remain high quality (Hadiyati et al., 2017). The HR aspect is one of the aspects that played an important role during the JKN era, because it is directly related to the National Health Insurance (JKN) era. There were 7 informants who were included in the inclusion criteria and interviewed in this study; consisting of 5 people who hold positions in structural, 1 executive, and head of the hospital. Another source of data is obtained from observations that can be observed from interactions between leaders and employees during meetings, during casual discussions, and when leaders assign tasks to employees. There are three ways to analyze the data, namely data reduction, data presentation and conclusion drawing. Data reduction was carried out on irrelevant interview transcripts by summarizing or removing things that were not important. The next step after data reduction is presenting the data. With the presentation of data, it serves to see the available data, whether it represents what is happening and what should be done based on the understanding in presenting the data. Drawing conclusions is the third stage in data analysis in qualitative research. The conclusions in this study are new and original findings. The validity and transferability of research data was carried out by peer debriefing, inviting external auditors, and data triangulation.

Result and Discussion
General Hospital X is a class C hospital that was founded in 2010 and is located in Bululawang District, Malang Regency. The hospital has collaborated with BPJS Kesehatan since 2014 and has been fully accredited by SNARS since March 2019. According to the leader of X General Hospital, 90% of patients are BPJS Kesehatan card holders. X General Hospital has 290 employees with details of 10 doctors, 23 specialist doctors, 2 dentists, 65 nurses, 27 midwives, 45 other medical personnel, and 118 non-medical personnel. The hospital has five types of services including outpatient, inpatient, IGD (Emergency Room Installation), IKO (Operating Room Installation), and ICU (Intensive Care Unit). Hospital supporting facilities include laboratories, radiology, and pharmaceutical installations. Based on hospital collaborated with BPJS Kesehatan (Healthcare and Social Security Agency) is 16 hospitals and 37.5% are class C hospitals (BPJS Kesehatan, 2019). General Hospital X is a class C hospital located in Malang Regency, led by a hospital leader with a relatively young age and has collaborated with BPJS Kesehatan since 2014 and has been accredited by KARS plenary since March 2019. According to the leader of General Hospital X, 90% of patients are BPJS Kesehatan card holders. X General Hospital has 290 employees with details of 10 doctors, 23 specialist doctors, 2 dentists, 65 nurses, 27 midwives, 45 other medical personnel, and 118 non-medical personnel. Based on the results of the preliminary study, employees described the leaders of General Hospital X as assertive, visionary, and realistic. When employees make mistakes, the leader never judges but guides and directs the truth. Thus, the research aims to explore the appropriate leadership style in X General Hospital so that it can get full accreditation and the existence of the hospital is still maintained today.

Method
The study used a qualitative study design with a case study approach. The research was conducted at one of the Class C Public Hospitals in Malang Regency which has collaborated with BPJS Kesehatan. This study takes the perspective of employee informants at General Hospital X. Therefore, an integrated and comprehensive experience is obtained and can gain an in-depth understanding of the existing leadership style at X General Hospital. Intensive research was carried out in February 2020 until March 2020. In this study, data source collection consisted of the results of informant interviews, observation, and data supporting documentation. Selection of prospective research informants has inclusion criteria as a determining indicator for informants who can become research respondents. The inclusion criteria for research informants were employees who worked at General Hospital X and experienced hospital leadership during the medical record data from 2016 to June 2019, the Bed Occupancy Rate (BOR) figure was 63%, the Average Length of Stay (ALOS) reached three days, and the total patient visits reached 6,069 patients with 79 beds.
The total number of participants was six people. Participants are employees who worked at General Hospital X and experienced hospital leadership during the National Health Insurance (JKN) era. The first informant was a 34 year old of midwife who worked at X General Hospital since before the hospital was launched, namely at the end of 2009 so that the participant's working period had reached more than 10 years. Currently, the participant is the Head of the PICU (Pediatric Intensive Care Unit). The second informant was a 24 year old of non-medical worker who served in the linen division and became the head of the linen division. The period of work of the participants reaches 5 years starting from graduating from school at the age of 18 when they join X General Hospital. The third informant was a 30 year old of male nurse who served in the ICU (Intensive Unit Care) and became the head of the ICU room. The period of work of the participants reached 9 years starting from 2011. When they first joined in 2011-2014, the participants experienced multiple jobs serving in the IGD (Emergency Room) unit, room, and poly. The fourth informant was a 29 year old of female nurse who served in the PPI (Infection Prevention and Control) unit as the head of the PPI unit. The work period of the participants is up to 7 years starting from 2013. The fifth informant was a 28 year old of female dentist. Currently the participant is assigned to be the deputy staffing director of General Hospital X with a working period of 2 years starting from March 2018. Before becoming deputy director of staffing, the participant was a functional doctor at a clinic adjacent to the hospital location. The sixth informant was a 37 year old of female non-medical worker who served as an officer in the linen division. The work period of the participants reaches 5 years starting from 2014. The seventh informant was the director of General Hospital X Malang Regency. The 34-year-old informant lives in Malang City served as hospital director since 2011 until now. Previously, the informant was a functional doctor at X General Hospital.
The transformational leadership style reflects the leader's personality in bringing changes to the hospital for the better in the JKN era. In general, the transformational leadership style refers more to providing motivation, attention to individuals, directing, and prioritizing the fulfillment of human rights in maximizing employee performance. A leader in applying this transformational style can also have an impact on raising the spirit of performance for employees in achieving goals. There are three sub-themes that reflect the leader's personality. The relationship between theme and sub-theme can be seen in Figure 1.
Transformational leadership style tends to emerge when the organization is developing and changes are needed (Gunawan et al., 2020). This is also a process to create conditions that are in accordance with the goals that have been set. Mei L, (2014) explains that the existence of a transformational leadership style can lead to innovation in an organization. The personality of the leader is a reflection of the leader in bringing about change for General Hospital X in the JKN (National Health Insurance) era which is known based on four dimensions in transformational leadership including 1) intellectual stimulation, 2) idealization, 3) inspirational motivation, and 4) consideration individual.

1.Implementation of Empowerment-Based
Internal Marketing Strategy During JKN, the leader implemented an internal marketing strategy by inviting all hospital employees to promote through social media. In addition, internal marketing is an advantage of the hospital. "Kelebihannya, rumah sakit ada di marketing e dok. " (3.1) "(The advantage is that the hospital is in marketing, doc)" (3.1) "Kalau ada gitu, ayo di share ke grup masingmasing. Dan nanti bikin status podo kabeh. " (3.1) "(If so, let's share it with each group. And later make a status for same all)" (3.1) Internal marketing strategy is carried out in the form of notification of service times and doctor's practice schedule every day. Internal marketing in the hospital is highly giving contribute to creating a positive sense of satisfaction for customers seeking treatment services, so that play a role in increasing the effectiveness of the marketing strategy followed and to achieve its marketing objectives. It can be said that the success of marketing health service efforts at the hospital's internal level and organizations operating in the health sector depend on creating an appropriate marketing climate within it organization by its employees, the more consistent between workers and management in the hospital, the higher the degree of the hospital in providing services and maintaining the relationship between the patient and the employees (Nsour, 2013).

2.Development of a Commitment to Performance and Quality of Work
In the era of National Health Insurance (JKN) it also affected the health service system provided to the community. Health services provided to patients can be a community assessment of the hospital. Therefore, it is necessary to increase the quality of employee performance.
"Iya di kumpulkan, kan itu disini pakek apa itu namanya tim dok ya. Jadi kayak berkas ruang ini yang maju akreditasi, di cepaki orangnya terus dilatih. Nah nanti yang ini nulari ke teman-temannya, seperti itu..... " (3.1) "(Yes, they are collected, right here, sir, is that a team, doc? So it is like this space file which progresses for accreditation, in accelerating the people continue to be trained. So, later this one will transmit to his friends, like that ...)" (3.1) The role of a leader in the aspect of developing commitment can also be done by creating a conducive work environment so that it will provide a sense of security to employees. If comfort is created, employee work activities can be effective (L.K., O. F, 2018). This will have an impact on high productivity and increased performance and quality of employee work.

Organizational Direction
One of the success factors in teamwork is the clarity of the direction the organization or team is headed for. The leader plays a role in setting the direction of the organization through increasing positive self-concept of organizational members. Thus the members of the organization will be able to overcome problems with their respective potentials without any pressure and can build a high commitment to the achievement of organizational goals.
"Ya tetap diarahkan, tapi tetep tugasnya bawahannya (targetmu ini, ini, ini.. harus bisa,....evaluasi.) Kayak ada apa namanya, keliling gitu. Kan bu Dir sendiri biasanya keliling, mengawali assessor. Jadi bu Dir keliling dulu, yakpa sih hasilnya tementemen. " (3.1) "(Yes, it is still directed, but still the job of the subordinates (this is your target, this, this ... must be able, .... evaluation.) Like what is it called, around like that. Mrs. Dir herself usually goes around, starting the assessor. So Mrs. Dir went around first, what the result was my friends)" (3.1) A leader plays a role in using his authority and leadership to direct the organization so as to achieve a goal. Leaders are an important element in managing human resources to work effectively and with direction.

4.Formulation and Implementation of SOP
The leader plays a role in setting the direction that an organization is headed by formulating and implementing an operational plan. At General Hospital X there is also an SOP that employees must comply with. If the employee does not comply with the applicable rules, he will be subject to strict sanctions.
"Kalau nggak mau nurut aturan dari rumah sakit ya silahkan. (silahkan keluar dari RS)" (2.1) "(If you don't want to follow the rules of the hospital, please. (please leave the hospital))" "Juga ada SKnya juga, kayak kita ini kan harusnya sesuai dengan SPO...Tapi dari kita sendiri yang terkadang ya melenceng dari SPO. " (2.1) "(There is also a decree too, like we should be in accordance with the SPO ... But from ourselves, sometimes we deviate from the SPO)" Consistency of leaders in implementing applicable rules and consistency of employees in carrying out work procedures is a requirement to create a strong culture. Consistent employees will always be strongly guided by the values that apply at work and carry out their duties to provide good service to patients (Fitri et.al., 2019). The formulation and implementation of the SOP by the leader has a positive and significant impact on employee performance. Employees will have trust, admiration, loyalty, and respect for the leader. In addition, employees will also be motivated to carry out SOP better than before.

Organizational culture 1.Rational on Employee Performance Appraisal
One of the things that is important in realizing quality health services in hospitals is how the quality of Human Resources (HR). Assessment of employees is also carried out by the leaders of General Hospital X. With regular employee assessments, it can become the controlling leader to find out how employees are performing. "Ehmmm.. pas apa ya. Pas saya masih baru disini sih dokter, ada karyawan baru dikeluarkan dari rumah sakit ini. Awalnya saya bilang ada masalah gini-gini akhirnya sungkan to. Terus akhirnya dari direktur itu bilang, "saya nggak mau kalau pas waktu nanti penilaian kinerja karyawan, setiap bulannya, menilai anak-anaknya itu dengan batas nilai yang tinggi, tapi pas waktu di lapangan dia batasnya nggak segitu. Yang saya mau itu pas benar apa yang dikerjakan. Meskipun jelek nggak masalah, nanti biar di.. apa itu dikasih kesempatan selama tiga kali, ya kalau ngga bisa ya terpaksa harus dikeluarkan". Soalnya kan disini nggak mau kalau kita mengecewakan pasien. Yang utama itu, Dokter. " (2.2) "(Uhmmm .. what fit. When I was just here, a doctor, a new employee was released from this hospital. At first I said there was a problem like this and finally I was reluctant to. Then finally the director said, "I don't want it when the employee performance appraisal, every month, assesses their employees with high value limits, but when they are in the field they don't have that limit. What I want is exactly what I do. Even though it's ugly it doesn't matter, let me give it three times, if I can't, I have to be expelled". The problem is that here we don't want to disappoint the patient. The main thing, Doctor)" The rationality of the leader in addressing the results of employee performance appraisals is in accordance with the dimensions of intellectual stimulation in a transformational style. The results of the performance appraisal can help the hospital to see achievements and as an evaluation material for future planning. Purpose of performance appraisal is to improve the service quality of healthcare. With the help of an effective performance appraisal program, employee's performance can be monitored, and employee will be kept motivated (Jha et al., 2016).

2.Giving Trust in Employees
The leader of General X Hospital also gives confidence in his employees in carrying out activities at the hospital.
"Ya beliau berusaha ngasih kepercayaan kepada kita sih, dok. " (5.1) "(Yes, she's trying to give us confidence, doc)" "Ya tetap diarahkan dan diberi kepercayaan, tapi tetep tugasnya bawahan" (3.1) "(Yes, it is still directed and given the trust, but the duties are still subordinate)" In addition, the leadership of General X Hospital also has the principle that the success of the hospital is not far from the struggle of its employees.
"Keberhasilan rumah sakit merupakan keberhasilan dari karyawan semuanya. Rumah Sakit tidak akan bisa maju apabila tidak memiliki karyawan dan tim manajemen yang semangat. Tentunya hal tersebut juga di dukung oleh semua bagian dari rumah sakit termasuk dari owner rumah sakit juga. " (7.1) "(The success of the hospital is the success of all employees. Hospitals will not be able to progress if they do not have enthusiastic employees and management teams. Of course this is also supported by all parts of the hospital including the hospital owner as well)" In transformational leadership, one of the characteristics of leaders is to foster trust in employees in carrying out activities that make them independent and foster creativity in achieving goals (Jahidi, 2020). The existence of trust given by the leader makes employees motivated to do something more than previously expected. Giving three opportunities to employees of General Hospital X shows the leadership's trust in employees to correct any mistakes they make. The leader believes that the success and success of the hospital is the result of the hard work and struggle of all its employees.

3.It's Not Easy to Blame Employees
The leader of General Hospital X in carrying out his leadership duties includes people who do not immediately blame their employees if someone is found to have made a mistake. "Enggak.. kuat.. iyaa tegar.. orangnya itu tegar dokter.. meskipun dia banyak masalah tapi beliaunya itu masih.. masih.. mau menuntun.. gitu lho dokter.. dan ee.. dan nggak pernah menyalahkan.. mesti dia gini "memang itu salah dari saya" (3.1) "(No .. strong .. yes tough .. the person is tough doctor .. even though he has a lot of problems but the young man is still .. still .. want to guide .. you know doctor .. and ee .. and never blame .. it must be "it was my fault)" Leadership has an influence on organizational culture which explains that in organizational culture every individual is encouraged to carry out collaborative learning, eliminate the culture of blame, prioritize patient safety, and reward individuals who have identified mistakes (Diana et al., 2017)

4.Generating and Fostering Teamwork Spirit
The leader of General X Hospital will direct and guide employees coherently and with direction so that they can generate team spirit and can be an improvement in employee performance.
"Kemarin itu ya kayak misalnya buat proker itu, misalnya kan maju, ada asesor dan sebagainya, dia ngasih contohnya tugasnya ya, dia ngajari dulu itu 'aku te opo nek ngarani...kate mbimbing apa...mmm... ' caranya aku menempatkan bukan sebagai asesor internal tapi aku surveyor gitu ya, aku akan tanya seperti ini...nah gitu.. Itu nanti bawahanya kan akan tau pertanyaannya itu kayak gimana... Nyontohin sampai 1 pokja penuh, sampe 1 pokja selesai nanti asesor2 internal kan jadi tau caranya. " (1.1) "(Yesterday it was like for example for the project program, for example, going forward, there were assessors and so on, she gave examples of her duties, she taught me first 'aku te opo nek ngarani...kate mbimbing apa...mmm... ' how do I assigning not as an internal assessor but I am a surveyor like that, I will ask like this ... well so .. That later the subordinate will know the question like how ... Exemplify it until 1 working group is complete, until 1 working group is finished later will be internal assessors right? so know how.)" "Nggak. Tapi lebih membimbing. " (5.1) "(Not. But more guiding.)" In transformational leadership, the leader will provide energy in everything. With this it can be an experience that can lift the spirits of employees (Abbasi et al., 2014). In the work environment, leaders also direct employees to be active and have the courage to speak out in front of the forum. The ability to communicate in issuing ideas, opinions and even receiving opinions and suggestions from others can be a success factor in carrying out a good task in working with team work or work groups. With the motivation and guidance by leaders in increasing the knowledge and enthusiasm of employees, it will also improve the quality of service (Mahmood, S & Khattak, M.A, 2017). This is evidenced by EK, K and Mukuru, E (2013) that there is a positive and significant influence between work motivation on employee performance, where work motivation is also an important predictor in improving employee performance.

1.Smart
The leader's personality in bringing change to the hospital is due to his intelligence and ideas.
"Jenius, selalu punya banyak cara dan selalu punya ide hehehe. " (1.1) "(Genius, always has many ways and always has ideas hehehe.)" Change occurs followed by the leader's action to develop the ideas he has. Organizations that are skilled by generating new ideas will get an edge in the competition and not be left behind by the rapid development of the marked. This also reflects the transformational leadership style, namely the leader must have the ability to improve the performance of his employees through his creative ideas so as to produce the value of harmony between leaders and employees (Givens, 2008). Thus, the idea developed by the leader made X General Hospital maintain its existence in the JKN era.

2.Decisive
Leaders are not only known as smart figures, but also as resolute.
"Direktur itu.. tegas.. tegas, dok orangnya, dok.. tegas.. kadang juga ganas heheee.. tegas, ganas, tapi penyayang, dok beliau itu. " (5.1) "The director is .. firm .. really firm, doc is the person, doc .. firm .. but sometimes also ferocious heheee .., ferocious, but compassionate, doc. " According to the fifth participant, the leader is known as someone who is sometimes ferocious. According to the Big Indonesian Dictionary (KBBI), malignant means fierce or angry. Skills as one of the supporting elements in showing effective leadership traits based on a trait approach (Yukl, 2013). With a firm leader, it can be one of the strengths in conveying the importance of the efforts made by employees and the contribution of employees in successfully achieving organizational goals (Iqbal et al., 2020). The assertiveness of the leader is shown through the provision of sanctions for employees who make mistakes, such as the results of employee performance appraisals that do not meet the standards will be deducted or postponed salary.

3.Hard worker
The leader is known as a hard worker who is known based on the persistence of the leader in fighting for hospital accreditation.
"Ya maksudnya kalau dari direktur sendiri ngga gelem ngoyo ngga mungkin sampai bawah-bawahnya seperti itu kan ya.. " (3.1) "(Yes, that means if the director himself doesn't 'ngoyo' , (complaining) it's impossible to get to the employer like that, right?)" The meaning of the word "ngoyo" is the nature of forcing oneself to do something without considering abilities, conditions, and time. The success achieved by the hospital cannot be separated from the hard work of the leaders and employees. Thus, the hard work produced by the leader makes employees follow the leader's spirit in realizing achievement. The dimension of idealization lies in the hard work of the leader in influencing the performance of employees at General Hospital X.

4.Mature and Strong-Willed
The personality of a leader who likes challenges has an effect on employee performance so that they always learn. "Iyaa.. oh nemen, dok kalau itu.. banyak yang diberikan tantangan-tantangan sama Direktur itu.. maksudnya beliau itu orangnya.. belajaro belajaro.. gitu lho.. " (5.1) "(Yes .. oh of course, doc if so .. many were given challenges to the director .. he meant he was the person .. who suggest to study more and more .. you know ..)" Giving challenges are not only done to one or two employees, but to many employees with the intention that employees continue to learn in providing services to patients at General Hospital X. This is in accordance with the research Usman et al. (2020), which explains that improving employee performance is the most difficult challenge to do in management because the success of achieving goals and survival depends on the quality of employees. In addition, the existence of challenges can bring progress for the organization in maintaining competition. Thus, the research conducted is linear with the use of the dimensions of inspirational motivation in achieving goals.

Have High Work Motivation
Changes in the hospital are accompanied by positive ambitions owned by the leader.
"Ambisi yang positif, ya untuk kesejahteraan rumah sakit... " (3.1) "(Positive ambition, yes for hospital welfare ...)" Work motivation is a process that directs and sustains the performance. Motivation encourages employees internally towards the actions which help them to achieve the goals or specific task which is assigned to him. Effectiveness of employees work can inspire them to their work and can bring more work motivation and more commitment of their jobs (Sohail et al., 2014).

Devote to God Almighty
Leaders are not only concerned with worldly hospital affairs. The leader is known as a religious figure by holding recitation every Friday and providing religious reading books. "Heem. Disini setiap hari jumat ada pengajian, kalau pengajian besar itu biasanya satu bulan dua kali sampai tiga kali di ruang pertemuan khusus untuk karyawan. " (2.2) "(Yes. Here every Friday there is a recitation (Islamic speech), if the big recitation is usually one month or two times to three times in a special meeting room for employees.)" "Disini itu kayak itu dokter, disediakan buku-buku keagamaan, untuk orang kristen juga ada. Kalau misal keluarga pasien atau pasien mau pinjem gitu. " (2.2) "(Here it is like that a doctor, religious books are provided, there are also for Christians. For example, the patient's family or patient wants to borrow it.)" The application of spiritual needs in the hospital can optimize the productivity of employee performance (Grant and McGhee, 2012;Sureskiarti et al., 2017). In addition, spiritual needs will have a positive influence on the patient's health and psychology. With spiritual support can improve the patient's condition and also make the patient comfortable with critical illness (Laili et al., 2019). The religious personality of the leader also has an impact on visitors who can enjoy the religious book facilities provided by Hospital X.
The democratic leadership style describes the leadership system applied in the JKN era and the method of problem solving at Hospital X.. In democratic leadership there is coordination of internal responsibilities and good cooperation. The roles and contributions of staff are important. The leader will gather opinions, suggestions and feedback from staff before making decision or issuing instructions to the team. Thus, the direction of the team is influenced by the staff 's involvement (Izidor & Iheriohanma, 2015). There are six sub-themes that describe the leadership system and problem solving. The relationship between themes and sub-themes can be seen in Figure 2.

Figure 2 Democratic Leadership Style
Source: Primary Data (2020) A democratic leadership style will be effective if the leader strives for a better direction and the leader has the spirit and democratic leadership style focuses more on people and there is greater interaction within the group (Dike, Ego & Madubueze, 2019). The democratic leadership style supports the existence of General Hospital X in the JKN era.

1.Tiered Leadership System
X General Hospital applies a tiered leadership system. "Ya berjenjang dokter, ya Karu-nya yang berperan. Baru nanti kalau Karunya nggak ngatasi, kasubag, terus Wadir, terus Direktur gitu, berjenjang jadinya. " (3.1) "(Yes, a doctor, must be who plays a role. Only later if Karunya doesn't solve it, the head of the subdivision, then Deputy Director, then the Director is like that, there are stages.)" "Tapi misalnya kalau kayak ada masalah, kalau direktur penyelesaiannya dari Wadir, Kasub, baru beda. " (6.1) "(But for example, if there is a problem, if the director of the solution is from the Deputy Head of Sub, then it is different.)" The tiered leadership system shows the transfer of authority between leaders and subordinates. The delegation of authority shows the leader implementing the delegation function. The function of delegation is carried out to show the leader's trust in his subordinate members so that the delegation of authority is carried out responsibly. In this case, the leader democratically delegates authority to others to encourage decision making in the organization .

2.Resolving Problems Quickly
The tiered leadership system makes it easy for the hospital to solve problems that are done quickly.
"Terus, kalau ada masalah yawes pokoke pengen diselesaikan cepet-cepet gitu. " (4.1) "(Then, if there is a problem , must be resolved it quickly.)" The leader's speed in solving problems is the leader's initiative or initiative in applying a democratic leadership style (Mtikulu, D.S et al., 2014). In addition, the leader acts as a disturbance-handler role (Yukl, 2013) who is responsible for all problems that arise in the organization.

3.Rational and Objective
Fast problem solving remains chronological problems through root cause analysis (RCA).
"Dan beliau itu tidak langsung nge-judge itu salah nggak, nggak pernah. Jadi, beliau itu selalu men RCA dulu gitu lho. " (5.1) "(And she doesn't judge right away, it's wrong or not, never. So, she always served RCA first, you know)" Every problem that has been sought is immediately discussed and given a solution by the leader of the X General Hospital through a forum. The data source for problem reporting can be said to be accurate (reliable) if it fits the flow and chronology of the problem so that the problem solving at General Hospital X is not only done quickly but also based on the chronology of the problem. This aims to supervise the attitudes, behavior and actions of subordinates.

4.Decision Making Involves Member Participation
If there is a problem at X General Hospital the leader does joint problem solving and the leader thinks of a solution to the problem. "Semuanya. Beliau juga bantu nyarikan (mencarikan data yang diperlukan). Jadi dipikir bersama gitu lhoo. " (1.1) "(All. She also helped find (find the necessary data). So think about it together, you know.)" Democratic leadership style involves subordinates in the decision-making process (Sanusi et al., 2020) . Democratic leaders are as people who share decision-making with other members. He asserts that democratic leadership is associated with higher morale in most situations (Choi, S, 2007). Collective problem solving can be done on ill-defined problems using a heuristic strategy.

5.Solving Problems Responsibly
Every problem that exists in X General Hospital is also resolved responsibly. Leaders teach hospital employees to be responsible for mistakes that have been done.
"Berarti sekarang dokter M juga harus membenarkan ini, harus bertanggung jawab. Jadi gitu sih. Kalau sudah gitu, nanti gitu udah biasa lagi nggak akan seperti.. " (5.1) "(Means that now doctor M also has to confirm this, must be responsible. So that's how it is. If it's like that, then it's normal again and it won't be like that anymore ...)" Leaders teach employees to be responsible for problems committed by employees. X General Hospital uses an approach in teaching responsibility to employees through a situation and condition approach based on delegating behavior.

6.Resolve Problems Consistently
The leadership system at X General Hospital when submitting unit needs is not only carried out in stages but is also carried out consistently until the submission process is accepted by the hospital director. According to the Big Indonesian Dictionary (KBBI), consistency has a fixed and appropriate meaning. The actions taken by the leaders of Hospital X reflect the order in which the goods are filed in the sense that the submission of goods also uses a tiered system. Resolving problems that are carried out consistently reflects the existence of firm orders in the application of a democratic leadership style. In addition, the consistency of leaders and employees shows the application of organizational culture at General Hospital X. Leader's consistency is shown through the application of applicable rules that make employees apply rules slowly without being seen by the leader, while employee consistency is shown through employee behavior in implementing guidelines or rules applies (Fitri et al., 2019a).
The moralist leadership style reflects the leader's personality in interacting with employees as well as the reward and punishment system at General Hospital X. There are five sub-themes that reflect the moralist leadership style. The relationship between the research theme and sub-theme can be seen in Figure 3. The strengths of the moralist leadership style lie in the warmth of the leader, a high empathy for every employee's problem, kind and honest. The weakness of people with moralist leadership styles lies in their emotions.

1.Flexible according to situations and conditions
Leaders are known as figures who can position themselves and by knowing when to become hospital directors and when to be friends to other employees. "Bisa, kadang itu kan koyok konco, pas apa... gimana ya, ya tergantung situasi se, mau mengkondisikan dirinya aku saiki direktur ya direktur, kalau sekarang jadi temen ya temen, yawes kayak gitu. " (1.1) "(You can, sometimes it's just friends, what fit ... how do you do that, depending on the situation, I want to condition him, if now I'm a director as director, if now I'm as a friend, acting as friend, yeah like that (proportional))" The term "koyok konco" is a term used by the first participant to describe a leader in positioning himself as a friend to other employees at General Hospital X. The strength of a moralist leader is an attitude of empathy towards other employees (Mattayang, 2019). Empathy makes leaders more flexible or able to adapt to situations and conditions at X General Hospital.

Friendly With Hospital Employees
A flexible leader's personality makes the leader known as a friendly person by his employees. The friendliness of the leader is shown through the style of greeting that is done. "Baik, ya enak se, enak. Kalau ketemu nyapa duluan. " (6.1) "(Good, yes delicious. If we meet greeting first.)" The warmth of a leader is one of the strengths of a moralist leader that makes it easy for the leader to be friendly to others (Mattayang, 2019). The warmth generated makes employees feel "uncomfortable" to interact with the leader.

3.Remember the Hospital Employee's Name
The leader has the advantage of a high memory supported by a style of greeting that makes the leader remember all the names of the employees at X General Hospital. "Hafal. Mayoritas tau. Kecuali yang sebulan dua bulan masih masuk lho ya. " (1.1) "(Memorize. The majority know. Except for those that are still in for a month or two, you know.)" Age has an influence on a person's memory or memory. The leader of General Hospital X has a relatively young age, in other words it is still classified as a productive age. The style of greeting the leader makes it easy for the leader to remember all the employees at X General Hospital, except for employees with a service period of 1-2 months.

4.Emotional
Three participants explained that emotional leaders manage hospital management. Emotional leaders are shown expressively through facial expressions including when mood swings (moody). An expressive leader's attitude can affect the performance of employees at X General Hospital so that employees must look at the situation and conditions first. Emotional intelligence can be a major contributor to leadership effectiveness (George, 2000). This is in accordance with the explanation that emotional instability expressed expressively is a challenge for a leader throughout his life.

5.Reward
The moralist leadership style is applied by the leader to present a reward system for employees of General Hospital X. The leader always provides rewards to employees with the aim of improving performance. "Reward?? Ada. Selalu ada reward, Dok. " (5.1) "(Reward ?? There is. There's always a reward, Doc.)" The rewards given vary, including gold, refreshing, chocolate, award certificates, and books.

Punishment
The application of the moralist leadership style is not only in the form of reward, but also the provision of sanctions to employees as material for evaluating and improving employee performance at General Hospital X. "Ada. Tapi potong gaji. Tapi potong gaji itu tidak dipotong untuk tidak diberikan lagi. Jadi di saving dok, sampai anak itu bertanggung jawab. " (5.1) "(There is. But cut wages. But the pay cut is not deducted from being given again. So in saving doc, until the person is responsible). " "Ooo ituu aaa.... kalo kayak nametag nya ilang itu nanti ada sendiri anunya 100 ribu dendanya trus kalo opo itu...kan sekarang masih berjalan itu. " (2.1) "(Ooo thats aaa .... if it's like the nametag is lost, there will be 100 thousand fine for it, then if it's ... it's still running right now.)" "Ada peringatan, nanti ada ranking rangkingnya juga. Perencanaan ke depan itu setiap karyawan ada raportnya. " (3.1) "(There is a warning, there will also be a ranking ranking. For the future planning, every employee has a report card.)" The provision of rewards is also offset by the imposition of sanctions for employees who are not successful. This is intended to provide encouragement to employees in improving their performance. In giving punishment is also expected as an effort to increase discipline and awareness of employees about the rules of the organization (Maryjoan et al., 2017). According to (Bergen, 2012) examples of effective punishment given to employees can be done by reprimanding employees who are less than optimal in doing their work, recommending salary cuts to employees who do not meet targets, and giving some special tasks given by the leader as punishment for violating actions. rules in the organization.

High Empathy for Employee Problems
The good relationship that exists between leaders and employees will affect communication, making it easier to coordinate. The leaders of General X Hospital have a high sense of empathy for the problems that are owned by employees. "Pernah.. sampek gagal.. kayak gitu.. itu juga sampe dr. X tau.. dr. X itu tau semuanya, dok.. karena kita nggak bisa menutupi, gitu lho.. beliau itu bisa membaca, ini masalahnya sedang di rumah, ini masalahnya sedang ada di rumah sakit.. " (6.1) "(Once .. until it failed .. like that .. that was also until dr. X knows .. dr. X knows everything, doc .. because we can't cover it, you know .. she can read, this is the problem being at home, this is the problem being in the hospital ..)" (6.1) The presence of empathy in leaders can increase our understanding of placing leader support for follower psychology and security needs at the forefront. Such understanding helps we better acknowledge the emotional needs of employees. and increase follower innovation every day, activities with increasing relevance in the workplace (Ned Kock et al., 2019).
CONCLUSION The study explains three major themes that explain the leadership style applied in the Class C X General Hospital during the JKN era. Three major themes include transformational leadership styles, democratic leadership styles, and moralist leadership styles. The trans-formational leadership style reflects the personality of the leader in bringing change to General Hospital X in the JKN era. The democratic leadership style reflects the leadership and problem-solving systems applied at General Hospital X. The moralist leadership style reflects the leader's personality in interacting with employees at General Hospital X. General Hospital X class C during the JKN era. Transformational Leadership style is the main core (core) in bringing change to General Hospital X in the JKN era, while the democratic leadership style and moralist leadership style is a support for General Hospital X.
First, the leader of General Hospital X has succeeded in cultivating a culture of courage in public opinion among all of its employees, this can be supported by providing public speaking training to employees. Second, in an effort to maintain team morale, the leadership of RS X can make various efforts, including giving employees the right position according to their competence, providing opportunities for outstanding employees to develop themselves, cultivating feelings of security to employees in facing the future, providing incentives the right one with clear rules and provide work facilities that can support employee performance at work so as to arouse employee morale.