MEASURING THE IMPACT OF HEALTHCARE SERVICE QUALITY OF HOSPITALS ON CUSTOMER SATISFACTION

How to cite this paper: Wulandari, R., Doddy, I. P., & Indaryani, L. (2024). Measuring the impact of healthcare service quality of hospitals on customer satisfaction [Special


INTRODUCTION
Over the last three decades, attention to service quality has significantly increased.The demand for improvement and better quality of healthcare services puts pressure on service providers.It poses a challenge for researchers to measure the level of customer satisfaction in various service providers, including hospitals.Government policymakers and patient needs, or service users aim to build satisfaction and loyalty.However, acquiring new patients requires higher expenses than retaining existing ones (Azari et al., 2023).Customer satisfaction is a crucial factor in the success of services, which can only be achieved by providing quality services and thus increasing customer loyalty.These improvement steps require effective strategies, cost allocation, and cost management (Agarwal & Dhingra, 2023).Health services are professional services whose output is intangible, perishable, inseparable, and heterogeneous (Kumar et al., 2023).
Therefore, evaluating service quality for patients is more challenging than evaluating tangible products (Agarwal & Dhingra, 2023).Patients assess the quality of health services based on their perceptions of service outcomes and treatment methods.Hence, hospitals need to understand, measure, and pay attention to patient needs in providing their services (Barik et al., 2023;Varriale et al., 2023).Service quality is increasingly recognized as critical in differentiating services and building a competitive advantage in professional service organizations.In the context of hospital services, customer satisfaction is influenced by hospital brand factors, service quality, and the effectiveness of treatment, as evidenced by customer satisfaction.Hospitals, as healthcare institutions, face unique challenges worldwide (Asha et al., 2023).
More and more hospitals are operating in a highly competitive environment due to open-door policies in the medical services market (Moshood et al., 2022).The growth of the elderly population and increasing focus on health dynamically increase the demand for special needs in the general population related to health.The medical services market is more inclined to favour buyers than sellers (Lombardozzi, 2023).Hospitals strive to develop marketing strategies that promote brand image among patients to increase patient satisfaction and loyalty and improve their performance.Social interaction between service providers and customers is the core of the service business, which differs from products.Such interactions can significantly influence customer evaluations and their focus (Weng et al., 2023).One important aspect is that service providers and users cannot be separated.Often, customers consider elements such as service personnel, physical facilities, and other tangible features an integral part of the service (Pauly et al., 2022).This study aims to analyze the effect of service quality and social trust in hospitals on increasing patient satisfaction (Vimarlund et al., 2021).Previous studies by several researchers showed that trust, satisfaction, and word of mouth impacted community visits to hospitals (Schneider et al., 2021).Other research shows that service quality and cost considerations influence hospital selection, and patient satisfaction is a connecting factor (Lin et al., 2023).Therefore, this research aims to understand the relationship between the quality of hospital services and social trust to increase patient satisfaction in the hospital.The hypotheses are proposed as temporary solutions until they are supported by accumulated evidence (Khoa, 2022).Based on previous research, the decision to choose a hospital is influenced by service quality, price factors, and patient satisfaction (Dhakate & Joshi, 2023;Windasari et al., 2024).Trust plays a significant role in developing an intention to return to using services related to pre-consumption and post-consumption evaluations of service characteristics such as convenience, security, assurance, and responsiveness (Doddy & Wulandari, 2022).According to researchers, the level of trust before and after service consumption influences the intention to reuse the service.The study results show that belief affects the choice to return (Indaryani & Wulandari, 2022).
In the current situation, Rumah Sakit Umum (RSU) Bunda Purwokerto has a total of 6,540 patients from 2017 to 2018.In 2018, management has set an annual increase target of 4,000 patients, which will be achieved in the following year.Assuming that nine doctors provide services, if it is assumed that the average outpatient patient is 150 patients per day, then in one year, with 300 days of service, they must be able to serve as many as 40,500 patients.This assumption aims to increase the number of patients achieved in the next two years, namely 2019 and 2020.However, in reality, there was a decrease in the number of patients in 2020, which continued into the following year.This research is very useful in increasing understanding of marketing management, especially in terms of outcome quality, the effectiveness of treatment, hospital location, and service quality, which influence patient choice and loyalty through patient satisfaction mediation.The results of this study are expected to provide information for the owner and management of RSU Bunda Purwokerto in determining policies related to the Mediation of patient satisfaction on patient loyalty at RSU Bunda Purwokerto and the variables that influence it.This study aims to identify: 1) the positive effect of treatment effectiveness on outpatient satisfaction at RSU Bunda Purwokerto; 2) the positive effect of service quality on outpatient satisfaction at RSU Bunda Purwokerto; 3) the positive effect of hospital location; and 4) the effect positive consumer satisfaction on outpatient loyalty at Bunda Hospital Purwokerto (Wulandari & Koe, 2022).
The rest of the paper is structured as follows.Section 2 provides a review of the literature.Section 3 presents the research methodology.Section 4 illustrates the research results and discussion.Section 5 presents conclusions.

Outcome quality
The service of a service refers to the results of actions and what is felt by service users, in this case hospital patients.Patients or customers can express their opinions about service quality, service outcome is what customers receive from these services.According to Blanchard et al. (2023), outcome quality is the quality of service perceived by customers.Defines outcome quality as consumer perceptions of excellence in service (Chung et al., 2023).The quality of service received by customers is to create a customer assessment of the product or service they have received whether it meets customer expectations or not the core aspects of service quality are directly related to customer satisfaction.Outcome quality affects the creation of customer satisfaction because the quality of the results will show whether customer expectations can be met.If customers or patients are satisfied with a service, it will have an impact on the decision to use services or buy products on an ongoing basis.This indirectly shows that outcome quality will also affect customer loyalty through satisfaction (Graco et al., 2023).

Service quality
Product and service quality is defined as a tool used to fulfil the desires and expectations of customers resulting from the production of goods or services, marketing carried out by the company and maintenance of these products or services (Guo et al., 2023).Service quality is how far the difference is between expectations and the reality of the customers for the services they receive.Service quality can be known by comparing customer perceptions of the services they actually receive with the actual services they expect.Service quality is a measure of service success, determined by the level of satisfaction of service recipients.Meanwhile, the level of satisfaction of the recipient of this service will be obtained if a recipient of the service gets the type of service in accordance with what they expect and need (Rahman et al., 2023).
To determine the level of service quality, there are two influencing factors, namely expected service and perceived service.In this case, if the expected service is appropriate, the quality of service provided is considered satisfactory (Wong & Chan, 2023).If the perceived service is in accordance with the expected service, the service quality will be considered good or positive.If perceived service exceeds expected service, then service quality is perceived as ideal quality.Conversely, if the perceived service is worse than the expected service, then the service quality is perceived as negative or poor.The quality or quality of health services requires health services that are in accordance with professional standards and service standards that use the potential resources available in hospitals or health centres efficiently and effectively, are provided safely and comply with the rules of norms, ethics, law, social culture by taking into account the limitations and capabilities of government and society (KhanMohammadi et al., 2023; Wu et al., 2023).

Customer satisfaction
Customer satisfaction is the customer's response to the mismatch between the level of prior importance and the actual performance felt after use (Li et al., 2023).Customer satisfaction is influenced by perceptions of service quality, product quality and services provided to consumers, suggesting that customer satisfaction is an overall or global assessment of the extent to which the performance of goods or services matches expectations, or as a post-consumption evaluation strategy that the chosen alternative at least meets or exceeds consumer expectations (Morgeson et al., 2023).Customer satisfaction will occur when customer perceptions are met or exceed customer expectations, mentioning four main factors that need to be considered in relation to customer satisfaction, including: 1) product quality consumers will be satisfied if the results of their evaluation show that the products they use are of high quality; 2) service quality consumers will feel satisfied if they get good service or in accordance with expectations; 3) emotional consumers feel satisfied when people praise them for using expensive brands; 4) price products that have the same quality but set a relatively low price will provide higher value.Customer satisfaction is a person's feeling of pleasure or disappointment that comes from a comparison between his impression of the performance of a product and his expectations.If expectations are high while performance is mediocre, satisfaction will not be achieved and it is likely that consumers will be disappointed.Conversely, if performance exceeds expectations, satisfaction will increase (Camilleri & Filieri, 2023).

Patient loyalty
Loyalty describes the loyalty of customers to continue to use products or services in a particular company continuously and customers voluntarily participate in promoting the company's products or services to others (Fitriani et al., 2020).Loyalty is the ideal situation most expected by product or service owners, where consumers are positive about the product or producer (service provider) and accompanied by consistent reordering.The benchmark for loyalty can be seen from consumers making regular purchases and using services, consumers are not affected by products or services offered by other parties with the same type of benefits.If the customer is satisfied, the customer will tell the product and service to the customer, and vice versa if there is dissatisfaction with the service received, the consumer can tell the unsatisfactory service (Ayodeji et al., 2023).Customer loyalty in the context of service marketing as a closely related response to uphold the commitment that underlies relationship continuity, and is usually reflected in continued purchases from the same service provider (Gomes & Ramos, 2019).

Hypothesis development
The core aspect of service quality is directly related to customer satisfaction.Outcome quality influences the creation of customer satisfaction because the quality of the results will show whether customer expectations are met or not.If customer satisfaction is created, it will have an impact on the decision to use the service or purchase the next product, where if the customer is satisfied, there will be a decision to use the service or product repeatedly.This indirectly shows that outcome quality will also influence customer loyalty through satisfaction and is stated in the first hypothesis.
H1: Loyalty has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
The research conducted used regression analysis to estimate the effect of satisfaction on patient loyalty, as well as maintaining sustainable quality measures based on hospital processes and characteristics where the study results found a statistically significant influence between satisfaction and loyalty (Pandey & Deshwal, 2018).
H2: Outcome quality has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
That outcome quality impact the relationship between patients and hospitals and result in responses that range from satisfactory to taking medical malpractice legal action depending on treatment outcomes.Cooper et al. (2023) prove that treatment effectiveness has a positive effect on patient loyalty to the hospital.Indicators to assess the effectiveness of treatment are effective treatment, reliable treatment and treatment with the right prescription.Therefore, this indirectly shows that outcome quality will have a positive effect on patient loyalty and is stated in the second hypothesis.
H3: Interaction quality has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
That interaction quality has an impact on the relationship between patients and hospitals so that interaction quality is a factor that influences patient loyalty.Kusumawardani et al. ( 2020) with the results that there is a positive relationship between interaction quality and customer satisfaction and customer loyalty.Therefore, this hypothesis indirectly shows that interaction quality will also influence customer loyalty through satisfaction and is stated in the third hypothesis.
H4: The effectiveness of treatment has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
That the results of treatment impact the relationship between the patient and the hospital and result in responses that range from satisfactory to taking medical malpractice legal action depending on the results of the treatment.Alqudah et al. ( 2023) research proves that the effectiveness of treatment has a positive effect on patient loyalty to the hospital.Indicators for assessing the effectiveness of treatment are effective treatment, reliable treatment and appropriate prescribed treatment.Therefore, this indirectly shows that the effectiveness of treatment will have a positive effect on patient loyalty and is stated in the fourth hypothesis.
H5: Service quality has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
That service quality has an impact on the relationship between patients and hospitals, in this case, service quality influences loyalty through the medium of patient satisfaction (Lu et al., 2023).Therefore, this indirectly shows that service quality will also influence customer loyalty through satisfaction and is stated in the fifth hypothesis.
H6: Location has a positive effect on outpatient satisfaction at RSU Bunda Purwokerto.
That location, together with rates, and facilities influence the relationship between patients and hospitals so that it directly influences patient loyalty through patient satisfaction (Nazarian-Jashnabadi et al., 2023).Therefore, we hypothesize that this indirectly shows that location will also influence customer loyalty through satisfaction and is stated in the sixth hypothesis.

RESEARCH METHODS
The method chosen in this paper is the monoquantitative method.This method is in the form of a survey questionnaire, in which there are a number of questions related to the factors that influence the level of customer satisfaction.Data collection in this study was carried out using a questionnaire technique (Damberg, 2023).This data collection will be carried out by providing questionnaires online using Google Forms and questionnaires in person (Huang et al., 2023).The research hypothesis was tested using the partial least square (PLS) approach based on the structural equation model (SEM).PLS is based on components or variants, PLS is an alternative approach that shifts from a covariancebased SEM approach to a variant-based one.
PLS is a component or variant-based SEM.According to Kassem et al. (2023), SEM is a multivariate analysis technique that combines factor analysis and regression analysis (correlation), which aims to examine the relationship between variables in a model, both between indicators and constructs or relationships between construct.The analysis technique in this study used the PLS technique, which was carried out in two stages: 1) the first stage tested the measurement model, namely testing the construct validity and reliability of each indicator; and 2) the second stage is testing the structural model, which aims to find out whether there is an influence between variables/correlation between constructs as measured using the t-test of the PLS itself (Agustina & Arganata, 2023).Covariance-based SEM generally tests causality or theory, while PLS is more of a predictive model (Cheah et al., 2023).The PLS-SEM model used in this paper to get a comparison between service quality and patient satisfaction is shown on the flowchart in Figure 1.

Figure 1. Dataset processing of service quality in hospital
Figure 1 shows the hospital's process flow of customer satisfaction data analysis.The first step is to define the quality of health services, hospital management and customer satisfaction, then form a dataset of service quality, analyzed using the SEM PLS model to produce discussions and report analysis.The population in this study were outpatient patients at RSU Bunda Purwokerto in 2017-2021, totalling 37,318 patients, taken based on the most data in that span of years by calculating the number of samples carried out using the solving technique (Kommadath et al., 2023).The sampling technique in this study was purposive sampling (Khan et al., 2023).In this study, the sample that will be used is consumers of outpatient patients at RSU Bunda Purwokerto in 2017-2021.Based on a population of 37,318 outpatients at Bunda General Hospital in Purwokerto, 380 outpatient samples were taken based on the Krejcie and Morgan (1970) table.
Field research information was collected through questionnaires filled out by respondents: quality, effectiveness, treatment and service quality, hospital location, and patient satisfaction, with patient satisfaction as an intervening variable (Shields et al., 2023).Table 1 below presents an overview of each variable and its operational definitions in the context of customer loyalty and satisfaction.Each variable is accompanied by a brief explanation of its operational definition, followed by the specific indicators that contribute to the measurement of that variable.The scale used for measurement is indicated as well.

Responsiveness with indicators:
-prompt and accurate service; -clear and accurate information.

Empathy with indicators:
-understanding; -specific services tailored to individual needs.

Sampling technique
The population in this study were outpatients at RSU Bunda Purwokerto 2017-2021, totalling 37,318 patients taken based on the most data in that range of years by calculating the sample size which was carried out using the solving technique obtained 99.73 respondents who were round up to 100 respondents.The sampling technique in this study was purposive sampling.Purposive sampling is a sampling technique with certain considerations.Meanwhile, non-probability sampling is a sampling technique that does not provide equal opportunities or opportunities for each element or member of the population to be selected as a sample.In this study, the sample that will be used is consumers of outpatient patients at RSU Bunda Purwokerto in 2017-2021.The sampling technique will be described in Table 2 below.Based on a population of 37,318 outpatients at the Bunda General Hospital in Purwokerto, 380 outpatient samples were taken based on the Krejcie and Morgan (1970) table which displays the amount of sampling data used in the research.

Smart PLS program
Research hypothesis testing was carried out using a SEM approach based on PLS.PLS is a SEM that is component or variant-based.SEM is a field of statistical study that can test a series of relationships that are relatively difficult to measure simultaneously (Nigatu et al., 2023).SEM is a multivariate analysis technique which is a combination of factor analysis and regression analysis (correlation), which aims to test the relationship between variables in a model, whether between indicators and their constructs, or the relationship between constructs.PLS is an alternative approach that shifts from a covariance-based to a variance-based SEM approach.Covariance-based SEM generally tests causality or theory while PLS is more of a predictive model.However, there is a difference between covariance-based SEM and component-based PLS in the use of structural equation models to test a theory or develop a theory for prediction purposes.

Goodness of fit test result
Based on the data processing that has been done using the Smart PLS program, the R-squared value is obtained as follows in Table 3 below: Derived from the results of calculating the PLS Rsquare number in Table 3, the R-squared number for the consumer satisfaction variable is 0.413.Because the R-squared number of the PLS form exceeds 0.33, it reflects customer satisfaction.F-squared effect size (F-squared) is a dimension used to consider the relative effect of an influencing variable (exogenous) on the affected variable (endogenous).The change in the R 2 number when the specific exogenous variable is removed from the form can be used to assess whether the omitted variable has a substantive effect on the endogenous construct (Xia et al., 2022).The research conducted at RSU Bunda Purwokerto examined several key factors influencing outpatient satisfaction.First, the outcome quality was found to positively affect patient satisfaction, as evidenced by t-statistics of 2.163 and a p-value of 0.031, both indicative of statistical significance, thus accepting H1.The study then assessed the treatment effectiveness.While the p-value of 0.008 suggested significance, an unexpected p-value of 0.000 emerged, leading to the rejection of the H2.
Further investigation into the service quality yielded a positive correlation with patient satisfaction, as demonstrated by t-statistics of 2.067 and a p-value of 0.039, accepting the H3.The research also revealed that the interaction quality significantly influenced outpatient contentment.Backed by t-statistics of 4.359 and a confirmatory p-value, the H4 was accepted.
The location of the hospital was another pivotal factor, and the hospital location was shown to play a positive role in patient satisfaction, with t-statistics of 2.202 and a p-value of 0.028 endorsing the acceptance of the H5.Finally, the research concluded that patient satisfaction had a substantial impact on patient loyalty, a conclusion supported by an impressive t-statistics value of 13.051 and a p-value of 0.000, leading to the acceptance of the H6.In essence, the study robustly suggests that factors such as the quality of outcomes, service, interaction, the hospital's location, and overall consumer satisfaction are crucial determinants positively affecting outpatient contentment and loyalty at RSU Bunda Purwokerto.

Discussion
In this study, we explored factors that influence patient satisfaction at RSU Bunda Purwokerto Hospital.We distributed online questionnaires to 351 outpatients, assessing variables like loyalty, outcome quality, interaction quality, treatment effectiveness, service quality, hospital location, and patient satisfaction.The results showed that these factors, alongside interaction quality and location, significantly impact patient satisfaction.This aligns with previous findings that emphasize the importance of multiple elements in shaping a patient's hospital experience.
Our findings revealed three main themes: 1) evaluating different aspects of service, 2) assessing the measurement form, and 3) examining structured evaluations.In healthcare, service quality is seen as the difference between what patients expect and how they perceive the received service.Essentially, the hospital's service quality is determined by how well patient experiences match their expectations.As healthcare providers aim to enhance patient experiences, these insights are valuable.
We also noted variations in patient satisfaction based on demographic characteristics such as age, gender, and education level.Our results suggest that factors such as age and education level play an important role in influencing patients' perceptions of healthcare quality.For example, younger patients may have different and higher expectations for health care compared to older patients.In addition, the level of education can also influence a patient's ability to understand medical information and communicate with medical personnel, which in turn can influence their level of satisfaction.This research provides a basis for RSU Bunda Purwokerto Hospital to improve patient experience by focusing on factors that influence patient satisfaction.Through a deeper understanding of how variables such as quality of care and effectiveness of treatment influence patient perceptions, hospitals can take concrete steps to improve patient care and outcomes.These efforts will help create a better environment for patients, improve the hospital's reputation, and ultimately improve the quality of health care provided.

CONCLUSION
This research has provided valuable insights into the factors that contribute to patient satisfaction at RSU Bunda Purwokerto Hospital.Through the data gathered from 351 outpatients, it is evident that variables such as loyalty, outcome quality, interaction quality, treatment effectiveness, service quality, hospital location, and patient satisfaction play a pivotal role in shaping a patient's experience.Our study, aligning with the findings of previous research such as that underscores the significance of these elements in the broader spectrum of healthcare.The delineation into three main themes further refines our understanding of patient perspectives and aids in pinpointing areas for potential improvement.In essence, for healthcare institutions to thrive, it is imperative that the services provided align seamlessly with patient expectations.As healthcare delivery evolves, providers should continually assess and adapt to ensure the highest level of patient satisfaction.This study confirms previous research findings that also emphasize the importance of these same variables in health services.This indicates that the findings are consistent and relevant in a broader context and help improve further understanding of patient perspectives.It also reflects an effort to understand problems in healthcare from the patient's perspective.The main message to be conveyed in this research is that in order to develop, health service institutions must ensure that the services provided are in line with patient expectations.This emphasizes that patient satisfaction must be the basis for planning and implementing health services.Limitations in data collection come from objects or patients who have different levels of knowledge about a service, one of which is determined by a low level of education.The results of this research can be used as a basis for developing subsequent research, which could be in the form of predicting customer satisfaction in a service or business activity that will be built, of course, to obtain material or social benefits.

Figure 2
Figure 2 below shows that profit and growth are achieved by customer loyalty.Moreover, loyalty is a direct result of customer satisfaction.Satisfaction is influenced by the services that have been provided to customers.

Figure 2 .
Figure 2. Service system in Bunda Hospital

Table 1 .
Variable operation

Table 2 .
The Krejcie and Morgen table