Syntax Literate: Jurnal Ilmiah Indonesia p�ISSN: 2541-0849 e-ISSN: 2548-1398

Vol. 7, No. 10, Oktober 2022

THE INFLUENCE OF PEOPLE, PHYSICAL EVIDENCE AND PROCESS ON OUTPATIENT SATISFACTION AT SITI FATIMAH HOSPITAL, SOUTH SUMATRA PROVINCE IN 2023

Intania Winalda, Innocentius Bernarto�

Faculty of Economics and Business, Pelita Harapan University, Indonesia

Email: [email protected], [email protected]

Abstract

Medical services provided to patients are inseparable from their satisfaction with the medical services they receive. This study aims to examine and analyze the influence of the three elements of service, in the context of health services on patient satisfaction (Patient Satisfaction). The research method used is a quantitative research method with a survey where the data is obtained by cross sectional (Cross Sectional). The results model or empirical model from the PLS-SEM analysis shows that this research model has moderate predictive accuracy for the patient satisfaction variable. Patient satisfaction dependent variable can be explained by 60% by the three independent variables. From the new Cross Validated Predictive Ability Test (CVPAT) method, it is confirmed that this research model can be said to have predictive abilities. The findings of this study indicate that the three service element variables, namely People, Process and Physical Evidence, have strong evidence to say they can positively influence patient satisfaction in government-owned hospitals. The results of the IPMA statistical analysis show that the managerial implications that can be given are in the form of suggestions for the management of Siti Fatimah Hospital in South Sumatra Province to better manage services at the outpatient polyclinic. This can have an impact on service performance, because doctors are forced to examine patients quickly and often have to be in a hurry due to long queues of patients.

Keywords: Patient satisfaction, People, Process, Physical Evidence, CVPAT, PL-SEM.

Introduction

The hospital is an organization carried out by professional medical personnel who are well organized from permanent medical infrastructure, nursing care, continuous medical services, treatment and diagnosis of diseases suffered by patients (Supartiningsih, 2017). Every hospital is obliged to provide safe, effective, anti-discrimination and quality health services by prioritizing the interests of patients based on hospital service standards (Silahi, 2018).

Even though the hospital has a semi-commercial purpose, in fact according to World Bank data, Indonesia's foreign exchange is lost every year because of the large number of Indonesian patients who go abroad for treatment/treatment. This means that the hospital service business is still seen as quite tempting because people are willing to pay costs to obtain the expected health services (Kuswibowo, 2020).

General Hospital (RSU) is a hospital that provides health services for all types of diseases starting from basic, specialist, to sub-specialty. General Hospitals (RSU) are divided into two types, namely government-owned RSUs and private-owned RSUs. Government-owned public hospitals are hospitals that provide health services for all types of diseases, starting from those that are basic, specialists, to sub-specialties that are carried out and managed by local, central, state-owned enterprises, as well as government and security departments (Ministry of Health, 2020).

Siti Fatimah Hospital in South Sumatra Province is the largest local government-owned hospital in Indonesia which was built on a 4.1 hectare land with a building area of 52,952.11 m2. Siti Fatimah Hospital in South Sumatra Province is regulated by Governor Regulation Number 38 of 2017 which has been adjusted to Government Regulation No. 72 of 2019 concerning changes to Government Regulation No. 18 of 2016, 2016 regarding the position, organizational structure, functions and job descriptions of the South Sumatra Provincial Hospital.

In an effort to improve the quality of its services, the Siti Fatimah Regional General Hospital of South Sumatra Province pays attention to the expectations and needs of the community so that services provided to customers (community) can be provided quickly, precisely, simply, openly, non-discriminatory and easily implemented. The performance of the apparatus at Siti Fatimah Hospital in South Sumatra Province can be measured in the context of providing services to the community as well as receiving and absorbing community aspirations regarding expectations and needs, so a Patient Satisfaction Level Survey is held at the Emergency Room Service Unit, Inpatient, MCU, PICU Perinatology ICU, Outpatient and Ponek RSUD Siti Fatimah South Sumatra Province every month (Kasi Nursing Fatimah, 2022).

Outpatient services are patient services for treatment, medical rehabilitation, diagnosis, observation, and other health services without staying at the hospital (Ministry of Health, 2020). In principle, outpatient services are part of the services of a hospital which not only provides services based on financial targets, but a service that prioritizes safety and puts love first by maximizing human resources through training or education (SNARS, 2015).

Patient satisfaction depends on the quality of service. Where service is defined as an effort carried out by employees to meet customer expectations with the services offered. Services can be stated as good if the services provided are able to meet the needs of patients. Satisfaction begins when the patient arrives for the first time until the patient leaves the hospital (Amin, 2020).

Process means activities that show the services provided to customers / customers while offering services or goods. This needs to be a concern of customers because there is a process in service products in a business field which includes target accuracy, service speed, and ease of service (Hidayat, Rahmawat & Hartono., 2022).

There are various things that are used as determining indicators in showing physical evidence of a service product, namely spatial planning, concept or design and environment (Hidayat et al., 2022). Kotler & Keller (2016) explained that Physical Evidence is evidence owned by service providers that is shown to customers as additional value reviews from customers.

People or personnel is a person's role as a provider of services or products which of course greatly impacts the quality of services or goods provided to customers. To achieve the best quality, training is needed for staff or employees to be able to provide the best service for their customers. The people referred to in this case are employees who participate directly or indirectly in the service process, which has a duty to provide sales or services (Hidayat et al., 2022).

The focus of this research is to see "the effect of People, Physical Evidence and process on outpatient satisfaction at Siti Fatimah Hospital Prov. South Sumatra in 2023�. This is supported by Bernarto and Linggo's research (2022) People, process, Physical Evidence, price fairness have a positive and significant effect on patient satisfaction. In this study, it was stated that the better the services obtained by patients from admins, health workers, and doctors, they would be able to maximize patient satisfaction.

Based on a short interview with the Head of Nursing at Siti Fatimah Hospital, South Sumatra Province (2022) in November 2022 and according to the report on the results of a survey on patient satisfaction levels in the Siti Fatimah Prov. Hospital service unit. South Sumatra every month, the patient satisfaction target is 88% -100%. While the facts are in the results of interviews with 20 outpatients, only 40% of patients were satisfied.

In the results of the interview, patients expressed their complaints such as doctors who were less communicative, toilets that were not clean enough, and waiting too long without any explanation when they could be called into the doctor's room for examination. To overcome these complaints, this research was conducted which aims to test hypotheses and analyze whether people, physical evidence, and processes have a positive effect on patient satisfaction at Siti Fatimah Hospital, South Sumatra Province.

These results are in accordance with the research by Nasution et al. (2020) who carried out research at an eye specialist hospital in Medan City which proved that the quality of service received by patients from staff/doctors/nurses had a positive impact on increasing patient satisfaction. In the research by Nasution et al (2020), who carried out research at the Tangerang city hospital, it was proven that Physical Evidence had a significant positive effect on patient satisfaction. As Physical Evidence increases, patient satisfaction also increases. In a study by Fuad et al. (2019) has research results that the marketing mix process has a significant effect on patient satisfaction.

In recognizing the problems above, the researchers tried to observe from the customer or service recipient side in evaluating the gap between perceptions and expectations of the quality of services at the outpatient installation of Siti Fatimah Hospital, South Sumatra Province. Therefore, researchers want to conduct this research to find out whether People, Physical Evidence and Process affect patient satisfaction at Siti Fatimah Hospital, South Sumatra Province.

This study aims to: 1) find out whether people influence patient satisfaction in outpatient care at Siti Fatimah Hospital, South Sumatra Province. 2) find out whether physical evidence has an effect on patient satisfaction in outpatient care at Siti Fatimah Hospital, South Sumatra Province. 3) find out whether the process has an effect on patient satisfaction in outpatient care at Siti Fatimah Hospital, South Sumatra Province.

The benefits of this research are expected to be used as input for the Siti Fatimah Hospital in South Sumatra as an effort to improve the quality of service for every visiting patient.

Research methods

This study uses a quantitative research type. Research In quantitative research isolate the variables and then link them in the hypothesis. Next, test the hypothesis with the data collected (Achmadi et al., 2020).

The object of this study is to understand and analyze the influence or relationship between People, Physical Evidence, and Process on patient satisfaction at Outpatient Hospital Siti Fatimah Hospital, South Sumatra Province. This research was conducted at the Siti Fatimah Hospital in South Sumatra Province. This research is divided into three independent variables, namely People, Physical Evidence, Process, and patient satisfaction as the dependent variable.

Population and sample are groups or units that have certain characters or forms that are deliberately chosen, so that data can be collected that can be used in research that has been designed. The population is the entire group whose data is taken. While the sample is part of the population that has characteristics similar to the population (Setiawan, et al., 2021). This research uses techniquenon-probability sampling (Sugiyono, 2019).

Based on the measurement scale, the data is divided into 4 groups, namely nominal, ratio, interval, and ordinal data (Setiawan et al., 2021). In this study using primary data, namely data collected or obtained directly by researchers from data sources. Researchers also use an interval scale to be able to assess the sequence of stages and quantification to assess an order of quality of a service with data collection techniques in the form of questionnaires/questions addressed to respondents. The questions given in the questionnaire are related to variables in the form of statements.

These problems include small sample sizes, missing data, and problems with classical assumption tests, for example multicollinearity. PLS is an analytical tool developed by a statistician and econometrician from Sweden, Herman Wold. PLS SEM is an analytical technique that combines structural approaches, factor analysis approaches, and path analysis (Respati et al., 2021).

In 1974, Wold introduced PLS in general by using the NIPALS (Nonlinear Iterative Partial Least Squares) algorithm which was a development of the previous algorithm, namely NILES. Partial Least Squares is a powerful analytical method and is often referred to as soft modeling because it eliminates OLS (Ordinary Least Square) regression assumptions, such as data must be normally distributed in a multivariate manner and there is no multicollinearity problem between exogenous variables (Wold, 1985).

This software was further developed by Wynne W Chin (Hair et al., 2010) to be under windows with a graphical interface and additional validation technique improvements by incorporating bootstrapping and jacknifing. The software developed by Chin is named PLS GRAPH Version 3.0 and is still in beta, the student version can be downloaded for free at www.bauer.uh.edu/plgraph/build1126.exe. The analysis stage using PLS-SEM is at least required to go through a five-stage process where each stage will affect the next stage (Ghozali and Latan, 2021).

Results and Discussion

Variable Description

In the descriptive analysis of the latent variables in this study, assessments of statistical data were used in the form of mean, standard deviation and maximum-minimum values, this information is considered necessary in a survey research (Sekaran & Bougie, 2017). The assessment is carried out, especially by looking at the average or mean value. This value is a measure of central tendency which provides information on the average value of the total respondents' answers for each questionnaire item (indicator) of the observed variables.

The value of the data distribution is seen in the standard deviation (SD), which describes the distribution of data over the mean value for each question item that represents the indicator. This standard deviation value provides information on how the distribution of data varies with the respondents' answers to a particular question item. From the minimum and maximum data values, one can identify the highest or lowest respondent's rating for a question item.

This research questionnaire uses a Likert measurement scale with a value of 1 to 5 for the answer choices, because it is considered an efficient 1-5 scale and makes it easier for respondents (Sekaran & Bougie, 2017). This scale is continuous, starting with 1, namely "strongly disagree" up to a scale of 5, namely "strongly agree". This is done using the formula (maximum value of the scale-minimum value of the scale)/point scale = (5-1)/ 5 = 0.800. From calculations with this formula, the interval value is 0.8.

Research Inferential Analysis

Multivariate statistical methods were used in the inferential analysis of this study, where the Partial Least Square-Structural Equation Model (PLS-SEM) was used which is considered a new generation of multivariate data analysis (Hair et al., 2022). Modeling with PLS-SEM has been widely applied in marketing research in various industries (Hair et al., 2019). The PLS-SEM method is variant-based and effective for simultaneously assessing complex relationships between variables.

In addition, this method is known for its ability to make predictions of behavior in social research. Unlike the covariance-based SEM (CB-SEM) with a common factor model approach, PLS-SEM follows a composite model approach in measuring constructs. Therefore, PLS-SEM can be relied upon to measure construct indicators reflectively (Hair et al., 2022).

Multivariate statistical analysis with PLS-SEM was carried out via the SmartPLS4 software with two main stages (Ringle et al., 2022). The first stage is carried out to assess the measurement model or what is known as the inner model. The essence of this stage is testing the reliability and validity of the indicators in a model.

The second stage is carried out to assess the inner model or structural model, where the relationships between variables in the model are assessed. In this second stage, there is also an assessment of the explanatory and predictive capabilities of the proposed model. The most important part at this stage is assessing the significance and coefficients of the paths studied in this model.

This study aims to examine and analyze the influence of the three elements of service, in the context of health services on patient satisfaction (Patient Satisfaction). In the 7P's marketing mix concept which was developed from the 4P's (Booms & Bitner, 1981) there are three specific elements in the service sector, namely People, Process and Physical Evidence. The 7P's marketing mix concept can be applied in various service industries including the health service industry.

The research model is structured with these three elements as independent variables, while patient satisfaction is the dependent variable. The selection of only these three elements was carried out with the consideration that the research was carried out in government-owned public hospitals (provinces) or public hospitals that were not profit-oriented. The source of operational funds for Siti Fatimah General Hospital in South Sumatra Province generally comes from the regional budget and is intended for general public services.

In general, government-owned hospitals also do not do marketing like private hospitals which have to compete fiercely. Therefore, other marketing mix elements such as promotion, price and place are irrelevant for use. This research model has been tested empirically with data originating from respondents who are outpatients from Siti Fatimah Hospital, South Sumatra Province in 2023.

The results of the questionnaire distribution obtained 201 research respondents, the majority of whom were BPJS Health patients (78%) and aged over 40 years (58%). Respondents who use BPJS generally have paid regular monthly contributions according to their group or paid by the insurer. The pattern of BPJS Kesehatan health services uses a case-based group (INA-CBG) system, this system is different from patients who spend money directly at the time of service (fee for service).

This can affect the patient's expectations of the services they receive. Generally, patients who feel they have paid more, or spent more money will tend to expect better service. Therefore, in patient satisfaction research, it was found that the level of patient satisfaction varied according to the patient's expectations. Research evaluating health services needs to consider the background of payor factors or those who finance them, such as the health insurance system, in order to get valid results.

This research was conducted at the Siti Fatimah Hospital in South Sumatra Province, where most of the respondents (78%) were BPJS Health patients, therefore the profile findings of these respondents were able to describe the background of the patients at the Siti Fatimah Hospital in South Sumatra Province.

The profile of the majority of respondents aged over 40 years can describe disease patterns that are more experienced by individuals over this age such as chronic degenerative diseases. This finding is reinforced by data from respondents who generally seek internal medicine specialists for treatment (44%). This finding is in accordance with data from the Ministry of Health which shows a trend of disease patterns most commonly found in the Indonesian population are diseases related to the heart and blood vessels.

Thus the respondents of this study can be considered to represent the profile of patients who seek treatment at Siti Fatimah Hospital, South Sumatra Province. This data can also provide information on which specialist polyclinics need attention because the number of patient visits is relatively more frequent than other polyclinics.����� The findings of this study indicate that the three service element variables, namely People, Process and Physical Evidence, have strong evidence to say they can positively influence patient satisfaction in government-owned hospitals.

With the increasing patient perception of Siti Fatimah Hospital in South Sumatra Province towards this variable, the greater the level of satisfaction felt by the patient. These results are in line with previous research (Ravangard et al., 2020) conducted in Iran which also used the basic 7P's concept in evaluating health services. The results of testing the three hypotheses of this study, which are statistically supported, can produce recommendations for the necessary interventions on these variables to increase outpatient satisfaction at Siti Fatimah Hospital, South Sumatra Province.

The new contribution of this research is to show that the three service elements of the 7P's can also be implemented in public services such as the Regional General Hospital (RSUD) managed by the provincial government. Previous research generally only tested the 7P's marketing mix in health service facilities held by private parties only. One of the previous studies (Ravangard et al., 2020) has conducted research on the 7P marketing mix concept in both public and private hospitals in Iran.

The results found different 7P elements in the two types of hospitals. For example, there is an element of place or access which is an important factor in public hospitals, while the people factor is dominant in private hospitals. Therefore, it is necessary to conduct specific research to confirm the importance of the 7P's service elements in RSUD. Even though from the operational funding aspect the Siti Fatimah Hospital in South Sumatra Province is supported by funds from the Provincial APBD and does not depend on income from patient payments, patient satisfaction needs to be an indicator of the success of public services.

Therefore, the management of the Siti Fatimah Hospital in South Sumatra Province must demonstrate the achievements of its services in a responsible manner to the stake holders or stakeholders of the Siti Fatimah Hospital in South Sumatra Province, for example the community as taxpayers who are the source of the APBD. Furthermore, RSUD in the health care system is a referral facility from level I health facilities (Faskes I) such as Puskemas. Patients served by general practitioners will be referred to hospitals if necessary.

The more patients feel satisfied with the referral service at the RSUD, the better the tiered service system in the national health service system. Therefore Patient Satisfaction can be useful for the evaluation of national health system policies. The results of this study indicate that people are the variable that has the greatest influence on patient satisfaction with a coefficient of 0.422 and an f2 value of 0.261 (medium effect). The findings of this study are in line with previous research (Chana et al., 2021; Yaghoubian et al., 2018) that the People element in health services is a factor that plays an important role in shaping patient satisfaction.

Therefore the findings of this study confirm previous studies that the role of human relations in the People element is the core of health services, including in public services such as hospitals. In theory about service management, value or benefits are perceived directly when the service is provided. When there is interaction between service providers and consumers (patients), perceptions of service quality are formed. This is consistent with the perishable and intangible nature of services and inseparability which also applies to health services.

People in this study refers to health services provided by doctors or nurses who directly interact with patients. Generally, patients have limited medical knowledge to assess the professional abilities of medical personnel. Therefore, patients will tend to evaluate the attitude shown by the medical personnel more. For example empathy, and the ability to communicate from these medical personnel. Patients who come are not only physically ill but also experience uncomfortable psychological conditions, therefore a humane approach that shows respect, courtesy and empathy for patient complaints will have a big emotional impact.

The findings of this study indicate that the management of Siti Fatimah Hospital in South Sumatra Province needs to pay attention to people in the context of human resource factors at Siti Fatimah Hospital in South Sumatra Province, especially medical personnel who have direct contact with patients. In addition to aspects of professional improvement, medical personnel also need to receive feedback so they remain motivated to serve patients well. Generally, the number of specialist doctors serving patients is still small, this affects their workload so that services are often given in a hurry.

Therefore, apart from planning for a sufficient number of specialist doctors, the management of the Siti Fatimah Hospital in South Sumatra Province needs to manage specialist doctors' hours of practice and their workload properly so that doctors are not too tired when serving patients. The findings of this study also show that Process has the second largest influence after People with a coefficient of 0.031. This finding is in line with previous studies in health services (Chana et al., 2021) and also in hospitals that accept insurance patients (Yaghoubian et al., 2018).

All of the research findings show that Process plays a major role in shaping patient satisfaction. However, in contrast to the study population, this study focuses more on services at provincial government hospitals. In general, in services by hospitals, the process is assessed as a whole starting from the time the patient arrives until he leaves the hospital. This concept is known as the patient journey where there are interactions at different points of service that the patient undergoes, for example at registration, waiting time, to picking up drugs at the pharmacy.

The results of this study have also shown that the Process, where patients will have their own experiences can affect the patient's evaluation of the services of the Siti Fatimah Hospital in South Sumatra Province as a whole. If the patient flow or registration process runs smoothly and the waiting time can be tolerated by the patient, then his satisfaction will increase. Therefore the management of the Hospital needs to identify and work on the waiting time at the outpatient polyclinic so that there is no accumulation of patients which results in long waiting times for patients.

The problem that is often faced by BPJS patients is the long queue at the polyclinic and the registration process which tends to take time. This still needs to be studied further and provided a solution according to the resources owned by the RSUD, especially regarding the number of available medical personnel or specialists. The service element that has the smallest influence is Physical Evidence. However, this variable was found to have a positive influence on patient satisfaction, so it remains relevant for attention.

The findings of the positive influence of Physical Evidence are in line with the findings of previous research (Chana et al., 2021) conducted in Thailand and Iran (Yaghoubian et al., 2018). Another study by Ravangard et al. (2020) showed that Physical Evidence was found to have more influence on private hospitals than government-owned hospitals. This is probably because patients in private hospitals pay their own medical expenses so they tend to expect better service facilities.

Respondents in this study were previously recorded as having had treatment experience at the Siti Fatimah Hospital in South Sumatra Province, therefore they already knew what facilities were available and assessed their condition. The facilities available in health services are known to support patient comfort. The findings of this study indicate that respondents are generally satisfied with the facilities in the waiting room. This is possible because this hospital is relatively new and has been well designed from the start.

The results of empirical research with three service elements People, Process and Physical Evidence at Siti Fatimah Hospital in South Sumatra Province show an R2 value of 0.602. Patient satisfaction can be explained by 60% by these three variables while the rest is explained by other variables outside the model studied. The R2 value can be categorized as having a moderate predictive, however this research is related to the subjective perception of the respondents, so the R2 value needs to be interpreted carefully.

From the Q2_predict and CVPAT (Cross Validated Predictive Ability Test) values, which are new methods, it can be confirmed that this research model has predictive value. Thus this research model and its indicators can be recommended for use in research with respondents from different hospitals.

Conclusion

The results of the conclusions of this study can be arranged as follows: 1) people have a positive effect on patient satisfaction. The more outpatients at the Siti Fatimah Hospital in South Sumatra Province have a good perception of the health services provided by people or health workers, the more their satisfaction will increase. 2) process has a positive effect on patient satisfaction. The more outpatients at Siti Fatimah Hospital in South Sumatra Province have a good perception of the process or the whole process of the health services they receive, the more their satisfaction will increase. 3) Physical Evidence has a positive effect on patient satisfaction. The more patients at Siti Fatimah Hospital in South Sumatra Province have a good perception of physical facilities when services are provided, the more satisfaction will also increase. The results model or empirical model from the PLS-SEM analysis shows that this research model has moderate predictive accuracy for the patient satisfaction variable. Patient satisfaction dependent variable can be explained by 60% by the three independent variables.

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Syntax Literate: Jurnal Ilmiah Indonesia

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