Introduction
A
hospital is a health facility that provides services within the scope of public
health science. This includes disease prevention efforts starting from early
diagnosis and appropriate treatment, intensive care, and rehabilitation of sick
people to optimal levels of healing (Pradnyana & Bulda Mahayana, 2020) .
In providing
services, hospitals must pay attention to quality and patient safety. Quality
health services are services that are safe, timely, efficient, effective,
patient-oriented, fair and integrated (Kepmenkes RI, 2022) . One of the hospitals that is a reference for public
health services in the city of Tangerang is Hospital X.
The
following is data that shows the Gmaps rating
for Hospital X, namely:
Figure
1. Gmaps Rating for Hospital
Google.
(2024, May). Hospital X gmaps rating. https://www.google.com/maps/place/Tangerang+City+General+Hospital/
Based
on the data above, it can be seen from the Gmaps rating given by patients with a value of 3.4 and the number of
reviews of 877, where this low rating contains complaints and criticism from
Hospital X patients regarding medical staff services which are considered slow,
or staff medical personnel who lack education, the service system is highly
complained about by patients so that it does not help patients in meeting their
medical service needs. Below you can see general patient visits from Hospital X in
2017-2023 until August.
Table 1. Hospital X General Patient Visit Data
|
No |
Year |
Outpatient
Installation |
|
1 |
2017 |
13,381 |
|
2 |
2018 |
19,402 |
|
3 |
2019 |
19,138 |
|
4 |
2020 |
10,346 |
|
5 |
2021 |
10,347 |
|
6 |
2022 |
12,355 |
|
7 |
2023
(January to August) |
7,640 |
Source: https://rsud.tangerangkota.go.id/
this data, it is known that general patient visits at Hospital
Outpatient installations in 2017 were 13,381. General patient visits to
outpatient installations in 2018 increased to 19,402, then decreased in 2019 to 19,138. General patient visits from
outpatient installations in 2020 decreased further to 10,346 and in 2021 outpatient
installations increased to 10,347 and in 2022 outpatient installations
experienced an increase again to 12,355 , and in this current year, in
2023 from January to August, the number of patients general outpatients were
7,640 patients.
Patient assessment of the quality of hospital services is important as a
reference in improving services so as to create patient satisfaction (Shilvira et al., 2022) . For healthcare providers, customer satisfaction drives positive outcomes,
for example, higher patient attendance rates, positive ratings and higher
profits (Fatima et al., 2018) . To
make a hospital good and widely chosen by the public and have customers who
come again and again, it is necessary to always maintain the level of trust and
quality of service towards customers, especially when providing medical
services in interpersonal meetings (Noor, 2018) . Efforts to improve service quality can use the service quality concept. The essence of service quality is to provide satisfaction to customers, both service quality and product quality. Everything can
be achieved if processes, systems and people are integrated with each other (Halim & Wulandari, 2016) . Customer
trust influences customer loyalty towards service providers (Islam et al., 2021) .
Patient
loyalty is formulated to achieve return visit rates which have an impact on
hospital profitability and stability (Utami et al., 2020) . The concept of
patient loyalty or patient commitment to a health service provider, which is
defined as the intention and demand of customers or patients to maintain a
doctor-patient relationship as a result of the high quality services provided
by the hospital. Therefore, service quality and patient satisfaction are
prerequisites for patient loyalty to the hospital (Tiara & Antonio, 2022) .
Based on the description
above, it is understood that Hospital that some patients do not want to return
for treatment to the hospital. Lack of interaction with medical staff can
reduce patient confidence in the quality of service. The fact regarding
fluctuations in the level of general patient visits during the period 2017 to
2022 is supported by data on total general patients showing a decline,
indicating reduced patient loyalty and declining service quality, which is also
reflected in criticism of the service system and inadequate medical staff. From
this phenomenon, it
can be further reviewed regarding patient loyalty at Hospital a study with the title "The Relationship between Hospital
Service Quality and Patient Trust, Mediated by Patient Satisfaction and Patient
Loyalty at Hospital X"
Conceptual framework
Framework conceptual Which explain about connection Between the
quality of hospital services and patient trust, it is mediated by patient
satisfaction and patient loyalty, in study This depicted on picture 2. following
Figure 2.
conceptual framework
By looking at the conceptual framework, the hypothesis is formulated as follows:
H1 :
The quality of
hospital services influences patient trust
H2 :
The quality of
hospital services influences patient loyalty
H3 :
The quality of
hospital services influences patient satisfaction
H4 :
Patient trust
influences patient satisfaction
H5 :
Patient
satisfaction influences patient loyalty
H6 :
The quality of
hospital services influences patient trust through patient satisfaction
H7 :
The quality of
hospital services influences patient satisfaction through patient loyalty
H8 :
Patient trust
influences patient satisfaction through patient loyalty
H9 :
Quality of
hospital services The quality of hospital services influences patient trust
through patient satisfaction and patient loyalty
Research methods
This study
uses a quantitative approach. Quantitative research is a research method based
on the philosophy of positivism as a scientific or academic method because it
meets scientific principles in a concrete or empirical, objective, measurable,
rational and systematic manner (Sugiyono, 2019) . The object of
research as an independent variable (independent
variable) is the quality of hospital services, the dependent (bound) variable is patient trust, the intervening
variable namely patient satisfaction
and patient loyalty. The population in this study were all general outpatient
patients at Hospital X in 2023 (January to August) with a total of 7,640 patients . Sample calculations
in this study used GPower software with
an effect size of 0.5 or 5%, a
significance level of 0.05, and power (1- 𝛽 𝑒𝑟𝑟 𝑝𝑟𝑜𝑏 ) 0.95. The
minimum sample required is 160 (Memon et al., 2021) . The sample
results obtained from calculating the total sample size with GPower were 162
samples. So, the number of samples used in this study was 162 samples of
general patients at Hospital Illness
Data analysis was carried out using the Partial
Least Square (PLS) method using SmartPLS version 3 software. PLS is a
method for solving Structural Equation
Modeling (SEM) which in this case is better than other SEM techniques.
Results and
Discussion
Respondent Characteristics
The respondents
used in this study were general patients at Hospital X totaling 162
respondents. The profile of
respondents in this study includes profiles based on characteristics based on
age, gender and occupation. The results of the respondent profile
characteristics in this study are presented as follows
Table 2. Respondent Characteristics
|
n |
% |
|
|
Gender |
|
|
|
Man |
99 |
61.1 |
|
Woman |
63 |
38.9 |
|
Total |
162 |
100 |
|
Age |
|
|
|
20-30 Years |
37 |
22.8 |
|
31-40 Years |
58 |
35.8 |
|
41-50 Years |
45 |
27.8 |
|
51-60 Years |
17 |
10.5 |
|
>61 Years |
5 |
3.1 |
|
20-30 Years |
37 |
22.8 |
|
Total |
162 |
100 |
|
Work |
|
|
|
Student/Students |
21 |
13.0 |
|
Private sector
employee |
83 |
51.2 |
|
Businessman |
20 |
12.3 |
|
Civil servants |
38 |
23.5 |
|
Total |
162 |
100 |
Source: Data processed by researchers, 2024
From the
characteristics of the respondents, it was found that the majority of general patients
at Hospital 51.2%%)
Data
analysis
In path
analysis, the first step before assessing the significance of the results is to
test the Outer Model . This is done
by checking validity (convergent and discriminant) and reliability. After the
measurement model is proven to be valid and reliable, the analysis can proceed
to the Inner Model to determine the
significance value.
Measurement Model (Outer Model)
The
measurement model test ( outer model ) also known as ( outer relation or
measurement model ) can describe how each indicator block is related to
its latent variable (Ghozali, 2018) . The outer
model test in this research was carried out with convergent validity,
discriminant validity and composite reliability .
Convergent
Validity Test
The results of convergent validity analysis
on outer loading 1 showed 9
indicators of Hospital Service Quality (KPRS1, KPRS2, KPRS3, KPRS4, KPRS5,
KPRS6, KPRS23, KPRS24, KPRS25, KPRS26), 3 indicators of Patient Trust (KP1,
KP2, KP3), 7 indicators Patient Satisfaction (KPU1, KPU7, KPU8, KPU9, KPU12,
KPU13, KPU16), 7 indicators of Patient Loyalty (LP7, LP8, LP9, LP13, LP14,
LP15, LP16) which have a loading factor
value of <0.7. Indicators with values <0.7 will be deleted and not included in the calculation. Then in outer loading 2, 4 indicators of Patient
Satisfaction were obtained (KPU10, KPU11, KPU14, KPU15) which had a loading factor value of <0.7.
Indicators with values <0.7 will be deleted and not included in the calculation. The results of the indicators that
have been removed are shown in the table below:
Table
3. Convergent Validity Test Results
|
|
Quality of Hospital Services |
Patient Trust |
Patient Satisfaction |
Patient Loyalty |
|
KPRS7 |
0.867 |
|
|
|
|
KPRS8 |
0.718 |
|
|
|
|
KPRS9 |
0.835 |
|
|
|
|
KPRS10 |
0.866 |
|
|
|
|
KPRS11 |
0.888 |
|
|
|
|
KPRS12 |
0.861 |
|
|
|
|
KPRS13 |
0.741 |
|
|
|
|
KPRS14 |
0.837 |
|
|
|
|
KPRS15 |
0.833 |
|
|
|
|
KPRS16 |
0.822 |
|
|
|
|
KPRS17 |
0.878 |
|
|
|
|
KPRS18 |
0.790 |
|
|
|
|
KPRS19 |
0.753 |
|
|
|
|
KPRS20 |
0.820 |
|
|
|
|
KPRS21 |
0.797 |
|
|
|
|
KPRS22 |
0.813 |
|
|
|
|
KP4 |
|
0.865 |
|
|
|
KP5 |
|
0.853 |
|
|
|
KP6 |
|
0.883 |
|
|
|
KP7 |
|
0.870 |
|
|
|
KP8 |
|
0.874 |
|
|
|
KP9 |
|
0.885 |
|
|
|
KP10 |
|
0.831 |
|
|
|
KP11 |
|
0.860 |
|
|
|
KP12 |
|
0.850 |
|
|
|
KP13 |
|
0.725 |
|
|
|
KP14 |
|
0.853 |
|
|
|
KP15 |
|
0.867 |
|
|
|
KPU2 |
|
|
0.866 |
|
|
KPU3 |
|
|
0.840 |
|
|
KPU4 |
|
|
0.843 |
|
|
KPU5 |
|
|
0.897 |
|
|
KPU6 |
|
|
0.826 |
|
|
KPU17 |
|
|
0.839 |
|
|
KPU18 |
|
|
0.836 |
|
|
KPU19 |
|
|
0.853 |
|
|
KPU20 |
|
|
0.822 |
|
|
LP2 |
|
|
|
0.891 |
|
LP3 |
|
|
|
0.882 |
|
LP4 |
|
|
|
0.868 |
|
LP5 |
|
|
|
0.878 |
|
LP6 |
|
|
|
0.849 |
|
LP10 |
|
|
|
0.892 |
|
LP11 |
|
|
|
0.877 |
|
LP12 |
|
|
|
0.864 |
Source: PLS Output Results ,
2024.
Figure 3. Model Construct after indicator abolished
Source: PLS Output Results,
2024.
Discriminant Validity Test and
Composite Reliability Test
disciminant
validity test
aims to determine whether a reflective indicator is a good measurement for the construct of
the latent variable used in the research. Discriminant
validity is carried out using an average variance extracted (AVE)
value of >0.50. The composite reliability test in this study used composite
reliability and Cronbach's
alpha with a value greater than 0.70
Table 4. Discriminant Validity Test
|
Variable |
Cronbach's
Alpha |
rho_A |
Composite
Reliability |
Average
Variance Extracted (AVE) |
|
Quality
of hospital services |
0.968 |
0.971 |
0.971 |
0.675 |
|
Patient
Trust |
0.966 |
0.967 |
0.969 |
0.726 |
|
Patient
Satisfaction |
0.951 |
0.953 |
0.958 |
0.718 |
|
Patient
Loyalty |
0.956 |
0.957 |
0.963 |
0.766 |
Source: PLS Output Results ,
2024.
The AVE results in table 4 show that all
constructs produce results mark AVE >0.5
Which means all construct fulfil condition validity
And construct Which
highly correlated. test reliability give results Cronbach's alpha and
composite reliability >0.7. This
shows that each variable has a value reliability Which
tall. Conclusion from analysis Outer Model
is that test validity convergent, validity discriminant, And test reliability show that all indicator And variable in study has fulfil condition
validity And reliability. By Because That,
can followed by analysis
Inner Model
Test
(Inner Model)
The inner model describes the
relationship between latent variables based on substantive theory. The inner
model test in this research was carried out through the R-square test and
the T statistical significance test. The inner model test can be seen
outlined in the table below:
R-square
test
The R- square
test aims to determine the extent of the model's ability to apply
variations in the dependent variable. The R-square
test criteria are if the R-square
value is 0.02 then it shows a small effect, a value of 0.15 shows a
moderate effect and a value of 0.35 shows a large effect (Hair Jr et al., 2019)
Table 5. R Square Test
|
Variable |
R Square |
Adjusted R Square |
|
Patient Trust |
0.309 |
0.305 |
|
Patient Satisfaction |
0.791 |
0.789 |
|
Patient Loyalty |
0.753 |
0.749 |
Source: PLS Output Results,
2024.
Based on
table 5, results test R 's square, seen that the patient trust variable is
0.309 which is included in the medium model, the patient satisfaction variable
is 0.791 which is included in the strong model and the patient loyalty variable
is 0.753 which is included in the strong model.
Hypothesis
testing
Direct
Connection
Hypothesis
testing is carried out to see the p-value and t-statistic. A significant
hypothesis can be accepted if the p – value <0.05 and t – statistic >
1.97509
Table 6. Direct Relationship Test Results
|
|
T
Statistics (O/STDEV) |
P
Values |
Hypothesis |
|
Quality
of hospital
services ->
Patient trust |
9,893 |
0,000 |
Accepted |
|
Quality
of hospital service
-> Patient Loyalty |
0.833 |
0.405 |
Rejected |
|
Quality
of hospital
services ->
Patient satisfaction |
4,709 |
0,000 |
Accepted |
|
Patient
trust -> Patient satisfaction |
16,551 |
0,000 |
Accepted |
|
Patient
satisfaction -> Patient Loyalty |
21,053 |
0,000 |
Accepted |
Source: PLS Output Results,
2024.
Based on table
6, there are 5 hypotheses regarding the direct relationship in this research,
namely:
H1
The quality of
hospital services is related to patient trust. The t-statistic value obtained
was 9.893>1.97509 with a p-value of 0.000<0.05. So the quality of
hospital services is related to patient trust. Hypothesis 1 is accepted.
H2
The quality of
hospital service is related to patient loyalty. The t-statistic value obtained
was 0.833<1.97509 with a p-value of 0.405>0.05. So the quality of hospital
services is not related to patient loyalty. Hypothesis 2 is rejected.
H3
The quality of
hospital services is related to patient satisfaction. The t-statistic value was
4.709>1.97509 with a p-value of 0.000<0.05. So the quality of hospital
services is related to patient satisfaction. Hypothesis 3 is accepted.
H4
Patient trust is
related to patient satisfaction. The t-statistic value obtained was
16.551>1.97509 with a p-value of 0.000<0.05. So patient trust is related
to patient satisfaction. Hypothesis 4 is accepted.
H5
Patient
satisfaction is related to patient loyalty. The t-statistic value obtained was
21.053>1.97509 with a p-value of 0.000<0.05. So patient satisfaction is
related to patient satisfaction. Hypothesis 5 is
accepted.
Indirect Relationship (Mediation)
Table 7. Indirect Relationships
|
|
T
Statistics (O/STDEV) |
P
Values |
Hypothesis |
|
Quality of hospital service -> patient trust
-> patient satisfaction |
9,435 |
0,000 |
Accepted |
|
Quality
of hospital service -> patient satisfaction -> patient loyalty |
4,396 |
0,000 |
Accepted |
|
Patient
trust -> patient satisfaction -> patient loyalty |
13,190 |
0,000 |
Accepted |
|
Quality
of hospital service -> patient trust -> patient satisfaction ->
patient loyalty |
9,267 |
0,000 |
Accepted |
Source: PLS Output Results,
2024.
Based on table
7, there are 4 hypotheses regarding indirect relationships in this research,
namely:
H6
The quality of
hospital services is related to patient trust through patient satisfaction. The
t-statistic value obtained was 9.435>1.97509 with a p-value of
0.000<0.05. So it is concluded that the quality of hospital services is
related to patient trust through patient satisfaction. Hypothesis 6 is accepted.
H7
The quality of
hospital services is related to patient satisfaction through patient loyalty.
The t-statistic value obtained was 4.496>1.97509 with a p-value of
0.000<0.05. So it is concluded that the quality of hospital services is
related to patient satisfaction through patient loyalty. Hypothesis 7 is accepted.
H8
Patient trust is
related to patient satisfaction through patient loyalty. The t-statistic value
obtained was 13.190>1.97509 with a p-value of 0.000<0.05. So it is
concluded that patient trust is related to patient satisfaction through patient
loyalty. Hypothesis 8 is
accepted.
H9
Quality of
hospital services The quality of hospital services is related to patient trust
through patient satisfaction and patient loyalty. The t-statistic value
obtained was 9.267>1.97509 with a p-value of 0.000<0.05. So it is
concluded that the quality of hospital services. The quality of hospital
services is related to patient trust through patient satisfaction and patient
loyalty. Hypothesis 9 is
accepted.
Discussion
The Relationship between Hospital Service
Quality and Patient Trust
The
results of this study show that the quality of hospital services is related to
patient trust in Hospital the patient. So it will create a sense of trust
between one another (Ar Bajamal & Anindita, 2020) . The
results of this research support research conducted by Amal et al., (2024) which
states that service quality influences patient satisfaction at the Cikampek
Private Hospital.
The Relationship between Hospital Service
Quality and Patient Loyalty
The
results of this study show that the quality of hospital services is not related
to patient loyalty at Hospital For example, patients may pay more attention to
aspects such as medical costs, hospital location, availability of medical
facilities, or interpersonal relationships with medical staff. The results of
this research are in line with research conducted by (Sektiyaningsih et al., 2019) which states that
service quality has no effect on loyalty.
The Relationship between Hospital Service
Quality and Patient Satisfaction
The results of
this study indicate that the quality of hospital services is related to patient
loyalty at Hospital satisfaction (Anasrullah et al., 2022) . Yu et al.,
stated that the quality of service, especially in the facilities and
environment within the hospital, can have a direct impact on the level of
patient satisfaction. The results of this study support research conducted by Shie et al., (2022) which stated that
the quality of hospital services has a positive effect and directly influences
patient satisfaction.
The Relationship between Patient Trust and
Patient Satisfaction
The
results of this study show that patient trust is related to patient satisfaction
at Hospital The results of this study support research conducted
by Purba et al., (2021) which states that
trust has a significant effect on outpatient satisfaction in the neurosurgery
polyclinic at RSUD dr. Doris Sylvanus Palangkaraya.
The
Relationship between Patient Satisfaction and Patient Loyalty
The
results of this study show that patient satisfaction is related to patient
loyalty at Hospital Hospitals can retain old patients and attract new patients,
because indirectly satisfied patients will have a good impression of this
hospital and tell other people about their experiences to come to this hospital
(Ar Bajamal & Anindita, 2020) . The results of
this research support research conducted by Andina et al., (2024) which stated that
patient satisfaction influences patient loyalty.
The
Relationship between Hospital Service Quality and Patient Trust Through Patient
Satisfaction
The
results of this study show that service quality is related to trust through
patient satisfaction. In increasing patient trust, the hospital must be able to
improve the quality of good service by fulfilling the desires, hopes and needs
of patients, the better the quality of service provided by the hospital, the
better the patient satisfaction will be, so it is hoped that the hospital can
improve the quality of its services so that can provide optimal results and the
more hospitals provide good treatment to patients, the more trust and
satisfaction they will receive from patients (Rahayu et al., 2022) .
The
Relationship between Hospital Service Quality and Patient Satisfaction Through
Patient Loyalty
The
results of this study show that the quality of hospital services is related to
patient satisfaction through patient loyalty at Hospital the. With patient
satisfaction, hospitals can maintain long-term relationships with existing
patients and also attract the attention of new patients. This is because the
satisfaction felt by patients indirectly creates a positive image of the
hospital, and they tend to share their positive experiences with others,
encouraging other people to also choose the same hospital so as to build
customer loyalty (Ar Bajamal & Anindita, 2020) .
The Relationship between Patient Trust and
Patient Satisfaction Through Patient Loyalty
The
results of this study show that trust is related to patient satisfaction
through patient loyalty at Hospital trust. If there is no trust then there will
be no commitment created. The creation of satisfaction can provide several
benefits, including the relationship between the hospital and the patient
becoming harmonious, thus providing a good basis for the hospital and creating
loyalty to the hospital as well as making a word
of mouth recommendation that is profitable for the hospital (Fadhila & Diansyah, 2018)
The Relationship between Hospital Service
Quality and Patient Trust Through Patient Satisfaction and Patient Loyalty
The
results of this study show that the quality of hospital services is related to
patient trust through patient satisfaction in patient loyalty at Hospital not
according to expectations. If the health services provided to patients are in
line with their expectations, then patients will always come to a
well-functioning service center for treatment (Suhendi et al., 2023) . Quality and
patient satisfaction have a big influence on patient loyalty because service
quality and satisfaction are important things for patients so that they can
increase trust in patients (Putri in Lintang & Widiyastuti, 2021) .
Conclusion
The
research results show several important findings regarding the relationship
between the quality of hospital services and various patient-related aspects.
First, the quality of hospital services is related to patient trust and
satisfaction, but does not have a significant impact on patient loyalty.
Second, patient trust is proven to have a relationship with patient
satisfaction, and patient satisfaction has a relationship with patient loyalty.
In addition, the quality of hospital services is indirectly related to patient
trust through patient satisfaction. It was also found that service quality has
an indirect influence on patient satisfaction through loyalty. Patient trust
also influences patient satisfaction through loyalty. Thus, the quality of
hospital services influences patient trust through patient satisfaction, which
ultimately influences patient loyalty.
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