THE EFFECT OF SERVICE QUALITY AND PATIENT SATISFACTION ON PATIENT LOYALTY MEDIATED BY PATIENT TRUST AT RUMAH INDONESIA SEHAT (RIS) HOSPITAL

The increasing number of hospitals and the development of health industry have resulted in competition between healthcare providers. In facing the inevitable competition in the health industry, healthcare providers are required to adjust and evolve to achieve higher standards. Things that can be done to face the demands of this market is improving the quality and patient satisfaction. The goal is to increase patient trust and loyalty. This research aims to determine the effect of service quality and patient satisfaction on patient loyalty mediated by patient trust at Rumah Indonesia Sehat (RIS) Hospital. There were 67 samples in this study. The data used in this study is a type of quantitative data obtained from filling out questionnaires by selected respondents through a simple random sampling method. The analysis method used in this study is the Structural Equation Model (SEM) using the SmartPLS program. The result of this study shows that there is a significant effect of service quality and patient satisfaction on patient loyalty with patient trust as an intervening variable.


INTRODUCTION
The availability of healthcare providers determines the health status of a country.The quantity of hospitals in Indonesia since 2015 until 2019 has increased by 13.52%.In 2015, Indonesia had 2,488 hospitals, followed by an addition in 2019 became 2,877 hospitals.There were 2,985 hospitals in 2020.The increasing number of hospitals and the development of health industry have resulted in competition between healthcare providers, either to maintain or increase the number of patients.
Healthcare providers must adapt and develop to achieve higher standards in facing this competition in the health industry.Things that can be done is improving the quality of service.Service quality is an indicator of succeed healthcare provider.In addition, another indicator of the succeed health services is the realizing of patient satisfaction.Patient satisfaction will affect the patient's desire to return for using the same health service.This is called loyalty.
Good service quality will also encourage patients to have trust in using the healthcare service.By growing trust in patients, good and long-term relationships will be formed between patients and healthcare providers.In other words, growing patient trust will also foster patient loyalty.Hospital must improve service quality on an ongoing basis, paying attention to patient satisfaction and trust to grow patient loyalty.
Rumah Indonesia Sehat (RIS) Hospital is a type C hospital located in the city area of South Tangerang, Banten.During nowadays intense business competition due to the increasing number of hospitals in Indonesia, RIS Hospital keep trying to improve the services provided.The quantity of patients in 2018 was 15,336.In 2019, there were 14,315 patients.There was a decrease in the quantity of patients in 2019.A decrease in patients quantity also occurred in 2020, which were Volume 2 No.4 (2023)

Patient Satisfaction
Very Satisfied Satisfied Dissatisfied 13,995 patients.However, in 2021, there was an increase in the quantity of patients, becaming 14,105 patients.
Here is a data on patient satisfaction with the services provided by RIS Hospital from 2021 to May 2022.This data was obtained from inpatient and outpatient patients who filled out a customer feedback form after receiving services at the hospital.This customer feedback form contains eight questions regarding hospital services: registration and cashier services, nurses, doctors, pharmacies, laboratories, radiology, facilities, and cleaning and security officers.The patient was then given three answer choices: very satisfied, satisfied and dissatisfied.RIS Hospital patient satisfaction data is presented in Figure 1.1..1 shows the categories of patient satisfaction at RIS Hospital.There are three categories.Those are very satisfied, satisfied, and dissatisfied.Since January 2021 -March 2021, the satisfied category had the highest percentage compared to other categories.However, over time, the highest percentage was found in the very satisfied category, especially in March 2022.This shows an increase in the percentage of patients who are very satisfied with the services provided by RIS Hospital.
In addition to patient satisfaction data, there is also data of patients' return visit at RIS Hospital throughout 2021 until May 2022.According to Tjiptono in Rahmawati et al. (2022) and Kotler and Keller in Rahayu & Syafe'i (2022), one indicator of customer loyalty is repeat purchases.Repeat purchases indicate attachment, and this can be used to measure the value of customer satisfaction with the company's products.In this case, repurchasing means returning of patients to the hospital.Data of patients' return visit at RIS Hospital is presented in Figure 1.2.
The purpose of this research is to find out: (1) Is there any effect of service quality on patient loyalty?(2) Is there any effect of patient satisfaction on patient loyalty?(3) Is there any effect of service quality on patient trust?(4) Is there any effect of patient satisfaction on patient trust?(5) Is there any effect of patient trust on patient loyalty?(6) Is there any effect of service quality on patient loyalty, which is mediated by patient trust?(7) Is there any effect of patient satisfaction on patient loyalty, which is mediated by patient trust?

2.LITERATURE REVIEW 2.1.Theoretical Concepts Service Quality
According to Pratiwi & Suparna (2018), service quality is a measure of the extent to which the efforts or services provided by the company can meet customer expectations.Some things must be considered in service quality.Those are the customer's expectation and the quality of service that is received or felt by the customer.If the service received by the customer is felt to be in line with expectations, then the service is good in quality (Fulgara et al., 2020).
One method that can be used to evaluate service quality is to use the Service Quality (Servqual) model.This model was developed by Parasuraman, Zeithmal, and Berry (Sharifi et al., 2021).This model consists of five dimensions, including: (a) Tangibles(physical evidence), including the physical facilities owned to support the operational activities (b) Reliability, regarding the reliability and accuracy in providing services (c) Responsiveness, refers to the speed of service (d) Assurance, refers to the ability to provide guarantees of the services provided, which include guarantees for knowledge and attitude during the process of service (e) Empathy, refers to attention given to customers (Primandaru, 2019;Wididana, 2017).
Internal regulation is needed within the organization to create service quality that meets standards (Fushen, 2021).Good quality health services will make patients and their families feel satisfied and trust the services provided by the hospital (Winata et al., 2022).To guarantee the quality of the services provided, training can be conducted to improve competence (Fushen, 2021).

Trust
Trust is generally defined as one party's expectation of another party to act as well as possible.Trust is built and maintained through consistent positive exposure (Arakelyan et al., 2021).McKnight et al. in Rahmawati et al. (2022) state that there are two essential things from trust (1) Trusting belief , refers to the belief of a person to trust another party.Three elements must be met to build a trusting belief : benevolence, integrity, and competence. (2) Trusting intention refers to customers who are aware, intend, and willing to depend on other parties.Things that can foster trusting intention include: i. Willingness to depend The willingness of customers to depend on the company.The customer is willing to accept all conditions that may arise in the future.
ii. Subjective probability of depending Customers are willing to provide personal information to the company, making transactions, and accepting company suggestions and requests.Ozawa & Sripad (2013) states that trust in the healthcare system influences the treatment process, medication adherence, and utilization of healthcare services.With the growth of trust in patients, a long-term relationship will be formed between the hospital and the patient.This affects the continuity of the hospital.The hospital can grow and develop because the patient's trust in this hospital will make the return to the hospital, whether for treatment or using other services available at the hospital (Vanessa Gaffar in Verriana & Anshori, 2017).

Loyalty
According to Philip Kotler & Keller in Verriana & Anshori (2017), loyalty means a firm commitment to reuse a company's products or services in the future.Loyalty is a form of the firm and consistent commitment, regardless of the marketing influence or temptation of other companies (Primandaru, 2019).

2.2.Previous Research
The following is research that has been conducted by previous researchers about the variables of service quality, patient satisfaction, trust, and loyalty.

2.3.Conceptual Framework
Based on the literature review, it is known that there are several things that can influence the formation of patient loyalty to healthcare providers, including service quality, patient satisfaction and trust.Patient trust can be influenced by patient satisfaction and the quality of services provided by healthcare providers.The conceptual framework of this research can be described as follows

3.RESEARCH METHOD 3.1.Object of research
The object of this research is patient loyalty at RIS Hospital, which is influenced by service quality, patient satisfaction and trust.The location of this research is at Inpatient Unit of RIS Hospital, which is located in the city of South Tangerang.Data collected by using a questionnaire that was distributed and then filled out by inpatients in September 2022.

3.2.Population and Sample Population
Population is a group of subjects with certain characteristics.These special characters are selected and analyzed in the process (Sugiyono, 2017).The population in this study were inpatients at Rumah Sehat Indonesia (RIS) Hospital during the study period (September 2022).The population size is set at 200 people (the average quantity of patients per month in 2022).

Sample
Sugiyono (2017) states that sample is part of a population that has certain characteristics.Sampling aims to determine the number of samples used in the research of an object.The sampling method used in this study is the probability method of simple random sampling technique.The inclusion criteria in this study include the following: (1) Inpatients ( 2) Previously hospitalized at RIS Hospital (3) 17-65 years old (4) Willing to be a respondent While the exclusion criteria in this study include the following: The patient is unable to read and write The sample size is determined based on the Slovin formula n = N 1+N(e) 2 Notes: n = sample size N = population size e = fault tolerance In this study, the population (N) was set at 200 people (the average quantity of patients per month in 2022), while the error tolerance was set at 10%.Based on the above formula, a sample of 67 respondents will be obtained.

3.3.Operational Variables
According to Sugiyono (2017), research variable is something that is determined as learning material by researchers.This research variable will provide information and conclusion about the things studied.
Variables in this study include (a) Independent variable Independent variables are variables that can result in changing or forming the dependent variable.In this study, the variables of service quality (X1) and patient satisfaction (X2) were selected as independent variables.(b) Intervening variable Sugiyono (2017) states that the intervening variable is the intermediary variable, influencing the relationship between the independent variable and the dependent variable to become an indirect relationship.The intervening variable in this study was the patient's trust (Z).

(c) Dependent variable
The dependent variable is a variable that is influenced by the independent variables.The dependent variable changes or becomes the result because of the existence of the independent variable (Sugiyono, 2017).The dependent variable in this study is patient loyalty (Y)

3.4.Data Collection Technique
He data used in this study was primary data.Primary data source means that the data is obtained and collected by the author from the source directly.The data collection technique that will be applied is the questionnaire method.
The questionnaire used was adapted from Primandaru (2019), Rahmawati et al. (2022), Subhan & Iswati (2022), and Priliagita et al. (2021).This questionnaire is able to provide an overview of the effect of service quality and patient satisfaction on patient loyalty mediated by patient trust.The instrument is a questionnaire consisting of 4 main variables with a total of 34 questions.Based on the questionnaire, the patient's opinion will be assessed regarding service quality and patient satisfaction at the hospital and how it affects the level of patient trust and loyalty.
In this questionnaire, respondents' ratings were measured using a Likert scale worth 1 to 5.This scale is used to measure the extent to which respondents agree with the indicators in the questionnaire.According to Siregar (2017), the Likert scale is a scale whose use is intended to measure the opinions, perceptions, and attitudes of a person regarding a matter or situation.The Likert scale consists of the following: (a) Score 5: Strongly Agree (b) Score 4: Agree (c) Score 3: Neutral (d) Score 2: Disagree (e) Score 1: Strongly Disagree

3.5.Data Analysis Technique
The data analysis used in this study is the Structural Equation Model (SEM) approach using SmartPLS 3.0 software.Hair et al. (2017) state that SEM is an analytical tool that can be used to examine causal relationships with latent variables.
SEM analysis includes two models, namely the measurement model (outer model), which refers to how the manifest variable represents the measurement of latent variables, and the structural model (inner model), which states the strength of estimation between latent or construct variables.(Ghozali, 2020).

Evaluation of the Measurement Model (Outer Model)
Evaluation of the measurement model aims to assess the validity and reliability of the model.The purpose of validity testing is to see the extent to which a measuring instrument is able to measure what is to be measured.Reliability aims to determine the consistency of measurement results when measurements are made more than once of the same phenomenon and with the use of the same measuring device (Siregar, 2017).Tests carried out on the outer model include: (a) Convergent Validity Hair et al., (2017) state that to assess convergent validity can be done by using the Rule of Thumb, which is, the loading factor must be worth more than 0.7.In addition, convergent validity can be determined by looking at the Average Variance Extracted (AVE) value for each construct with a correlation between constructs.The expected AVE value, which is over or above 0.5, means that 50% or more of the variance of the indicator can be explained.

(b)
Discriminant Validity Discriminant validity indicates that a construct has certain characteristics and is not described by other constructs.There are two methods that can be used to test discriminant validity, which are based on cross-loading values and Fornell Lacker criteria.The crossloading value, namely the discriminant validity value of an indicator, must be greater than the cross-loading value of other constructions.The use of the Fornell Lacker criterion is by comparing the square root of the AVE value with the correlation of latent variables.The AVE square root must be greater than the highest correlation with other constructs Hair et al., (2017)

. (c) Cronbach Alpha and Composite Reliability
The reliability of a construct using the PLS-SEM method using SmartPLS 3.0 can be tested by looking at the Cronbach Alpha and Composite Reliability values.Cronbach Alpha is used to determine the lower limit of the reliability of a construct, while Composite Reliability is used to see the reliable value of a construct (Ghozali, 2020).The use of the Rule of thumb in assessing construct reliability is based on the composite reliability value.Composite reliability is expected to be above 0.7 (Hair et al., 2017).The Cronbach Alpha value is said to be reliable if it is greater than 0.7 (Ghozali, 2018).

Evaluation of the Structural Model (Inner Model)
The purpose of evaluating the inner model is to predict the relationship between variables.The relationship between variables that is significant or not seen is based on the value of the path coefficient.The path coefficient value is obtained from the bootstrapping process.The direction of the path coefficient must be in accordance with the hypothesized theory.The tests on the inner model used include: (a) Coefficient of Determination (R 2 ) According to Siregar (2017), the coefficient of determination shows how much contribution is made by one or more variables, X to variable Y.The coefficient of determination (R 2 ) measures the size of the model's ability to explain variations in the dependent variable.The value of the coefficient of determination is in the value range of 0 to 1. AccordingHair et al. (2017), the value of the coefficient of determination is strong if it has a value of 0.75.In contrast, a value of 0.50 means moderate and is said to be weak if the value is 0.25.

(b)
Blindfolding and Predictive Relevance (Q 2 ) Predictive relevance, which is marked with the Q² value, shows how well the observed value is generated using the blindfolding procedure (Ghozali, 2018).In the inner model, it is said that the model has predictive relevance for certain endogenous constructs if the Q² value is greater than zero.If the result of calculating the Q2 value is 0.02, it means that it is weak.If the Q² value is 0.15, it means medium, while 0.35 means strong (Hair et al., 2017).

Hypothesis
This study uses several variables, including service quality, satisfaction, trust, and patient loyalty.To test the hypothesis, multivariate analysis was carried out with the PLS-SEM test using the SmartPLS program.The t-test statistic is used to show how an independent variable influences the variation in the dependent variable (Ghozali, 2018).Then look at p-value with the significance level = 10%.If the p-value < 0.05, then Ho is rejected.In contrast, Ho is accepted if the p-value > 0.05.The following is the basis for decision-making, namely: (a) If the value of t statistic < t table, then Ho is accepted, and Ha is rejected.(b) If the value of t statistic > t table, then Ho is rejected, and Ha is accepted.

Mediation Effect
Intervening variables are variables that can cause changes in the relationship between the independent variables and the dependent variable.This variable is called an intervening variable because it is between the two variables.The existence of an intervening variable makes the independent variable not directly cause a change in the dependent variable (Sugiyono, 2017).
This study uses t-table values and p-values to analyze the effect of the independent variables of service quality (X1) and satisfaction (X2) on patient loyalty (Y) mediated by patient trust (Z).The effect of mediation is said to be significant if the calculated t value is greater than the t table value (> 1.96).If the p-value is less than 0.05, it can be said that the variable has a significant influence and effect (Hair et al., 2017).
The estimation of indirect effect was conducted to examine the indirect effect of mediating variables.The mediating variable is accepted with the following criteria (Hair et al., 2017) (a) Full mediation, that is, a variable is declared to mediate entirely if the path of the independent variable coefficient to the dependent variable becomes insignificant (b) Partial mediation, that is, a variable is said to mediate partially if the path of the independent variable coefficient to the dependent variable has a value that remains significant or only slightly decreases.The variable is declared not to mediate if the direct and indirect effects show insignificant results.

4.1.Characteristics of Respondents
Respondents of this study were inpatients who had ever been hospitalized at RIS Hospital.Respondents based on the characteristics of age, gender, last education, and marital status are shown in tables below.Convergent validity can also be determined based on the Average Variance Extracted (AVE) value.The expected AVE value is above 0.5.In this study, the four variables met the convergent validity requirements because they had a value of more than 0.5.The following is the AVE value of each variable.

Discriminant Validity
Discriminant validity can be determined by looking at the cross-loading indicator value.Cross-loading on the intended construct must have a value that is greater than the loading value of other constructs.Discriminant validity can also be seen through the Fornell-Larcker criteria.In this study, the AVE square root of each construct was greater than the highest correlation with the other constructs.

Cronbach's Alpha and Composite Reliability
The results of the reliability test in this study can be seen in the following table, where it can be seen that the value of Cronbach's alpha and composite reliability shows a value greater than 0.7.This means that all variables are reliable or reliable., all of the path coefficient values are positive.The greatest path coefficient value is found in the effect of service quality on trust, which is equal to 0.712.The greater the path coefficient value of the independent variable on the dependent variable, the greater the influence of the independent variable on the dependent variable.

Coefficient of Determination (R 2 )
The following is the value of the coefficient of determination in this study The coefficient of determination in this study was found to be greater than 0.50, which means it is moderate.In this case, service quality and satisfaction simultaneously have a moderate effect on patient trust and loyalty.The R Square value on trust is 0.702.This means that the percentage of trust can be explained by service quality and satisfaction is 70.2%.Furthermore, the R Square value of loyalty is 0.676.This means that the percentage of loyalty can be explained by the quality of service and satisfaction is 67.6%.

Blindfolding and Predictive Relevance (Q 2 )
In this study, the results of the calculation of Q 2 > 0.35, it can be concluded that the predictive relevance of the exogenous variables used to predict the endogenous variables is strong.
.9035 The results of the calculation above interpret the results of the diversity of research data that can be explained by the research model, which is equal to 90.35%.In contrast, the remaining 9.65% is explained by other things that are not included in this research model.

Hypothesis
Hypothesis in this study were analysed by using the SEM (Structural Equation Model) approach through the Smart PLS program.The following are the results of testing each hypothesis.H1: Service quality has a positive effect on loyalty, where the path coefficient value is 0.212.In this study, the t statistic was greater than the t table (1.96), which was 2.225, and the pvalue was smaller than 0.05, which was 0.027.Thus, this hypothesis is accepted.H2: Satisfaction has a positive effect on loyalty, where the path coefficient value is 0.205.In this study, the t statistic was greater than the t table (1.96), which was 2.169, and the pvalue was smaller than 0.05, which was 0.031.Thus, this hypothesis is accepted.H3: Service quality has a positive effect on trust, where the path coefficient value is 0.712.In this study, the t statistic was greater than the t table (1.96), which was 14.305, and the pvalue was smaller than 0.05, which was 0.000.Thus, this hypothesis is accepted.

Mediation Effect
In the direct effect test, the effect of service quality on loyalty is significant.In the indirect effect test, with the variable of trust, the effect of service quality on loyalty remains significant.The direct and indirect effects are equally significant.This means that trust has partial mediation effect.With or without trust, service quality still has a significant impact on loyalty.
Likewise, with variable of patient satisfaction.In the direct effect test, the immediate effect of patient satisfaction on loyalty is significant.In the indirect effect test, with the variable of trust, the effect of satisfaction on loyalty remains significant.Tests for direct and indirect relationships are equally significant.With or without trust, patient satisfaction still significantly impacts loyalty.This means that trust has partial mediation effect.

H1:
The Effect of Service Quality on Patient Loyalty Subhan & Iswati (2022) stated that health service facilities must be able to provide quality health services to maintain patient loyalty.The better the quality of service, the more loyal the patient will be (Coal, 2019).The result of the research shows that service quality has a significant positive effect on patient loyalty.H2: The Effect of Patient Satisfaction on Patient Loyalty The patient's desire to return to the same healthcare provider will increase if the patient feel satisfied (Zhou in Ekananta et al., 2019).Improving patient satisfaction will increase patient loyalty to the hospital (Holiwono & Pattyranie Tan, 2021).The result of the research shows that patient satisfaction has a significant positive effect on patient loyalty.H3: The Effect of Service Quality on Patient Trust Nemati et al. (2020) stated that the higher the quality of services provided by the hospital, the higher the level of patient trust would be.The result of the research shows that service quality has a significant positive effect on patient trust.

5.CONCLUSIONS AND RECOMMENDATIONS 5.1.CONCLUSIONS
The conclusions in this study include 1.
Service quality has a significant positive effect on patient loyalty.2.
Patient satisfaction has a significant positive effect on patient loyalty.

3.
Service quality has a significant positive effect on patient trust.4.
Satisfaction has a significant positive effect on patient confidence. 5.
Trust has a significant positive effect on patient loyalty.6.
Trust is significant and positively mediates the effect of service quality on patient loyalty.7.
Trust is significant and positively mediates the effect of patient satisfaction on patient loyalty.

5.2.RECOMMENDATIONS 1.
For further research Further researchers can develop this research model by including other variables as mediating variables.In addition, further researchers can increase the quantity of samples and use different methods for data collection, such as direct interviews with respondents 2.
For institutions, RIS Hospital Paying more attention to various aspects or factors that can influence the improvement of service quality, patient satisfaction, patient trust, and patient loyalty.

Figure
Figure1.1 shows the categories of patient satisfaction at RIS Hospital.There are three categories.Those are very satisfied, satisfied, and dissatisfied.Since January 2021 -March 2021, the satisfied category had the highest percentage compared to other categories.However, over time, the highest percentage was found in the very satisfied category, especially in March 2022.This shows an increase in the percentage of patients who are very satisfied with the services provided by RIS Hospital.In addition to patient satisfaction data, there is also data of patients' return visit at RIS Hospital throughout 2021 until May 2022.According to Tjiptono inRahmawati et al. (2022) and Kotler and Keller inRahayu & Syafe'i (2022), one indicator of customer loyalty is repeat purchases.Repeat purchases indicate attachment, and this can be used to measure the value of customer satisfaction with the company's products.In this case, repurchasing means returning of patients to the hospital.Data of patients' return visit at RIS Hospital is presented in Figure1.2.

.Data analysis Evaluation of the Measurement Model (Outer Model) Convergent Validity In
this study, there are 34 indicators of the variables used.The indicator is declared valid if the loading factor value is > 0.7.The following is the loading value of the 34 indicators in this study.

Table 4 .9. Reliability Test Cronbach's Alpha Composite Reliability
Evaluating the structural model can be done by looking at the value of the path coefficient.The results of the path coefficient can be seen in the following table.