The Effect of Service Quality on Patient Satisfaction in Obstetrics and Gynecology Polyclinic of PKU Muhammadiyah Gombong Hospital, Kebumen District During the Covid-19 Pandemic

Received 06 June 2021 Accepted 26 August 2021 Published 15 September 2021 Health is one of the indicators of community welfare, so the community needs quality health services to meet their basic needs. To improve services and increase patient satisfaction, hospitals need to apply the Covid-19 policy in screening and service flows which are predicted to affect patient satisfaction. Aim of this study wasdetermine the effect of service quality on patient satisfaction during the COVID-19 pandemic. The research method in this study used a cross-sectional approach. The population was outpatients at the obstetrics and gynecology polyclinic. The sample was determined using the accidental sampling technique with a total of 360 patients. The data were analyzed to determine the most dominant factor by using a logistic regression test. Based on the results of multivariate analysis, the variables with the greatest influence on patient satisfaction are the assurance variable (95% CI 1.50-6.06 with a p-value of 0.012), empathy (95% CI 1.38-4.65 with a p-value of 0.006), and tangible (95% CI 1.044.08 with a p-value of 0.001). Based on the results, it can be concluded that there is a relationship between the dimensions of service quality and patient satisfaction. The quality of service during the Covid-19 pandemic is considered good but needs to be optimized on the dimensions of assurance, empathy, and tangible.. Keyword:

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INTRODUCTION
In Indonesia Sehat 2025, it is expected that the community can access quality health services and obtain health insurance in which they get protection in meeting their basic health needs (Bella, 2013). Through a healthy environment and behavior and increasing access to obtain quality health services, the highest degree of health for individuals, families, and communities can be realized (Kesehatan et al., 2019). Health care is a system consisting of many interrelated and interdependent component . Hospital service quality is the end product of complex interactions and dependencies between various aspects of service .
As the middle class grows, the demand for higher quality health services increases(World Health Organization, 2020). Therefore, it needs a program to maintain the quality of health services to provide satisfaction to the community(World Health Organization, 2020). Indonesia has not been fully able to provide good health services (E. & K., 2016). Health services in hospitals often receive complaints from the community due to different mechanisms and rules applied in hospitals and community service hours in the village government which closes earlier than the schedule (Broughton & Latief, 2016).
Besides, at the beginning of 2020, the world was shocked by a pandemic of new Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) called Coronavirus Disease 2019 (COVID-19) (Widya Astari et al., 2021). It was first discovered at the end of December 2019 in Wuhan, China(World Health Organization, n.d.). The Covid-19 pandemic has caused a decrease in the number of patient visits(World Health Organization, n.d.). It was due to changes in the health service flow, limitation on the number of patients to avoid crowds, as well as the implementation of standard prevention measures, early identification, and control of virus sources (Kementerian Kesehatan Republik Indonesia, 2020). Limiting the number of patients per day is guessed causing patients to go to other hospitals, resulting in a decrease in the number of patients (Kementerian Kesehatan Republik Indonesia, 2020).
Patient satisfaction is correlated with the quality of service in the hospital (Imelda & Nahrisah, 2019). By understanding the level of patient satisfaction, hospital management can learn and improve service quality (Murhadi & Karsana, 2021). Patient satisfaction is measured using standard instruments based on hospital performance indicators of the Ministry of Health of the Republic of Indonesia in 2005 (Kementerian Kesehatan Republik Indonesia, 2020). Patient satisfaction is an essential measurement that is fundamental to the quality of service (Swain & Kar, 2018). It is because it provides information on the success of service providers with the desired values and expectations (Widya Astari et al., 2021). Thus, it is important to improve the quality of services to be more optimal during a pandemic. This study aims to determine the relationship between service quality and patient satisfaction in the obstetrics and gynecology polyclinic during the covid-19 pandemic.

METHODS
This study used a quantitative approach with a crosssectional design. It was conducted at the obstetrics and gynecology polyclinic from January to May 2021. It used an accidental sampling technique. The sample was 360 outpatients at the obstetrics and gynecology polyclinic.
The study used both primary and secondary data. The data were collected by questionnaire in Google form. The questionnaire link was shared via social media (Facebook, WhatsApp). The questionnaire used a Likert scale. The descriptive data analysis used Microsoft excel.

Data Analysis
This study was beginning with univariate analysis for each variable in characteristics. Bivariate analysis was carried out in this study. The logistic regression test was performed to find variables with the most influence on services in the obstetrics and gynecology polyclinic. Most of the respondents Moslem (93.0%) and aged 30-39 years old (33.3%), had university or higher education levels (35%) and worked as housewives (51.7%). Most of the gestational age was 14-28 weeks (55%) with parity of multipara (52.2%). Table 2 shows that the reliability variable has a p-value of 0.516 which is higher than p-value >0.05 it means that there is no influence between reliability and patient satisfaction. The results of the statistical test on the responsiveness variable showed a p-value of 0.453 which means that there is no influence between responsiveness and patient satisfaction. The p-value of assurance, empathy, and tangible variables reaches 0.004, 0.001n, and 0.047 respectively. It means that there is an influence between assurance, empathy, and tangible variables on patient satisfaction. Based on the multivariate analysis above, the logistic regression analysis shows 3 variables with a dominant effect of the quality of service on patient satisfaction in obstetrics and gynecology polyclinic. The first is the empathy variable with a significant value of 0.006 (p-value <0.05) 95% CI 1.38 -4.65, which means this variable has a 3 times effect on patient satisfaction. Second, the assurance variable with 0.012 (p-value <0.05) 95% CI 1.50-6.06 means that this variable has a 5 times effect on patient satisfaction. Third, the tangible variable with 0.001 (p-value <0.05) 95% CI 1.04 -4.08 which means that this variable has 3 times effect on patient satisfaction.

DISSCUSSION
The results of the statistical test of the assurance variable obtained a p-value of 0.012 <0.05. It means that there is a relationship between the dimensions of assurance and patient satisfaction. The Assurance dimension is the employee's ability to have proper product, safety assurance, skills, knowledge in providing security in utilizing the services offered, and the ability to instill customer trust in the company (Asnawi et al., 2019). The dimension of assurance is a combination of the dimensions of competence (complete) of the competencies and knowledge possessed with employees to carry out services, courtesy which includes friendliness, attention, and attitude of employees, and credibility which includes trust in the company such as reputation, achievements and so on (Swain & Kar, 2018).
The results of this study are in line with a study by Ika Cahyaningrum entitled The Effect of Health Service Quality on Patient Satisfaction in Outpatient of General Polyclinic of PKMS Participants (Free Healthcare Program) in Surakarta City Hospital in 2012. She revealed that the Assurance dimension based on the Chi-Square test reaches 0.011 < 0.05, then H0 is rejected (Harun, 2020). It means that there is a relationship between assurance and patient satisfaction at the Surakarta Hospital (Khrestianto et al., 2020). However, this present study is in contrast with a study by Eka Masi Lumban entitled The Effect of Health Service Quality on the satisfaction of inpatients at the Pelabuhan Medan Hospital (Prima Husada Cipta) in 2017. The results of the chi-square test showed 0.699 > 0.005 which means that there is no relationship between the dimensions of assurance and patient satisfaction (Imelda & Nahrisah, 2019).
Currently, health services follow the first edition of COVID-19 Prevention Guidelines issued by the Ministry of Health of the Republic of Indonesia (Kementerian Kesehatan Republik Indonesia, 2020). Patient satisfaction can be influenced by the existence of health protocols and the flow of Covid-19 triage services (Widya Astari et al., 2021). The appeal to keep distance in hospital, to always wear masks in hospital, and early identification and control of the source of infection causing the changes in the flow of health services can make patients feel uncomfortable (Widya Astari et al., 2021).
The results of the statistical test of the empathy variable obtained a p-value of 0.006 <0.05 meaning that there is a relationship between the empathy dimensions and patient satisfaction. The results of this study are in line with a study by Andini Mentari Tarigan entitled Effect of Service Quality on Patient Goodness in Cardiac Outpatient Polyclinic at Advent Hospital Medan in 2018. She found that there is a very significant relationship between empathy and patient goodness with the p-value of 0.009 <0.05 (Tarigan et al., 2018). Further, she explained that everyone's satisfaction is different in which satisfaction is strongly influenced by the characteristics of patients including education, social status, and others so that each patient may have different expectations in getting services (Tarigan et al., 2018). Personal factors that can influence perceptions are attitudes, motivations, interests, past experiences, and expectations (Hawrysz et al., 2021). Patient satisfaction is assessed based on the patient's perception of the services received and their expectation of health care workers' skills and politeness, and completeness of facilities and infrastructure in providing services (Khrestianto et al., 2020).
The results of the statistical test of this tangible variable obtained a p-value of 0.001 <0.05. It means that there is a relationship between the tangible dimensions and patient satisfaction. Tangibles (appearance/physical evidence) is a form of physical reality that includes the appearance and completeness of physical facilities such as comfortable treatment rooms, front office, availability of parking spaces, cleanliness, neatness, waiting rooms, examination rooms, completeness of equipment, communication, and appearance (Arsita & Idris, 2019). The results of this study are in line with a study by Ani Sepatiani entitled The Influence of Service Quality Factors on the Patients Goodness in the Emergency Units of Sumedang District Hospital. The results of the chi-square test were 0.000 < 0.05 meaning that the null hypothesis is rejected so that the results are significant.
The Covid-19 pandemic has changed the quality of nursing services in hospitals that previously depended on skills, speed, convenience, and accuracy in carrying out nursing practices (Widya Astari et al., 2021). The patient has high expectations in which they consider the facility has a good quality of service if the service received is in accordance with or exceeds their expectation . Meanwhile, if the service received is lower than expected, the quality is considered unsatisfactory (Asnawi et al., 2019). The quality of health services and patient satisfaction are important elements in providing health services (Murhadi & Karsana, 2021). Assessing and evaluating a health service based on user perceptions is important for the continuous improvement of health services (Pratama & Hartini, 2020). Patient satisfaction is believed to correlate with service quality and becomes the key to service outcomes (Tariq Rafi et al., 2020) CONCLUSION AND SUGGESTION During the COVID-19 pandemic, monitoring and measuring patient satisfaction has become a basic need for every service provider as such evaluation can provide feedback and input for developing and implementing strategies to increase patient satisfaction. In principle, patient satisfaction can be measured by various methods and techniques. The results of the multivariate analysis show that the assurance, empathy, and tangible dimensions dominantly affect patient satisfaction in obstetrics and gynecology polyclinic. It requires an improvement of longterm supporting factors such as improving the quality of services or infrastructure and improving the performance of health care workers including the attitude.