The Satisfaction Analysis of National Health Insurance ( JKN ) Patient Using the Hospital Consumer Assessment Healthcare Providers and Systems ( HCAHPS ) Survey Between Public Hospital and Private Hospital in D . I . Yogyakarta

Received 11 July 2021 Accepted 21 August 2021 Published 10 September 2021 Patient satisfaction is an essential indicator of the effectiveness and success of health care providers. HCAHPS is a survey instrument with 29 questions and is a data collection methodology to measure patients' perceptions of hospitalization experiences while in hospital. This study aims to analyze the level of patient satisfaction of Jaminan Kesehatan Nasional (JKN) using the Hospital Consumer Assessment Healthcare Providers and Systems (HCAHPS) between Public Hospital and Private Hospital in D. I Yogyakarta. This research is quantitative research using cross-sectional methods. The population of this research is all inpatients with JKN insurance. The number of samples in public hospitals is as many as 208 people and private hospitals as many as 191 people—data analysis using Mann Whitney and Chi-Square. This study showed no difference in the level of patient satisfaction of national health insurance in public and private hospitals with a significance value of 0.21. The results of crosstabulation testing relationship between BPJS categoric class of patients with patient satisfaction in public hospital and private hospital both obtained results of significance values of 0.846 and 0.7999 so that there is no relationship between BPJS categoric class with patient satisfaction levels using HCAHPS between public hospital and private hospital. Keyword:


A B S T R A K
Kepuasan pasien merupakan indikator penting dari efektifitas dan keberhasilan pelayanan kesehatan. HCAHPS adalah instrumen survei yang didalamnya terdapat 29 item pertanyaan dan merupakan metodologi pengumpulan data untuk mengukur persepsi pasien tentang pengalaman rawat inap ketika di rumah sakit. Penelitian ini bertujuan untuk menganalisis tingkat kepuasan pasien Jaminan Kesehatan Nasional (JKN) menggunakan metode Hospital Consumer Assessment Healtcare Providers and Systems (HCAHPS) antara Rumah Sakit Umum Daerah dengan Rumah Sakit Swasta di Provinsi D.I Yogyakarta. Penelitian ini merupakan penelitian kuantitatif menggunakan metode cross sectional study. Populasi dalam penelitian ini adalah pasien rawat inap menggunakan asuransi JKN. Jumlah sampel di PUBLIC HOSPITALS sebanyak 208 orang dan RS Swasta sebanyak 191 orang. Analisis data menggunakan Mann Whitney dan Chi-Square. Hasil penelitian ini menunjukkan tidak terdapat perbedaan tingkat kepuasan pasien jaminan kesehatan nasional di PUBLIC HOSPITALS dan RS Swasta Provinsi D.I Yogyakarta dengan nilai signifikansi 0,215. Hasil pengujian crosstabulation hubungan antara kelas BPJS pasien dengan tingkat kepuasan pasien JKN di PUBLIC HOSPITALS dan di PRIVATE INTRODUCTION Badan Penyelenggara Jaminan Sosial (BPJS) is a public legal entity in Indonesia that organizes health insurance programs for all Indonesians. Because BPJS is a publicly owned body, the BPJS or National Health Insurance (JKN) program's success indicator is the same as that of other governments: the level of public satisfaction (Hakim & Suryawati, 2019) One method for assessing service quality is to measure patient satisfaction (Dahyanto & Arofiati, 2018). Patient satisfaction has long been recognized as essential and increasingly emphasized by healthcare systems in developed countries like the United States and the United Kingdom. Beginning in 2002, the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) in the United States launched a program requiring hospitals in the United States to report patient satisfaction via Hospital Consumer Assessment Healthcare Providers and Systems (HCAPHS) to qualify for the renewal of the annual inpatient retrospective payment system in the United States (Davidson et al., 2017).
HCAHPS is a survey instrument with 29 questions and is a data collection methodology to measure patients' perceptions of hospitalization experiences while in hospital. The three main objectives driving the development of the HCAHPS survey are 1) Motivating hospitals to improve the quality of their services related to patient satisfaction, 2) Providing transparent public reporting containers for survey results, and 3) Enabling patients to compare hospitals objectively (4). HCAHPS was initially conducted in the United States, resulting in many studies measuring patient satisfaction levels. One study conducted by Siddiqui et al. (2014) aimed to look for differences in patient satisfaction between specialist hospitals and public hospitals in the United States using HCAHPS surveys. There are significant differences among the number of hospitals in the United States. Indonesia urgently needs to conduct a survey using HCAHPS for all hospitals in Indonesia because HCAHPS results later as a form of public reporting on hospital performance information regarding patient satisfaction (Siddiqui et al., 2014).
In Indonesia, the SERVQUAL instrument is used to assess patient satisfaction and is the most commonly used instrument in Indonesia in research to evaluate patient satisfaction. But the SERVQUAL instrument has not described specific nursing services about how the nursing service process can meet the needs of patients from the time the patient enters the hospital to discharge from the hospital (Badrin et al., 2019). In Indonesia, several studies conducted in the last five years that use HCAHPS to measure patient satisfaction levels with various variables, such as research conducted by Pasinringi et al. (2015) with the results of patient satisfaction levels at two type B hospitals in Makassar city by 49.3 percent and by Pare Layuk (2020) with the level of patient satisfaction >70 percent at Undata Palu Hospital (Pasinringi et al., 2015)(Pare Layuk, 2020. In Indonesia, there have been no studies on differences in JKN patient satisfaction levels between public and private hospitals. There were no studies on the differences in JKN patient satisfaction levels between public and private hospitals in Indonesia. There has been no analysis of the relationship between patient satisfaction levels and BPJS patient care classes that use HCAHPS as a patient satisfaction survey instrument. As a result, researchers are intending a study titled "The Satisfaction Analysis of National Health Insurance (JKN) Patient using The Hospital Consumer Assessment Healthcare Providers And Systems (HCAHPS) Survey Between Regional Public Hospital and Private Hospital in D.I. Yogyakarta".

METHOD
This is a quantitative study that uses a cross-sectional study design and an analytical survey approach. The population is patients who used financing from the National Health Insurance (JKN) at Panembahan Senopati Bantul Hospital as a Public Hospital and PKU Muhammadiyah Yogyakarta Hospital as a Private Hospital. To select the sample was probability sampling. The sample size was from Panembahan Senopati Bantul Hospital with as many as 208 patients and PKU Muhammadiyah Hospital as 191 patients. There are inclusion criteria in the selection of samples: patients over the age of 18 years, patients at least two days, patients who are willing to fill out questionnaires, and patients who will go home. In contrast, the exclusion criteria are uncooperative patients and patients who experience impaired consciousness.
The HCAHPS (Hospital Consumer Assessment Healthcare Providers and Systems) patient satisfaction survey developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) is used in this research instrument to assess patient satisfaction. This questionnaire contains 19 questions, 16 of which have answers on four Likert scales: 4 = always, 3 = usually, 2 = sometimes, and 1 = never. There are two questions with Yes/No answers and one with scoring number answers. According to Koutly et al., the questions in this study are valid and reliable. The HCAHPS survey can be used in developing countries with validity values between 0.52 -0.92 and Cronbach alpha coefficient 0.87. The data analysis used in the study was Mann-Whitney and Chi-Square, which previously conducted normality tests using Kolmogorov-Smirnov.

Description of Respondents
Some of the common characteristics of respondents assessed included age, gender, education level, occupation, income level, treatment classes, and the number of hospital inpatient visits. The number of men and women is not much different, namely for the percentage in male public hospitals 38.5% and women 61.5%, while in private hospitals men have a rate of 43.5% and women 56.5%. The majority of respondents were over the age of 29. The education level of most respondents was high school at 43.3% in public hospitals and 39.3% in private hospitals. Based on the most types of work, namely not working / homemakers both in public hospitals and private hospitals with the income of respondents mostly, namely not having income of 52.4% in public hospitals and 48.7% in private hospitals. In addition, the distribution of respondents' frequency based on BPJS treatment class in proportion to most patients was in class 3 care class both at public hospitals and at private hospitals. According to the number of inpatient visits in both hospitals, more patients are newly hospitalized for the first time, with public hospitals accounting for up to 55.3 percent and private hospitals accounting for up to 70.2 percent.  Table 1 shows that most respondents were satisfied with the dimensions used to assess the quality of experience at public hospitals. From the dimension of communication with nurses, almost all respondents, 207 respondents (99.5%), had a satisfying assessment. The dimension of communication with doctors has a satisfying review because all respondents, namely 208 respondents (100%), claimed to be satisfied in communicating with doctors. Of the dimensions of the hospital environment, 207 respondents (99.5%) were met, and the responsive dimension of staff, with 191 respondents (91.8%) satisfied. A total of 183 respondents (88%) were satisfied with the communication of medicines delivery from the officer to the patient.
Regarding the discharge planning submitted by nurses, 187 respondents (89.9%) were satisfied, and the patient's understanding of the discharge planning information provided was also satisfied by 197 respondents (94.7%). The last two dimensions are the recommendation, and there are 204 respondents (98.1%) and 208 respondents (100%) who assess the hospital rating dimension with a satisfied opinion.  Table 2 shows the frequency of respondents at private hospitals that most respondents are satisfied with the dimensions used to assess the quality of experience in public hospitals. From the dimension of communication with nurses, almost all respondents, 189 respondents (99%), have a satisfying assessment. The dimensions of communication with doctors had a satisfied review of 187 respondents (97.9%). Of the dimensions of the hospital environment, 190 respondents (99.5%) were satisfied, and the responsive dimension of staff, as many as 185 respondents (96.9%), were satisfied. A total of 167 respondents (87.4%) were satisfied with the communication about medicines from the nurses to the patient.
Regarding the discharge planning submitted by nurses, 181 respondents (94.8%) were satisfied, and the patient's understanding of discharge planning information was also satisfied by 178 respondents (93.2%). The last two dimensions are the recommendation dimension, and there are 182 respondents (95.3%) and 189 respondents (99%) who assess the hospital rating dimension with a satisfied opinion. The patient's experience during hospitalization is an assessment of patient satisfaction through what the patient wants related to the implementation of health services. Table  3 shows that almost all respondents in each hospital, 99.5% of respondents, are satisfied with inpatient treatment using national health insurance.

Normality Test
The normality test for patient satisfaction rate using national health insurance data at public hospitals and private hospitals using the Kolmogorov-Smirnov test. The significance value (Sig.) of both tests is 0.000. By taking a whole level of α = 5%, it is showing that the significance value (Sig.) of 0.000 is less than the value of = 0.05, implying that the data on patient satisfaction levels of national health insurance public hospitals and private hospitals do not follow a normal distribution.  Table 4 obtained a value of significance (Sig.) which is 0.215. By taking an actual level of α = 5%, it shows that the significance value (Sig.) of 0.215 is greater than the value of α = 0.05, so it can be concluded that there is no difference between the level of patient satisfaction of national health insurance in public hospitals and private hospitals of D.I Yogyakarta. Based on Table 5, the results of crosstabulation analysis (cross-table) between BPJS classes category with patient satisfaction levels of public hospitals from 208 respondents showed that patients in class 1, 2, and 3 mainly were satisfied with national health insurance facilities, namely 8.2% (17 people), 16.8% (35 people), and 74.5% (155 people) respectively. At the same time, there are 3 rd class patients who are dissatisfied with national health insurance, which is as much as 0.5% or one patient.  Table 6, from the results of chisquare calculations, with α = 5% of the value of the Chi-Square table, which is 5,991, it is known that the value of Chi-Square calculated is 0.335, smaller than the value of Chi-Square. The table is 5,991 and obtained a significance value (Sig.) of 0.846, more significant than the value α = 0.05. As an outcome, it's indeed reasonable to conclude that there is no relationship between the BPJS class category and the level of patient satisfaction with national health insurance at public hospitals.
Based on Table 7, the results of crosstabulation analysis between BPJS classes category with patient satisfaction levels of private hospitals from 191 respondents showed that patients in classes 1, 2, and 3 mainly were satisfied with national health insurance, namely 25.1% (48 people), 5.8% (11 people), and 68.6% (131 people) respectively. At the same time, there are class 3 patients who are dissatisfied with national health insurance, which is as much as 0.5% or one patient. Gender both from public hospitals and private hospitals are women more than men. In research on critical thinking skills by Zetriulista et al. found that in terms of necessary thinking, women have a higher score than men (Zetriuslita et al., 2016) while in research by Torrance (1983) in Shubina and Kulakli (2019), contrary that there is no difference in terms of gender for critical thinking (Shubina & Kulakli, 2019) The results of this study mentioned that the age of most respondents is >29 years. According to the Ministry of Health (2009), the age category of 26-35 years is classified as early adulthood, so the age of >29 years categorized in this study is included in adult patients. The level of patient satisfaction in patients aged up to 60-80 years has a high level of satisfaction (Jaipaul & Rosenthal, 2003).
Based on the results of this study, respondents with high school education are more satisfied than respondents with other levels of education. The level of education is an indirect factor that affects a person in determining the level of satisfaction in health services; as stated by Jafari et al. (2014), patients satisfaction is related to the level of education(Jafari Kelarijani et al., 2014) Respondents to the study mostly didn't work. Respondents who are classified as not working are housewives and people who do not have a job. Many other factors are influential in determining the selection of health care places. Employment has an unequal tendency to understand and react to the health services received (Montol et al., 2014) This study obtained patients in terms of the most income is those who do not have income. Listiani (2017) explained in her research that someone who has a high income because they are financially able will be more demanding of the health services needed, while respondents with low incomes will prefer health facilities that are cheaper so that they can still receive more affordable health services (Listiani, 2017) .
Based on the level of BPJS classes category in this study, it was found that all class 1 and 2 patients had a 100% satisfaction level. In contrast, class 3 patients were one patient who was dissatisfied with inpatient health services both in public hospitals and private hospitals. Like a study conducted by Erilisanawati (2018) found a difference in the level of satisfaction of class 1 inpatients higher than patients in 3 class hospitals at Dr. Soediran Mangun Sumarso Hospital. According to Erilisanawati (2018), it can be influenced by differences in expectation levels with the services experienced by the services provided by the hospital (Erilisanawati, 2018) The number of visits of more than one patient in public hospitals and private hospitals is less than the first time in hospitalization. Increased inpatient dissatisfaction can decrease the number of visits by patients who refused to be admitted to the same hospital before. Low patient satisfaction results in patients not using the services provided. Patients with experience can convey their recommendations to relatives, friends, and others not to use health services offered by a hospital (Hafizurrachman, 2009)

Communication with Nurses and Doctors
Increased patient satisfaction with communication with nurses was 99.5% and 99%, respectively. Similarly, communication with doctors obtained a satisfaction level of 100% in public hospitals and 97.9% in private hospitals. In the results of this study from the aspect of communication with nurses, one patient was dissatisfied with communication with nurses in public hospitals and two patients in private hospitals. From the Indonesian Ministry of Health data in 2015, patient dissatisfaction with nurse communication is still found. The average data obtained from several hospitals in Indonesia shows that 67% of patients were dissatisfied with accepting health services. Attitude and nurse communication to patients will impact patient satisfaction, where the patient's needs over time will increase (Evisusanti, 2020) The communication component with doctors found dissatisfaction by 2.1% in private hospitals. A form of patient dissatisfaction found in another study in private hospitals that as many as 17 out of 20 patients were dissatisfied with the services provided by doctors. The form of patient dissatisfaction in private hospitals is the availability of very little doctor time in offering health services both in communicating and conducting examinations to patients who seem like a rush (Pasaribu, 2020) The thing discovered directly at private Hospital is a patient who is dissatisfied with communication with the doctor, expressing that the doctor is sometimes only visited by the patient 2-3 days after the patient is hospitalized because the doctor's visit schedule is adjusted to the doctor's policlinic schedule. While at public hospital, according to specialist doctor visit hours compliance data, DPJP obtained the highest value of 93 percent and at least 83 percent. The results of this study revealed that all respondents were satisfied with communication with doctors. Related to this, some things that can be improved are determining the criteria for compliance with the specialist's visit hours where the compliance of specialist visit hours as DPJP is a specialist doctor's visit to see the development of the patient who is his responsibility every day before 14.00 WIB including on holidays. Concerning this, some things that can be improved are determining the criteria for compliance with the specialist's visit hours, where the submission of specialist visit hours as DPJP is a specialist doctor's visit to see the development of the patient under his care every day before 14.00 WIB, including holidays.

Hospital Environment
The hospital environment includes cleanliness and quietness. The results showed that most public and private hospitals respondents were satisfied with the hospital environment, with the percentage of both hospitals the same, which is 99.5%. The physical environment that affects patient satisfaction in terms of calmness is noise pollution in hospitals. In each respondent in both hospitals, dissatisfaction was felt due to noise pollution obtained from the guard room/nurse station at night and brought from other patients who met with patients. The main components that have shown tangible results for patients and medical personnel are the spatial relationship of walls, rooms, and their proximity to the patient's bed and nurse's room. In variable design nursing units, placement of these spaces and walls becomes essential for successful health outcomes from the patient experience (MacAllister et al., 2016) Staff Responsiveness The response received by the patient includes the patient's need to be helped to the bathroom or use a potty. This study showed that patient satisfaction in public hospitals was 91.8%, while in private hospitals, the percentage was 96.9%. From research submitted by Simbolon et al. (2020), it turns out that patients with good nurse responses have a satisfaction level 7.8 times higher than patients who argue that nurse responsiveness is unsatisfactory (Simbolon et al., 2020). The level of patient dissatisfaction with the responsiveness or responsiveness of hospital staff in public hospitals is greater than that of private hospitals. The number of patients in public hospitals that are larger than private hospitals can cause officers' responsiveness to decrease due to the duty of nurses who must provide services to all patients. Still, the number of nurses is insufficient, so patients will have to wait a while before being met by nurses, as Yaghoubi (2011) explained. (Yaghoubi, 2011) Communication About Medicines In the survey component of drug administration listed is whether the officer explained the treatment procedure and side effects of treatment to the patient. The study data results obtained as many as 183 respondents (88%) were satisfied with the communication of drug delivery from officers to patients in public hospitals and as many as 167 respondents (87.4%) who felt satisfied at private hospitals. Among other components of the survey that have a high level of dissatisfaction is the communication of drug administration. There were 25 respondents and 24 respondents in each hospital who were dissatisfied with the explanation given.
The information provided does not match the components of the question in the questionnaire, namely an explanation of the benefits of treatment and side effects of the drug. Based on the description of HCAHPS Fact, in charge of conveying drug delivery information is pharmaceutical or pharmacist. Still, most hospitals in Indonesia, especially in both hospitals, conducted this study information about drugs delivered by nurses to the inpatient. But in the delivery of 7 true in supporting medication safety, there is valid information that all of the medication safety must be known both by doctors, pharmacists, and nurses(Lestari, 2016).

Discharge Planning
Discharge planning is a communication about the assistance needed by the patient if the patient has left the hospital and written information about the symptoms that must be considered after the patient returns from the hospital is valuable two points on the survey questionnaire on the discharge planning component, with a yes or no response on the survey questionnaire. A total of 88% of public hospital respondents were satisfied with the information provided, and 94.8% of respondents at private hospitals were also satisfied with the discharge planning provided by nurses and doctors. Discharge planning (DP) information in this study was given to patients who had completed hospital administration and were given clear and demand information to patients and patients' families along with the administration of the inpatient's medication at home.
This study is in line with Hardivianty's research (2014), where the discharge planning provided to patients and their families supports patient satisfaction with this assessment component (Hardivianty, 2017) Patients dissatisfied with the discharge planning provided at the public hospital amounted to 10.1% (21 respondents) and 5.2% (10 respondents) at private hospitals. The patients who are not satisfied with the discharge planning can be caused by the implementation of the DP is still uneven and has not become a deep-rooted culture in health workers, including nurses, so the performance has not been maximal and has not been able to provide satisfaction to patients as recipients of services. In line with Asmuji and Faridah (2020) research, the study data collection results found a reality index whose value is below 2.00. The average value of expectations higher than reality can be used as a reference to conclude that patients are not satisfied with the implementation of discharge planning (Asmuji & Faridah, 2020) Discharge Planning Information The patient's understanding of the information obtained for his return that doctors and nurses take into account the opinions of the family about the patient's health care after discharge from the hospital and the patient's understanding of maintaining health and treatment goals after the patient's return from the hospital. The results of the study obtained data on this component are in the hospital the patient's understanding of the discharge planning information provided was also satisfied by 197 respondents (94.7%) and at public hospitals a total of 178 respondents (93.2%). The patient's understanding of the discharge planning information that doctors and nurses consider the family's opinions about the patient's health care after discharge from the hospital and the patient's understanding of maintaining health and treatment goals after the patient's return from the hospital.
According to this study's findings, in the public hospital, the patient's understanding of the discharge planning information provided was also satisfied by 197 respondents (94.7 %). At private hospitals, a total of 178 respondents were satisfied (93.2 %). Eleven respondents in public hospitals and ten respondents in private hospitals expressed dissatisfaction. Research by Hardivianty on the evaluation of the implementation of DP at PKU Muhammadiyah Gamping Hospital concludes that the performance of DP implementation is still not running optimally. One of the reasons for dissatisfaction is that patients' and families' understanding of the patient's continued care is still poor, as evidenced by the education provided less, and the contents of the discharge planning delivered consist only of the patient's control schedule and home medicines to be consumed by the patient. Nurses rarely communicate symptoms, complications, physical activities, and what the patient should avoid. (Hardivianty, 2017) Recommendation Patient recommendations to others are in the form of a willingness from patients to advise friends and relatives as a hospital for their health referrals. In this component, as many as 98.1% in public hospitals and 95.3% in private hospitals said they are satisfied and recommend hospitals that provide inpatient health services to their friends and relatives.
Patients who are dissatisfied and choose not to recommend public hospitals have four respondents (1.9%), and in private hospitals, there are nine respondents (4.7%).
Although having a small percentage, this will impact the image of the hospital in the future and influence patients to recommend the hospital to others. According to researchers, respondents disagreed if they had to recommend both hospitals to their friends and relatives. Because, during the national health insurance era, this has become one of the government guarantee systems for patients seeking treatment to hospitals, which is related to the division of national health insurance service coverage areas and tiered systems that are also laws and regulations. This is in line with research conducted by Wahyu P (2018) (Wahyu P, 2018) Hospital Rating The provision of a patient's grade of the hospital as a whole was the final component in the HCAHPS survey. Judging from this component, as many as 208 respondents (100%) in public hospitals and 189 respondents (99%) in private hospitals provided a satisfying value to all components of inpatient services. According to the results of this study, much all patients provided an excellent predicate to the hospital. Furthermore, only private hospitals have as many as two respondents who are dissatisfied with the overall assessment (1 %).
As the Fitra Nova study (2010) found conformity between the services provided by PKU Muhammadiyah Surakarta Hospital with the expectation of patients there is a gap/satisfaction level of (-0.36), this score is categorized in moderate groups. However, it has not fully met patient expectations, but the services provided are good enough (Fitra Nova, 2010 The discovery of one patient from each hospital with a final result was dissatisfied with hospital services due to the total satisfaction score obtained from the questionnaire < = 40. The components of the service that make these two patients dissatisfied are almost the same, and most prominently related to communication with nurses, hospital environment, drug delivery communication, return information, and patient understanding of return information. In these aspects, the researchers expect maximizing related to the delivery of information and education to patients can be further improved. The findings of this study can be interpreted that the National Health Insurance System (JKN) and the BPJS class category system, which is divided into classes I, II, and III, is well accepted in the community and can be viable options for the community to seek treatment. With a satisfaction rate of 99.5 percent between Public and Private Hospitals, the community no longer has to choose between receiving accurate and satisfactory health services. Some studies conducted abroad on public hospitals and private hospitals turned out to have gaps, such as research by Chari et al. They found that private hospital patients generally showed higher scores across all dimensions evaluated than patients admitted to public hospitals (Chari et al., 2017)

LIMITATION OF THE STUDY
This research is a new topic at each public and private hospital in D. I. Yogyakarta. Future researchers must carry out this research at several hospitals throughout the province of D. I. Yogyakarta. The HCAHPS survey includes several components, such as communication about medicine, the implementation of which differs slightly depending on the country of origin of this questionnaire survey instrument.

CONCLUSIONS AND SUGGESTION
National health insurance patient satisfaction rate using the HCAHPS survey at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was 99.5%. There was no difference between national health insurance patient satisfaction levels using the HCAHPS survey between public and private hospitals in D.I Yogyakarta. There was also no association between the BPJS class category with the level of satisfaction of JKN patients using the HCAHPS survey at public and private hospitals in D.I Yogyakarta.
The future researcher can establish the target with more hospitals in D. I. Yogyakarta to avoid so that the data generated is not homogeneous. This research has the potential for more profound results with mixed-method analysis. Future researchers should use different sample criteria from previous studies that used HCAHPS surveys.