Service quality and its effect on inpatient satisfaction at Purwodadi islamic hospital

Service quality can be a driving force that is created and perceived by patients in order to establish a relationship that can provide long-term mutual benefits with the hospital. Service quality will affect patient satisfaction, thus encouraging patients to continue using hospital services when needed. The purpose of this study was to determine the effect of service quality on patient satisfaction. This research is a case study with a cross-sectional design. The population is inpatients at RSI Purwodadi. A sample of 100 patients was taken by purposive sampling. Data collection used a questionnaire. Data analysis technique used multiple linear regression. The results showed that service quality significantly affected patient satisfaction with an F of 14.641 and a p of 0.000 (p < 0.05). The tangible dimension of service quality has no effect on patient satisfaction (t = 0.809, p = 0.421). As for service quality, the dimensions of reliability (t = 2.028, p = 0.045), responsiveness (t = 3.135, p = 0.002), assurance (t = 2.613, p = 0.010), and empathy (t = 2.480, p = 0.015) have a positive effect and significant to patient satisfaction. The study concludes that service quality has a significant effect on patient satisfaction. The tangible dimension of service quality does not affect patient satisfaction. Service quality dimensions of reliability, responsiveness, assurance, and empathy positively and significantly affect patient satisfaction


INTRODUCTION
The hospital which is an important health institution in the health care system can provide health services in the community and plays an important role in consumer satisfaction in terms of providing health services (Kardanmoghadam et al., 2015). Health services in hospitals must be able to provide satisfaction and be in accordance with what is the patient's expectation, improving the quality of service is one of the hopes and foundations of the hospital to get more patients.
Every hospital strives to provide its best service, so that services are like commodities produced by the hospital which are intended for the community to be used according to their expectations and needs. The hospital, which was originally a social organization, has now transformed into an organization that leads to socio-economic organization. This is because the hospital must also be able to support its operations and be able to develop. With this shift so that the parties concerned have their own views and demands, the hospital wants to benefit, while users of hospital services want quality hospital services that can represent their wishes for hospital services (Trisnantoro, 2006).
Service quality can be one of the drivers that can be created and perceived by customers in order to establish a relationship that can provide mutual long-term benefits with service providers. Thus, the company can understand carefully in terms of customer needs which can make the company always improve its capabilities from the aspect of patient satisfaction. If health institutions can create a sense of satisfaction for consumers, a strong bond can be established to be able to give each other the best (Tjiptono & Chandra, 2013).
Service quality is seen as a strategic and dynamic concept that is very important for hospitals to gain competitive advantage, so it needs to be improved and measured (Amankwah et al., 2019). Service quality is a patient's evaluative assessment or impression regarding the overall performance and excellence of service providers during service (Boakye et al., 2017). Parasuraman et al (1988) in Ahmed & Samreen (2011) introduced five dimensions of service quality, namely: (1) tangible: physical facilities, equipment, and personnel appearance; (2) reliability: the ability to perform services as promised, trustworthy and accurate; (3) responsiveness: willingness to help customers and provide prompt service; (4) assurance: knowledge and courtesy of employees and their ability to inspire trust and confidence; (5) empathy: caring, individual attention given to customers.
Improving the quality of service based on patient satisfaction needs to be done based on patient experience on certain aspects of the health services they receive (Batbaatar et al., 2016). Based on this, the hospital must be able to position itself to be able to provide a good experience for patients. Patient experience is important because it can have a significant impact on the results of services that have been provided, because this will lead to an assessment of patient satisfaction (Aaronson et al., 2018). Patient satisfaction is an important thing in a health service. Perceptions that arise about patient care are often associated with service quality, assessment of service quality is important to increase patient satisfaction (Abolfotouh et al., 2017).
Patient satisfaction with hospital services is very important for the development of a hospital. If the patient is satisfied with the services provided, the patient and his family will become loyal, thus the patient will continue to use the service when the patient needs it, or they will recommend it to their family or close people (Son & Yom, 2016). When patients are satisfied with the health services they get at the hospital, they are likely to use these health services on an ongoing basis as a result of satisfaction which has an impact on patient loyalty (Yom & Lee, 2010).
Previous researchers have done a lot of research on the effect of service quality on patient satisfaction. However, there are still differences in the results of previous studies (research gap). Jandavath & Anand (2016) research shows that service quality dimensions of tangible, responsiveness, assurance, and empathy have a positive effect on patient satisfaction, while the reliability dimension has no effect on patient satisfaction. Kitapci et al. (2014) research showed that the quality of service dimensions of assurance and empathy have a positive effect on patient satisfaction, while the dimensions of tangible, reliability, responsiveness have no effect on patient satisfaction. Aliman & Mohamad (2016) research shows that service quality dimensions Tangible, responsiveness, and assurance have a positive effect on patient satisfaction, while the dimensions of reliability, and empathy have no effect on patient satisfaction. Meanwhile, Dewi (2016) research shows that the tangible, reliability, responsiveness, and empathy dimensions of service quality have a positive effect on patient satisfaction, while the assurance dimension has no effect on patient satisfaction.
The inconsistency of the results of previous studies above prompted researchers to examine the effect of hospital service quality on patient satisfaction. The research was conducted at Purwodadi Islamic Hospital, which is one of seven hospitals in Grobogan district. Purwodadi Islamic Hospital is a private hospital with type D which is located in the city of Purwodadi, Grobogan district. Purwodadi Islamic Hospital already has the initial KARS Accreditation certificate for a special program. This hospital has medical support facilities, namely radiology and laboratory, also has several polyclinic services, including internal polyclinic, surgical polyclinic, gynecology polyclinic, pediatric polyclinic, psychiatric polyclinic, orthopedic polyclinic, general polyclinic, dental polyclinic. This hospital is located not too far from other private hospitals so that patients will have more choices of hospital services for themselves. This will affect the level of patient visits.
Measurement of service quality and its effect on patient satisfaction has never been done at RSI Purwodadi. However, Purwodadi Islamic Hospital wants to always be able to improve the quality of service so that patients who have visited and enjoyed hospital services are always satisfied, so it is hoped that they will get a place in the hearts of patients and their families who are expected to be able to continue to enjoy hospital services and not switching to other hospitals when the patient needs hospital services, and is expected to attract other patients to visit this hospital because it is considered appropriate as a health facility that has satisfaction and can provide satisfaction for every patient who visits.

METHODS
This type of research is a case study obtained by a survey by collecting data related to research variables. Based on the problems studied, the research tools and techniques carried out in this study are non-experimental quantitative descriptive, using descriptive correlation which is looking for a relationship between the two independent and dependent variables (Arikunto, 2010).
The population in this study were all inpatients at RSI Purwodadi. A sample of 100 patients was taken by purposive sampling. The sample inclusion criteria in this study were patients who had been hospitalized for at least 24 hours in the inpatient ward of Purwodadi Islamic Hospital, were at least 17 years old, and voluntarily agreed to become research respondents. The exclusion criteria were patients who were employees or close relatives of Purwodadi Islamic Hospital employees, had mental retardation, as well as patients who were in an unconscious/coma condition, lost their memory.
The data collection technique in this study was a questionnaire. In this study, the service quality questionnaire was adopted from Goula et al. (2021). The patient satisfaction questionnaire was adopted from the 2017 Patient Satisfaction Questionnaire (KKP-2017) from Imaninda & Azwar (2016).
The research variables are categorized based on the average value of the items, by making class intervals based on the range of scores, namely 1-5. Based on these intervals, the categories of research data can be arranged as follows: 1.00 -1.80 : Very Unfavorable/Very Dissatisfied 1.81 -2.60 : Not Good/Not Satisfied 2.61 -3.40 : Enough 3.41 -4.20 : Good/Satisfied 4.21 -5.00: Very Good/Very Satisfied The data analysis technique in this study used multiple linear regression techniques. Partial hypothesis testing is carried out using the t test, and simultaneous testing is carried out using the F test. The coefficient of determination (R 2 ) is used to measure the magnitude of the influence of the independent variables simultaneously on the dependent variable.

RESULTS AND DISCUSSION
The research was conducted by distributing questionnaires to 100 respondents in the inpatient wards of Purwodadi Islamic Hospital. Based on the research results, the profile of the respondents can be described as follows:  Table 1 shows that based on age, the majority are 41-50 years old, amounting to 32 respondents (32.0%), and at least > 60 years old, amounting to 12 respondents (12.0%). Based on gender, the majority were women, amounting to 54 respondents (54.0%). Based on their last education, the majority were SMA/SMK, amounting to 43 respondents (43.0%), and at least SD/equivalent, amounting to 6 respondents (6.0%). Based on occupation, the majority were housewives, amounting to 21 respondents (21.0%), and at least the TNI/Polri, amounting to 3 respondents (3.0%).
Based on the research results, the service quality data can be described in the following When hospital staff promise to do something by a certain time, they do it 3.72 Good 6 When the patient has a problem, the hospital staff is willing to help 3.65 Good 7 Hospitals are reliable and always provide the right services from the start 3.74 Good 8 The hospital provides its services at the promised time 3.64 Good 9 Hospitals keep accurate records of themselves (e.g., medical records, appointments, etc.) 3.68 Good Reliability 3.69 Good 10 The hospital staff provides the information the patient needs 3.83 Good 11 Hospital staff provides prompt service to patients 3.76 Good 12 Hospital staff is always willing to help patients 3.72 Good 13 Hospital staff always respond to requests, no matter how busy they are 3. The hospital staff pays special attention to each patient 3.81 Good 19 The hospital operating hours are convenient for all patients 3.80 Good 20 Hospital staff understand and are knowledgeable about the health needs of their patients 3.83 Good 21 The hospital pays attention to the interests of its patients 3.89 Good 22 Hospital staff understand the special health needs of their patients 3.83 Good Emphaty 3.83 Good Source: Data analysis, 2023 Table 2 shows that the average score of the tangible dimension of service quality is 3.73 so that it is in the score range of 3.41 -4.20, so it is concluded that the tangible dimension of service quality is included in the good category. All items in the tangible dimension are also included in the good category, with the lowest average score on hospital facility items (for example, waiting rooms/halls, clinics, wards, toilets) that are visually attractive, namely 3.69. The highest average value for equipment items used for maintenance is always well cared for, with an average of 3.78.
The average value of the service quality score on the reliability dimension is 3.69 so that it is in the range of 3.41 -4.20, so it is concluded that the service quality reliability dimension is included in the good category. All items in the reliability dimension are also included in the good category, with the lowest average score on the Hospital item providing services at the promised time, with an average of 3.64. The highest average score for the Hospital item is reliable and always provides the right service from the start, with an average of 3.74.
The average value of the responsiveness dimension of service quality score is 3.76 so that it is in the score range of 3.41 -4.20, so it is concluded that the responsiveness dimension of service quality is included in the good category. All items in the responsiveness dimension are also included in the good category, with the lowest average score on the item Hospital staff always respond to requests, no matter how busy they are, with an average of 3.71. The highest average score on the hospital staff item provides the information needed by the patient, with an average of 3.83.
The average value of the service quality score for the assurance dimension is 3.65 so that it is in the range of 3.41 -4.20, so it is concluded that the service quality for the assurance dimension is included in the good category. All items in the assurance dimension are also included in the good category, with the lowest average score on the hospital staff item being consistent and polite to patients, with an average of 3.53. The highest average score on the behavior and attitude items of hospital staff generates trust in patients, with an average of 3.74.
The average value of the empathy dimension's service quality score is 3.83 so that it is in the score range of 3.41 -4.20, so it is concluded that the empathy dimension's service quality is included in the good category. All items in the empathy dimension are also included in the good category, with the lowest average value in the item comfortable hospital operating hours for all patients, with an average of 3.80. The highest average value for hospital items pays attention to the interests of the patient, with an average of 3.83.
Based on the results of the study, patient satisfaction data can be described in the following  Table 3 shows that the average patient satisfaction score is 3.76 so that it is in the score range 3.41 -4.20, so it is concluded that patient satisfaction is included in the satisfied category. All patient satisfaction items are also included in the satisfied category, with the lowest average score on the doctor's item explaining the purpose of the medical tests being carried out, with an average of 3.65. The highest average score for items getting lost when heading to another room is due to the lack of directions in this hospital, with an average of 3.83.
Data analysis in this study used multiple linear regression. The results of multiple linear regression analysis can be tabulated as follows:  Table 4 shows that the quality of service on the tangible dimension, obtained a β value of 0.067, t-count of 0.809 and p of 0.421. Based on the p value > 0.05, it can be concluded that the tangible dimension of service quality has no effect on patient satisfaction. This shows that hypothesis 1 is not supported. The research results are supported by the research results of Ratnawati et al. (2020) which shows that in small hospitals, tangibility has no effect on patient satisfaction. The research results also support the results of Kitapci et al. (2014). The tangible dimension refers to the physical facilities, tools or equipment used to provide services and the appearance of staff. Physical facilities such as signs, comfort, accessibility, spaciousness, functionality and cleanliness (Ahmed et al., 2017). In hospitals, the tangible dimension is manifested in modern, well-maintained equipment, visually attractive hospital facilities, and attractive-looking hospital staff.
When referring to the results of the study, the service quality of the tangible dimension is considered good by patients. If you look at the research results that are not significant, it shows that the tangible dimension is not considered as an important thing in the service of inpatients so that it does not affect patient satisfaction. Inpatients are more focused on other things that give comfort to the patient, because the patient is in an uncomfortable condition with his illness. In this condition, patients need more hospital staff who are responsive to their needs and complaints, and want to be cared for personally. This will create a feeling of comfort and become an important factor for him in serving at the hospital.
In the service quality variable, the reliability dimension, the β value is 0.181, the t-count is 2.028 and the p is 0.045. Based on a positive β value and p > 0.05, it can be concluded that service quality in the reliability dimension has a positive and significant effect on patient satisfaction. This shows that hypothesis 2 is supported.  (2016) who showed that reliability has a positive effect on patient satisfaction. As for research by Jandavath & Anand (2016); and Kitapci et al. (2014) found that reliability does not affect patient satisfaction.
Reliability includes service consistency and dependability, which refers to the ability to provide services reliably and accurately that customers want (Ahmed et al., 2017). Reliability includes providing appropriate services and according to promises, being willing to help patients when they experience problems, performing services as promised, and keeping patient medical records accurately. The results showed that the reliability dimension of service quality at Purwodadi Islamic Hospital was considered good by inpatients.
Reliability is a dimension of service quality that is considered important by inpatients, so the results of the study show that service quality has an effect on inpatient satisfaction. In the condition of feeling uncomfortable because of the illness, the patient really needs the right service and according to the promise, requires fast action when experiencing problems, and requires the hospital to provide services as promised. All of these things will make the patient feel comfortable and cared for while undergoing hospitalization, so that it will lead to satisfaction for him.
In the responsiveness dimension, the service quality variable obtained a β value of 0.265, a t-count of 3.135 and a p of 0.002. Based on the positive β coefficient value and p <0.05, it can be concluded that the service quality dimension of responsiveness has a positive and significant effect on patient satisfaction. This shows that hypothesis 3 is supported. The research results are supported by the research results of Ratnawati et al. (2020) which shows that in small hospitals, responsiveness has a positive effect on patient satisfaction. The research results also support the results of Zahlimar et al. (2020); Dewi (2016); and Jandavath & Anand (2016) who obtained responsiveness results that had a positive effect on patient satisfaction. As for Aliman & Mohamad (2016); and Kitapci et al. (2014) found responsiveness did not affect patient satisfaction.
Responsiveness concerns the willingness or readiness of service providers to offer fast services (Ahmed et al., 2017). Responsiveness in hospital services includes hospital staff who provide information needed by patients, provide fast service, are willing to help patients, and always respond to patient requests, even though they are busy. All of these things are needed by inpatients. Various information, especially about the disease, will make the patient better understand the disease and understand the actions taken by doctors or nurses. Fast service is needed by inpatients, so that all problems regarding their illness can be detected early and the necessary actions can be taken. The willingness of nurses to respond to patient requests even though they are busy, makes patient problems can be handled immediately. All of these things will increase patient satisfaction.
In the service quality variable in the assurance dimension, a β value of 0.240 was obtained, the t-count was 2.613 and the p value was 0.010. Based on a positive β value and p <0.05, it can be concluded that service quality in the assurance dimension has a positive and significant effect on patient satisfaction. This shows that hypothesis 4 is supported. The research results are supported by the results of Zahlimar et al. (2020);Hastuti et al. (2017); Dewi (2016);and Jandavath & Anand (2016) who found that assurance has a positive effect on patient satisfaction.. Ratnawati et al. (2020) research found that in small hospitals, assurance has no effect on patient satisfaction. Aliman & Mohamad (2016); and Kitapci et al. (2014) research also found that assurance has no effect on patient satisfaction. Assurance (guarantee) refers to employee knowledge, courtesy and ability to convey trust and confidence (Ahmed et al., 2017). Assurance at the hospital includes the behavior and attitudes of hospital staff that generate patient trust, staff who can provide a sense of security when dealing with patients, staff who are consistent and polite.
Assurance or assurance that is in accordance with what is expected by inpatients, will have an impact on increasing their satisfaction. Staff who can be trusted, and bring a sense of security, as well as consistent and polite, will make patients feel happy and comfortable when they are patients and receive services in inpatient services. This causes inpatients to feel satisfied.
In the empathy dimension, the service quality variable obtained a β value of 0.216, a t-count of 2.480 and a p of 0.015. Based on a positive β value and p <0.05, it can be concluded that the empathy dimension has a positive and significant effect on patient satisfaction. This shows that hypothesis 5 is supported. The research results are supported by the research results of Ratnawati et al. (2020) which shows that in small hospitals, empathy has a positive and significant effect on patient satisfaction. The research results also support the results of Hastuti et al. (2017); Dewi (2016); and Kitapci et al. (2014) who got the result that empathy has a positive effect on patient satisfaction. As for research by Ampaw et al. (2020); and Aliman & Mohamad (2016) found that empathy did not affect patient satisfaction.
Empathy refers to caring, knowing customer demands and individual attention given to customers (Ahmed et al., 2017). Empathy at the hospital includes hospital staff who pay special attention to each patient, comfortable hospital operating hours, staff who understand and have knowledge of patient health needs, pay attention to patient interests, and understand patient special needs. Quality of service on the empathy dimension that meets patient expectations will have an impact on increasing their satisfaction.
Basically every inpatient, wants himself to be cared for personally. This causes patients to really need hospital staff who give special attention and pay attention to the needs and interests of patients. Needs and interests that are well considered by hospital staff, cause patients to feel comfortable in carrying out inpatient services. This will affect the increase in patient satisfaction.
In simultaneous testing, the calculated F-value was 14.641 and p was 0.000. Based on the p value <0.05, it can be concluded that service quality has a significant effect on patient satisfaction. This shows that hypothesis 6 is supported. Furthermore, the magnitude of the influence of service quality which includes tangible dimensions, reliability reliability, responsiveness, assurance, and empathy on patient satisfaction, is shown from the value of the coefficient of determination (R2). The results of the analysis obtained a coefficient of determination (R 2 ) of 0.438. This means that the effect of service quality on patient satisfaction is 43.8%. The remaining 56.2% is influenced by other variables outside the research variables.
Basically the five dimensions of service quality can complement each other, so that it will form a service quality that is able to provide satisfaction to patients. Staff who are responsive and responsive to patient needs and problems will make patients feel comfortable. This is further strengthened by the personal attention of the staff to patients with full empathy, so that all their needs can be met. The existence of services that are reliable and as promised will further increase patient confidence in hospital services. The sense of trust in the hospital will be stronger with good, adequate and well-maintained facilities and equipment. All of these will lead to increased patient satisfaction.

LIMITATION OF THE STUDY
This research was only conducted at one hospital, namely Purwodadi Islamic Hospital. This causes it to be less able to describe the condition of service quality and patient satisfaction in general at all hospitals.

CONCLUSIONS AND SUGGESTIONS
The results showed that service quality has a significant effect on patient satisfaction. The tangible dimension of service quality has no effect on patient satisfaction. As for service quality, the dimensions of reliability, responsiveness, assurance, and empathy have a positive and significant effect on patient satisfaction.
Based on the results of this study, the management of Purwodadi Islamic Hospital should be able to periodically survey patient satisfaction with services, and the results will be used as a reference for improving hospital services. In addition, it should be able to create a system of supervision and guidance on employee service performance. This is expected to increase patient satisfaction. The next research should be able to conduct research on patient satisfaction, by taking variables other than service quality, for example trust, price, and so on. This is expected to identify which variables influence patient satisfaction.