The Effect of Service Quality on the Satisfaction of Inapest Askes Patients in Sanglah Hospital Denpasar

In line with reforms in the health sector, Sanglah General Hospital in Denpasar continues to improve the quality of its services to satisfy patients. This study aims to determine the effect of service quality variables on the satisfaction of inpatients care at Sanglah Hospital Denpasar. The type of this study was a cross-sectional study with 78 respondents of Askes patients who were hospitalized or their families at Sanglah Hospital Denpasar. The research sample was taken through a purposive sampling technique according to the inclusion criteria. The variables of this study consisted of tangibles, reliability, responsiveness, assurance, and empathy as independent variables and patient satisfaction as the dependent variable. The instrument of this study was a questionnaire with a 5 level Likert scale measurement. Data were analyzed by multiple linear regression analysis. The results of the study show that the dimensions of service have a significant simultaneous effect on patient satisfaction. Next partially three dimensions of service: Responsiveness. Assurance and Empathy have a positive and significant effect on the satisfaction of Askes patients. The dominant free variable is Responsiveness. It is suggested that the tangible and reliability service dimensions can be implemented consistently to satisfy patients.


Background
As one of the health service institutions, the hospital is expected to provide comprehensive, integrated, fair and affordable services to the community. The hospital also has activities to organize health care efforts to maintain and improve optimal health status for the community [10,11]. Integrated steps are needed in providing certainty of social protection in the context of optimal welfare for all Indonesians [18]. To realize optimal health status for the community, health efforts are carried out with the approach of maintaining health promotion, disease prevention, healing of diseases and health rehabilitation which are carried out comprehensively and continuously.
Patient satisfaction is an indication of the success of health efforts. Therefore, hospital management needs to be oriented toward patient satisfaction. Satisfaction can be built through the relationship between services, facilities, added value, and meaning [24,26,27,30]. Environmental availability with symbiotic relationships and education is a good start for health efforts [21,29]. The role of agents and mediators does not less determine the quality of service and achievement [25,28]. That is, patient satisfaction can be understood to have a close relationship with the quality of the service it receives. Quality of service can motivate patients to develop strong relationships with hospital staff. Given the strong impression in the patient relationship as a customer, the hospital as a service company needs to be more guarded by minimizing errors which result in patient disappointment as an external customer [15]. That encourages hospitals to be able to take advantage of opportunities based on existing strengths and make changes to health services to improve the quality of health services [4]. Aspects of change can affect environmental, cultural and economic conditions [21,22,23].
Aspects of change in health services are demanded to be able to improve conditions and improve the quality of health services, as stated in the vision and mission of the Sanglah General Hospital (RSU) in Denpasar. The vision of Sanglah Hospital is "To become a World-Class National Referral Hospital in 2019". This vision is translated into several mission items, namely: (1) Providing complete and quality interprofessional health services for all levels of society; (2) Conducting professional and competitive 126 The Effect of Service Quality on the Satisfaction of Inapest Askes Patients in Sanglah Hospital Denpasar health education for workers and conducting research in hospital-based health; (3) Organizing partnerships with relevant health stakeholders; and (4) Creating a safe and comfortable work environment. Following its vision and mission, Sanglah Hospital continues to improve the quality of its servants to satisfy its customers, including patients who are supported by health insurance.
To support its services, Sanglah General Hospital has 365 human resources. Of these, 302 were specialist doctors, 53 general practitioners, and 10 dentists. Plus 1,160 nurses. While other professional staff from departments such as pharmacists, psychology, radiology, physiology, etc. as many as 416 people, and non-clinical personnel as many as 948 people. Sanglah General Hospital also has several types of superior services. Among them, heart services, intensive care (ICU, ICCU, NICU, PICU), and cancer services. Sanglah General Hospital has 34 installations, and a capacity of 765 beds, consisting of 164 VIP beds, 80 class I, 106 class II, 358 class III, and 57 special classes. In 2018 inpatient services when viewed from the Bed Occupancy Rate (BOR) reached 88.5 percent [31].
As a referral hospital in the quality of health services, Sanglah General Hospital is ready to receive input from internal and external customers to improve its quality of services. A quality service due to aspects of tangibles, reliability, responsiveness, assurance, and empathy [37]. However, the recapitulation of patient complaints conducted in 2012 shows that several types of services and infrastructure still cause complaints from patients, namely 57.14% of patients complaining about medical services, 33.33% of administrative problems, 4.76% of infrastructure problems and 4.76% of security problems [14]. Among these complaints came from Askes patients.
In general, it can be said that BPJS support for hospitalization at Sanglah Hospital is sufficient, but Askes patient services are not optimal. As a regular customer, Askes patients complained that it was difficult to get drugs that followed the Drug List (DPHO), long and convoluted administrative flow to get guarantees, difficulties in getting rooms for hospitalization, inhospitable staff attitudes, and financial problems hospital borne by Askes. There are still Askes participants who do not understand their rights and obligations. Some Askes participants at Sanglah Hospital have the perception that all costs have been borne by hospitals such as BPJS patients. Although this is not the case, Askes patients only get health services provided by health care centers (RS), while the cost of drugs is borne by the patient himself.

Research Problem
This scientific work will present the dimensions of health services (tangibles, reliability, responsiveness, assurance, and empathy) and their relation to the satisfaction of Askes patients at Sanglah Hospital Denpasar with the formulation of the research question: (1) How does the variable quality of service simultaneously affect the Askes patient satisfaction variable? ; (2) How does the variable quality of service affect the satisfaction variable of Askes patients? ; (3) What are the dominant service quality variables that affect the satisfaction of the Askes patient?

Research Objective
Theoretically, the results of this study are expected to be part of the development of the Hospital Marketing Management Sciences. Furthermore, the results of this research are expected to be used as to formulate recommendation to improve the quality of service at Sanglah Hospital so that the satisfaction of its customers can be increased, including Askes patients.

Service Quality
Service quality is an aspect of service that can have an impact on customer loyalty. Quality of service is built from standard activities for satisfying service. The form of customer satisfaction or according to the expectations of service provider organizations is a benchmark of excellent quality service [32].
Vincent Gespers views that service quality includes the following dimensions [32] : a) timeliness of service related to waiting time and process; b) service accuracy; c) courtesy and hospitality; d) responsibility for handling complaints; e) facilities supporting the implementation of complete services; f) a place that is conducive to service; g) cleanliness of the location in conducting services. Besides, excellent service is expected to meet: 1) there is an effort to meet customer expectations; 2) quality of service is maintained; 3) there is service motivation beyond customer expectations.

Satisfaction
Satisfaction is an expression of attitude based on experience [33]. Satisfaction is characterized by feelings of pleasure that come from the impression of an individual or organizational performance [36]. Tse and Wilton suggest that satisfaction is a response born of perceptions of expectations and practices [34]. When practice outcomes exceed customer expectations, the customer will be very satisfied [37]. Satisfaction is born through a balance between a combination of interests, expectations, and performance [35].

Askes Insurance Patient
Askes insurance patients are a group of patients who use health insurance coverage when seeking medical treatment.
Health insurance can be seen as a system of managing funds regular from contributions of their members to finance the health services needed by them [38].
BPJS is the name of this health insurance from PT. Askes Indonesia seeks to guarantee the affordable cost of medical health care for patients classified as poor at Indonesia. Broadly speaking, two types of treatments can be obtained from patients who use Askes: 1) inpatient treatment and 2) outpatient treatment.

Sanglah Hospital Denpasar
Sanglah Hospital Denpasar is a General Hospital located around Jalan Pulau Nias Denpasar Bali with the support of magnificent buildings, experienced medical personnel and quality facilities [31]. Strategically, Sanglah Hospital is located on a land area of 13.5 ha with a radius of 7.2 km from Sanur, 9.2 km from Kuta and 12 km from Ngurah Rai Airport.
Sanglah Hospital Denpasar is known as the largest General Hospital on the island of Bali. Aside from being a complete health care institution for patients, Sanglah Hospital Denpasar is also open as a destination for research and education. The philosophy of service at the Sanglah Hospital Denpasar upholds human dignity and dignity in the fields of service, education, and research [31].

Research Sites
The study that examined the level of satisfaction of inpatients inpatient care was carried out at Sanglah Hospital in Denpasar. This research is a type of analytic research with the cross-sectional method (cross-section). This research was conducted on November 2018.

Population
Population is a generalization area consisting of objects or subjects that have certain qualities and characteristics, while samples are part of the number and characteristics possessed by the population [39]. If the number of research samples is less than 100, it is better to take all of them until the research is a population research [2]. The population in this study were patients with Askes or their family members who were hospitalized at Sanglah Hospital in Denpasar.

Samples
The average visit of Askes patients in 2018 per month is 520 people. With a purposive sampling technique, 78 respondents (15% of the population) were selected as research samples with inclusion criteria that selected samples were Askes patients who had received services for more than three days and were able to communicate, while exclusion criteria were Askes patients who had not undergone treatment for three days, patients in ICCU / ICU care and critical patients, coma during the study period for ethical reasons.

Data Source
Primary data were obtained by conducting a site survey and distributing questionnaires to respondents. Secondary data were obtained through literature studies on health, management and humanity.

Data Analysis Techniques
The research instrument was tested by validity and reliability. The test results show that the instrument is valid and reliable. The collected data is then analyzed by multiple linear regression analysis. Before carrying out multiple linear regression analysis the classic assumption test was carried out, namely the normality test, multicollinearity test, linearity test, and heteroscedasticity test.

Characteristics of Respondents
The characteristics of the respondents were described in Table 1 and Table 2. Of the 78 respondents in the Askes patient, hospitalizations were found that 55.1% were male and female were 44.9%. In terms of age group, the majority of respondents (55.1%) were middle-aged (31-50 years), 34.6% were over 50 years old, and 10.3% were still young <30 years old. Judging from the educational background, the majority of respondents (57.7%) had tertiary education (Bachelor / S1 / S2 / S3), then 33.3% had a high school education, and 9.0% had elementary / SLP education. Furthermore, in terms of work, it is known that the majority of respondents (62.8%) work as civil servants, then other jobs (33.3%), and only 3.9% of their jobs are retired TNI / POLRI.
In terms of membership of Askes, it is known that the majority of respondents (55.1%) are Askes participants and the remaining 44.9% are family members of Askes (AKPA) participants. The ranks of the respondents as civil servants are in the third group (55.13%), then 28.21% in the fourth group, 15.38% in the second group, and only 1.28% in the first group. The majority of respondents (43.59%) received inpatient care in class II, then 29.49% chose the VIP class, and 20.51% were treated in class I, only as many as 6.41% were treated in class III (Table 2).

Research Conceptual and Variable Framework
To win the competition in the increasingly tight business world, customer satisfaction is the main thing to do. To achieve this, companies must assess several factors that will affect customer satisfaction. According to Kotler, there are five criteria for determining service quality, namely: tangibles, reliability, responsiveness, assurance, and empathy [16]. This element is the main source of this research.
The research variable consisted of independent variables namely service quality variables, and the dependent variable was patient satisfaction. There are five independent variables that determine service quality and one dependent variable, patient satisfaction (Table 3).  The research instrument used was a questionnaire that was created using a Likert scale with five choices that had been modified which were only made extreme points very dissatisfied = 1, very satisfied = 5 [13]. The questionnaire was distributed by the researchers themselves with the help of the Sanglah Hospital officers who had been explained first.

The Effect of Simultaneous Variables on Variables Bound Simultaneously
The F Statistic Test is used to show whether all independent variables included in the model have a joint effect on the dependent variable. If the value of F count is greater than F table, it can be said that all independent variables together influence the dependent variable. With a confidence level of 95% or a significance level of 5%, if F count> F table, then Ho is rejected which means that each independent variable has a significant effect on the dependent variable. Then if F count <F table, then Ho is accepted which means that each independent variable together does not have a significant effect on the dependent variable [5]. The Influence of Inpatient Service Quality at Sanglah Hospital on the Simultaneity of Askes Patients simultaneously can be seen in Table 4. Table 4 shows that the influence of service dimensions together (simultaneous) affects the satisfaction of Askes patients at Sanglah Hospital Denpasar. This is evidenced by the value Fc = 97,000 greater than the critical value 2,15999. Simultaneously service dimensions, namely tangibles, reliability, responsiveness, assurance, and empathy affect the satisfaction of Askes patients.
The magnitude of the effect simultaneously the dimension of service to patient satisfaction is reflected in the results of the R Square value. From the results of the Multiple Linear Regression Analysis it is known that the value of R Square is 87.1%, which means that 87.1% of post-service satisfaction in Sanglah General Hospital is influenced by service variables, namely tangibles, reliability, responsiveness, assurance, and empathy, and as many as 12, 9% are influenced by other variables not examined in this study.

Effect of Partial Independent Variables on Bound Variables
Partially, the effect of service quality variables on patient satisfaction can be seen in the value of t obtained through regression analysis with the Backward Stepwise Method. Table 5 shows that the three independent variables of Xi, namely the dimensions of service responsiveness, assurance, and empathy, have a significant and positive effect on the satisfaction of the Askes (Yi) Sanglah Hospital in Denpasar with t values of (5,630), (3,310), and (2,330 ) which is greater than the value of tt, α= 0.05, df = 73 = 1.671 (Table 5). As shown in Table 5, the determination coefficient value is 90.11%. This means 90.11% variation in satisfaction of Askes patients Sanglah Hospital Denpasar is caused by variations in the dimensions of the service, namely responsiveness, assurance, and empathy. The remaining 9.89% is caused by other factors outside the service factor.
Partially, the dimensions of service namely responsiveness, assurance and empathy have a significant and positive effect on the satisfaction of inpatients inpatient care at Sanglah Hospital Denpasar. The coefficients of each dimension are 0.484, 0.321 and 0.250. The dimension of the regression coefficient responsiveness is the highest of 0.484 so that means that, this variable has the most dominant influence on the satisfaction of Askes patients hospitalized at Sanglah Hospital Denpasar. The second most influential dimension is assurance with a coefficient of 0.321, and the third is empathy with a coefficient of 0.250.

Effect of Service Quality on Simultaneous Patient Satisfaction
The satisfaction experienced by patients is closely related to the quality of services provided by the hospital. Patients assess their level of satisfaction or dissatisfaction after using hospital services and using hospital services and use this information to update their perceptions of the quality of services provided by nurses at the hospital. A good quality image is not based on the point of view or perception of the service provider, but based on the customer's point of view or perception [19,20].
The results of multiple linear regression analysis showed that simultaneously the quality of service variables affected the satisfaction of inpatients Askes in Sanglah Hospital Denpasar with a value of Fc = 97,000 greater than the critical value of 2.15999. The magnitude of the effect simultaneously the dimensions of service to patient satisfaction is reflected in the results of the R Square value of 87.1%. This figure indicates that 87.1% of post-service satisfaction in Sanglah General Hospital is influenced by service variables, namely tangibles, reliability, responsiveness, assurance, and empathy, and as many as 12.9% are influenced by other variables not examined in this study.
The five service quality variables together (simultaneous) affect patient satisfaction [3]. These results are findings that the quality of health services consisting of tangible physical variables (tangibles), reliability, responsiveness, assurance (assurance), and empathy (empathy) significantly influence patient satisfaction (Askes participants) at the Wangaya Hospital in Denpasar The service dimension (R Square value) succeeded in contributing 87.1% for the satisfaction of Askes patients. This is by the respondent's response to Sanglah Hospital services, most of which expressed satisfaction (47.44%), Satisfied (30.77%), Very Satisfied (19.23%), and only a few respondents said they were not satisfied (2, 56%). In general, the quality of services provided by RSUP Sanglah has satisfied the Askes patient.
These findings research that the quality of health services at Sanglah Hospital Denpasar by external parties is considered included in the category of good service with an average percentage of five dimensions of service quality (responsiveness, reliability, assurance, attention, direct evidence) amounting to 83.82% [15]. Service quality greatly determines the level of customer satisfaction. The higher the quality of service, the higher the satisfaction received by consumers. A good service quality will create long-term and profitable relationships for service providers and consumers [7,8].

Effect of Service Quality on Partial Satisfaction of Patients
The results of the regression analysis with the Backward Stepwise Method show that the three dimensions of service responsiveness, assurance, and empathy have a significant and positive effect on the satisfaction of the Sanglah Hospital of Askes (Yi) patients. The contribution of the three dimensions of service is reflected in the results of the coefficient values of each dimension, namely responsiveness of 0.484, assurance of 0.321, and empathy of 0.250. This means that the quality of service for Pasient Askes RSUP Sanglah Denpasar is determined by the responsiveness dimension of 48%, assurance by 32%, and empathy by 25%.
In general, the results of the study are slightly different from the results of the study which analyzed the effect of quality of service on the satisfaction of inpatients of Social Askes participants at the Regional General Hospital, Dr. Pirngadi Medan [40]. He concluded that the variable quality of health services consisted of dimensions; reliability, responsiveness, assurance (assurance), attention (empathy), and direct evidence (tangibles) affect the satisfaction of inpatients of social Askes participants in RSUD, Dr. Pirngadi Medan. If five dimensions of service affecting the satisfaction of Askes patients, then in this study the dimensions of tangibles and reliability services partially do not affect the satisfaction of Askes patients [40].
The results of study prove that education is considered as one of the factors associated with quality of life [17]. Education is one of the factors that influence direct behavior towards health [9]. The level of education of respondents also affects the level of satisfaction. The higher of the education level of education the higher the patient's satisfaction with technical quality [20]. The majority of respondents in this study had higher education, namely 57.7% of high schools (SM / S1 / S2 / S3) and 33.3% of high school students, the rest are SD and SLP (9%). These generally educated Askes patients consider that services at Sanglah Hospital have not been supported by the dimensions of tangible (physical appearance)reliability (reliability), so that these two variables do not have a significant effect on satisfaction of Askes [20].

Effect of Dominant Dimensions of Service Quality on Patient Satisfaction
Service Quality Variables that predominantly contribute to satisfaction of Askes patients at Sanglah Hospital Denpasar are responsiveness dimensions of 48%. This means that the Askes patient has received service that is friendly, fast, responsive and smooth (responsiveness). Thus to be able to increase the satisfaction of the Askes patient, hospitalization requires always high responsiveness so that the Askes patient who is undergoing treatment gets his wishes delivered to the officer who treats him at the Hospital. Askes patients are permanent customers of hospitals so that satisfaction is fulfilled, it will increase hospital utilization.
In addition to the dimensions of responsiveness that affect the satisfaction of Askes patients at Sanglah Hospital Denpasar are assurance dimensions (contributing 32%) and empathy dimensions (contributing 32%). This means that the actions of service providers who are friendly, fast, responsive and smooth (responsiveness) and who guarantee the security and convenience of services (assurance) need to be maintained. In addition, service providers at Sanglah Hospital also have to be empathetic, always pay attention and share in feeling the Askes patient problem, because the health staff's empathy attitude in the Askes treatment room can provide better satisfaction for Askes patients.

Discussion
The quality of inpatient services at Sanglah Hospital in Denpasar affects the satisfaction of Askes patients they care for. The level of service in Sanglah Hospital can be said to be relatively high. Patients are satisfied with the quality of service at Sanglah Hospital reaching 83.82% [42]. Patients' satisfaction at Sanglah Hospital Denpasar is inseparable from the diagnosis and the form of services provided. Diarrhea is still the cause of hospitalization of pediatric patients at Sanglah Hospital and the etiology is rotavirus [39]. Most complaints of swollen Sanglah Hospital patients are overcome [40]. Likewise, service quality has an impact on Askes patient satisfaction.
The service quality variables that are proven to affect Askes patient satisfaction are the dimensions of response, service and service empathy. These three service dimensions have a simultaneous and partial effect on patient satisfaction. Whereas two other service dimensions, namely tangible-reliability, have been proven not to provide significant contributions to support quality services at Sanglah Hospital Denpasar.
The Askes patient was admitted as a permanent patient at the Sanglah General Hospital. Therefore, the management of Sanglah Hospital needs to provide high-quality services for them. Sanglah Hospital Management needs to maintain an adequate service dimension, and need to increase the service dimension that does not support service quality, especially physical evidence, including the availability of parking areas for vehicles to the bathroom that must be kept clean and comfortable and the dimensions of service reliability, which are able to provide information and accurate service and schedule certainty. Further efforts will require staff support and improvement in the implementation of clinical governance [42]. Staff support and improvement of clinical governance need to be highlighted given the incidence of malnutrition and the death rate of patients at Sanglah Hospital. The incidence of hospitalization for 132 The Effect of Service Quality on the Satisfaction of Inapest Askes Patients in Sanglah Hospital Denpasar malnourished patients at Sanglah Hospital reached 30.1% and tended to increase by 3.69% when patients were treated for more than a week [41]. The incidence of neonatal sepsis at Sanglah Hospital, Denpasar 5% with a mortality rate reaching 30.4% with low birth weight and prematurity associated with death in neonatal sepsis [43]. Based on these cases it can be stressed that the Sanglah Hospital still needs to strengthen the quality of service to patients. This is in line with the recommendation that the management of Sanglah Hospital needs to increase the capacity of staff who have direct contact with consumers [12]. The interests of users of hospital services need to be considered to increase public satisfaction for users of Sanglah Hospital, Denpasar.

Suggestions
The management of Sanglah General Hospital needs to maintain the dimensions of service quality responsiveness, assurance (empathy), and empathy (empathy) and carry out consistently the dimensions of tangible services (physical appearance) and reliability (reliability) to satisfy their patients.