THE ROLE OF HOSPITAL SERVICE QUALITY IN THE NATIONAL HEALTH INSURANCE / JAMINAN KESEHATAN NASIONAL (JKN) ERA AND THE COVID-19 PANDEMIC

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J u r n a l A p l i k a s i M a n a j e m e n J o u r n a l o f A p p l i e d M a n a g e m e n t

V o l u m e 2 1 I s s u e 1 M a r c h 2 0 2 3

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THE ROLE OF HOSPITAL SERVICE QUALITY IN THE NATIONAL HEALTH INSURANCE / JAMINAN KESEHATAN NASIONAL (JKN) ERA

AND THE COVID-19 PANDEMIC

Aqlya Zuhra Ilma Catur Sugiarto

Faculty of Economic and Business Universitas Sebelas Maret, Surakarta, Indonesia

Abstract: Fewer people are visiting the outpatient clinics at Pandan Arang Hospital, Boyolali, due to the Covid-19 pandemic and the hospital class transition, with the exception of the Gastroentero Hepatology (GEH) clinic. The primary focus of this research is to learn how the GEH clinic's administration can improve service quality to attract and retain patients. This research aimed to identify the factors (service quality, customer experience, and perceived value) that lead to trust, satisfaction, and loyalty among consumers and patients when choosing healthcare providers. This study used a Sequential Exploratory design with a mixed-method approach, interviewing GEH's management and consultant doctors first and then sending out questionnaires to 307 patients of the GEH clinic at various times. Based on this research, Pandan Arang Hospi- tal has the necessary facilities and staff to qualify as a type B hospital. Pandan Arang Hospital provided outpatient services during the pandemic, with a separate service flow for Covid-19 and Non-Covid-19 patients, as the World He- alth Organization and the Ministry of Health recommended. Quantitative studies show a positive and significant connection between service quality, customer experience, and perceived value on trust. Then, there's a powerfully positive connection between service quality, the value customers perceive they receive, and their level of trust in the company. Further, a positive and statistically significant correlation exists between contented customers and continued business.

Keywords:ServiceQuality,CustomerExperience,CustomerPerceivedValue, Trust, Satisfaction, Loyalty, National Health Insurance (JKN) Era, Pandemic Covid-19

CITATION

I N D E X E D I N

D O A J - D i r e c t o r y o f O p e n A c c e s s J o u r n a l s

A C I - A S E A N C i t a t i o n I n d e x S I N T A - S c i e n c e a n d T e c h n o l o g y I n d e x

D i m e n s i o n s G o o g l e S c h o l a r R e s e a c h G a t e G a r u d a

I P I - I n d o n e s i a n P u b l i c a t i o n I n d e x

I n d o n e s i a n O N E S e a r c h

C O R R ES P O N D I N G A U T H O R

A q l y a Z u h r a I l m a F a c u l t y o f E c o n o m i c a n d B u s i n e s s ,

U n i v e r s i t a s S e b e l a s M a r e t , S u r a k a r t a ,

I n d o n e s i a

E M A I L

a q l y a . i l m a @ g m a i l . c o m

OPEN ACCESS

e I S S N 2 3 0 2- 6 3 32 p I S S N 1 6 9 3 - 5 2 41

Ilma, A. Z. and Sugiarto, C. 2023. The Role of Hospital Service Quality in the National Health Insurance / Jaminan Kesehatan Nasional (JKN) Era and the Covid-19 Pandemic. Jurnal Aplikasi Manajemen, Volume 21, Issue 1, Pages 82-111. DOI: http://dx.doi.org/10.21776/ub.jam.2023.02 1.1.07.

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83 INTRODUCTION

Maintaining and improving the quality of a hospital services is a big challenge in the JKN era, first during the Covid-19 pandemic. The approach taken by each hospital should be tailored to its specific needs and resources. All Indonesians must p- articipate in JKN (Jaminan Kesehatan Nasional, or National Health Insurance). It is governed by Law No. 40 of 2004 on the National Social Security Sy- stem or Sistem Jaminan Sosial Nasional (SJSN) and Law No. 24 of 2011 on the Social Security Administering Body or Badan Penyelenggara Ja- minan Sosial (BPJS). The rules are in place to protect the rights of citizens and ensure that everyone is treated fairly. The health sector will manage and implement BPJS Health. With the JKN era through BPJS, every hospital in Indonesia constantly improves to remain the hospital of choice for people who need health services. The referral system for healthcare is being rolled out in phases according to the evolving demands of the healthcare system (BPJS, 2021). Impacted heavily by Covid-19 pandemic, the current outbreak has severely tested Indonesia's healthcare infrastructure. Hospitals must be flexible and operate effectively with the help of an integrated and complete information system covered by JKN (BPJS, 2021).

The Covid-19 epidemic is changing patient beha- vior, resulting in decreased hospital attendance. In addition, the application of the BPJS Health com- petency-based online referral system is in fact, based on hospital class and not on competence and distance. Outpatient services are one of the profit centers and give the patient the first impression of the facilities in the hospital (Sinaga, 2018). In general, the number of outpatient service visits at the outpatient installation of Pandan Arang Hospital experienced a significant decline during the transition period for hospital types and the Covid-19 pandemic. However, this is not the case with GEH clinic. The number of visits at GEH remains high and tends to increase. The Gastroentero Hepatolo- gy outpatient services are relatively new and are not found in every hospital. Based on data from Indonesian Gastroenterology Foundation (YGI), in the Solo Raya area, which includes Surakarta, Boyolali, Sukoharjo, Karanganyar, Klaten, Sragen,

Wonogiri, there are only five GEH consultant doctors who are in three hospitals, namely RSUD dr.

Moewardi,Surakarta;PandanArangHospital,Bo-

yolali; and the Panti Waluyo Hospital, Surakarta.

KGEH services are included in the internal medi- cine specialist department at the hospital that han- dles problems with the digestive system, such as the stomach, pancreas, intestines, liver, and gallbl- adder. Pandan Arang Hospital is a Regional Gene- ral Hospital located in Boyolali Regency, Central Java. Pandan Arang Hospital is now a type B facility as of February 2021. There are eight general hospitals of type D in Boyolali Regency, and among them are doctors from Pandan Arang Hospital who specialize in the various fields. As opposed to when it was still type C, referrals to the Pandan Arang Hospital cannot come directly from lower- level health facilities, known as Fasilitas Keseha- tan Tingkat Pertama (FKTP). Patients requiring o- utpatient services, especially those with underwri- ters BPJS, decreased significantly during the hospital's status transition and the subsequent Covid- 19 pandemic.

This research seeks to identify the service quality strategy implemented by the administration of Pandan Arang Hospital during the Covid-19 Pandemic and the JKN era to generate patient satisfaction and loyalty, particularly at the GEH subspecialty clinic to serve as a benchmark for hospitals interested in introducing new subspecialty services. This study examines the factors that motiva- te patients to choose a hospital as a means of treatment and how they influence their intention to review the products and services they receive from that hospital. There is a need to comprehend the function of trust and customer satisfaction in fos- tering customer loyalty, among these determinants being service quality, customer experience, and perceived value. A previous study (Susanti et al., 2021) found an effect of service quality based on reliability, responsiveness, and assurance on inpatient satisfaction at Labuang Baji Hospital Makas- sar during the Covid-19 pandemic in inpatient ins- tallations. Similar research was also found by (So- umokil et al., 2021) that there was a relationship between reliability, assurance, physical evidence, empathy, and responsiveness with patient satisfaction. Improving service quality is necessary for ex- pertise according to their respective scientific fields for all health service providers. On the other hand, the results of research from (Yanuarti et al., 2021) stated that overall patient perceptions of the five dimensions of service quality are still not go-

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od, namely 57.1% reliability, 63.8% responsiveness, assurance 56.2%, empathy 50.5% and physi- calevidence55.2%andthereisaninfluenceofage, gender, education, and occupation on the patient's perception of service quality. Furthermore, based on the results of the journal reviewed by (Ahmad et al., 2022) explained that the impact of Covid 19 on hospitals was more pronounced in the decrease inthenumberofpatients,thetotalcapacityofbeds, and the lack of services provided to patients consi- dering that not all patients can be fully served because it is limited to the Covid protocol which requ- ires the number of patient visits to be reduced to maintain social distancing.

Furthermore, in the results of review (Ahm- ad et al., 2022), it was concluded that the 5 dimen- sionsofservicequalityaremorepronouncedinthe aspect of physical evidence where the number of beds has decreased, especially in hospitalization, and has increased in special services for Covid-19.

Regarding guarantees, we still maintain the Covid protocol system, where some people at risk, such as the elderly and pregnant women, cannot check themselves directly at the hospital. Regarding responsiveness and reliability, the hospital maintains how to provide services and improve service delivery using telenursing. Then related to the JKN tiered referral system, (Fahmi et al., 2020) in his findings stated that the tiered referral regulation not only makes patients feel difficult and complicated, but health workers also feel disadvantaged becau- sethenumberofpatientshasdecreaseddrastically.

It is also difficult for patients to get services directly from Dr. Hospital Fauziah Bireuen, so to over- come these obstacles, the effort that can be made is to present sub-specialist polyclinics that are not owned by type D hospitals and try to serve supporting facilities such as CT Scans and rehabilitation.

Therefore, this study aims to identify the cause of the decrease in patient visits at the outpatient installation of Pandan Arang Hospital by making the GEH clinic a reference for one of the clinics that has a stable number of patient visits and even tends to increase compared to other outpatient clinics at Pandan Arang Hospital. The following is a decrease in the number of patients at Pandan Arang Hos- pital from 2020, 2019, and 2021, which can be se- en in the table 1. There was no Covid-19 pandemic in 2019, and Pandan Arang Hospital continued to be a type C facility. Outpatient visits dropped by

28.3 percent in 2020, the first full year of the Cov- id-19 pandemic; in 2021, after the hospital switch- ed to type B status but the pandemic's effects were still felt, outpatient visits dropped by 80 percent from the previous year, among all outpatient clinics, only the Gastroentero Hepatology (GEH) subspecialty clinic saw no change in patient volume.

Pandan Arang Hospital's GEH clinic saw the following patients in 2020 and 2021, as listed in the table 2. In 2020 the number of GEH clinic patients was 3.5% of the total outpatients of Pandan Arang Hospital, and in 2021 the number of patients increased to 12.8%.

Table 1. Number of Patient Visits in the Outpatient Installation of Pandan Arang

Hospital in 2019-2021

Year Number of patients

2019 159.868

2020 114.568

2021 32.491

Source: RSUD Pandan Arang

Table 2. Patient Visits at the GEH clinic at Pandan Arang Hospital in 2020-2021

Year Number of patients

2020 4.044

2021 4.184

Source: RSUD Pandan Arang

Further research is necessary because first, referring to the explanation of the phenomenon a- nd research gaps found in this background, there is a research gap that shows differences in results from several previous studies related to the role of hospital service quality during the Covid-19 pandemic. Second, related to the topic of the role of service quality in the era of the JKN tiered referral system on the number of patient visits in hospitals, it is quite interesting to study because not many have used a mix method approach (qualitative and quantitative) and use of qualitative methods domi- nated previous research. Then there is the object specification in this study, namely the GEH clinic.

Third,thisstudycontributestoexaminingwhatele-

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85 ments affect the patient satisfaction and loyalty to

determine the effectiveness of the service quality strategy provided, such as analyzing the role of service quality at Pandan Arang Hospital in the JKN era related to outpatient clinic services for Gastro- entro Hepatology, analyzing the role of service quality of the Pandan Arang Hospital during the Co- vid-19 Pandemic related to outpatient clinic services for Gastroentro Hepatology, knowing the effect of the service quality on customer satisfaction, knowing the effect of the service quality on trust, knowing the effect of the customer experience on trust, knowing the influence between customer perceived value on trust, the effect of customer perceived value on customer satisfaction, to determine the effect of trust on customer satisfaction, and knowing the effect of customer satisfaction on customer loyalty. It is expected to move the Pandan Ar- ang Hospital to achieve organizational goals, improve better services and improve human resources to be of higher quality. Based on the phenomena and the research gaps described, it is necessary to research to find out "The Role of Hospital Service Quality in the JKN Era and the COVID-19 Pande- mic Period".

LITERATURE REVIEW Service Quality

TjiptonoandChandra(2020)statedthatser- vice quality is an organization's "effort to meet the needs and desires of customers and to provide acc- uracy in a manner that is consistent with the appro- priatelevelofcustomerexpectations."Meanwhile, according to Kotler and Keller's (2009) book "Ma- rketing Management," a service is any intangible action or activity that can be offered by one party to another that does not result in any ownership by either party.

Customer Perceived Value

Customers' value evaluations are vital to a company's overall success. The success of a company's management is measured by more than just the amount of money it brings in. The customer's perception of value is an additional consideration.

Customer perceived value is defined as the "overall evaluation of a product's usefulness based on perceptions of what is received and what is suppli- ed," as stated by Zeithaml and Bitner (2005). This rating takes into account the buyer's overall satis-

faction with the product. According to yet another definition, "customer perceived value" means "the consumer's total estimate of the utility of a product (or service), based on the perception received and delivered."

Customer Experience

The satisfaction of customers is essential to the ongoing success of a business. When a customer has a positive experience with a product or service provider, the provider will see an increase in customer loyalty, customer retention, and revenue.

These three factors will contribute to the progress that the company makes. According to Gentile et al. (2007), a customer's experience results from a series of interactions between the customer and the company, product, or aspect of the organization that elicits a reaction from the customer. This experience is meaningful to me and hints at client involvement levels (rational, emotional, sensory, physical, and spiritual). He described this analysis as a comparison between the aspects of a product or service that the consumer "gets" and those that the provider "gives." The ratio or compromise between the quality and cost is the most common in- terpretation of what is meant by "value for money"

(Cravens et al., 1988).

Customer Satisfaction

Customer satisfaction can also be defined as the degree to which an individual is a content after contrasting the delivered service or product with their preconceived notions of what should be provided. There is a strong correlation between customer satisfaction and customer loyalty as two dis- tinct but related concepts (Fernandes and Solimun, 2018). Another aspect of customer satisfaction is the degree to which consumers have the impression that the products or services they purchase ful- fill all of their prerequisites and expectations (Ko- tler, 2000).

Brand Trust

Wijaya (2013) There is a brand for virtually every product, and nearly all companies work hard to cultivate and protect the good name associated with their product brands. To build a customer or brand loyalty, a brand must establish itself as trust- worthy. A customers who believe in a product or company are more likely to recommend it to their

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friends and family. It is because customers are sus- ceptible to being swayed by a brand's reputation.

It makes no difference what kind of income they bring in, how old they are, where they live, or what gender they are. Customers often describe trust in a brand as something that grows over time through some learning process. As a result, brand trust is typically derived from previous interactions and experiences (Garbarino and Johnson, 1999). The evaluation of each consumer's direct (involving the use of the brand) and indirect (involving other consumers) contact with the brand has an impact on this as an experience attribute (Delgado, 2004).

According to his findings (Huang, 2017), having a positive brand experience and being loyal to the brand are mediated by having a positive brand im- age and trust.

Customer Loyalty

Oneofthemarketinggoalsistowinexisting customers' loyalty. Consumers are encouraged to develop brand loyalty and repeat purchases when offered incentives, such as customer loyalty progr- ams. Customers dedicated to a particular company report a high level of contentment with the products and services they purchase from that company and are eager to recommend those products and services to others. Kotler (2000) stated that customers with high brand loyalty make purchases from a single company an increasing proportion of the time compared to their purchases from other busi- nesses. Loyalty is a primary concern for many bu- sinesses because it can significantly impact the co- ntinuedexistenceofabrandoreventheentirecom- pany (Yuliana, 2017).

HYPOTHESIS DEVELOPMENT

Summing up, customer satisfaction can be defined as the degree to which the actual performance of the purchased goods or services meets or exceeds the customer's expectations (Sangadji and Sopiah, 2013). That's why it's essential to focus on providing high-quality service to your customers (Rigopoulou et al., 2008). There is no static conce- pt of the service quality; instead, it is comprised of multiple factors, all of which fluctuate concerning one another and the overall impact of the service on the patient's experience (Saunders, 2008). Tan et al. (2016); Wang and Shieh (2013); Carmona et al. (2021), to name a few, have all found positive

and statistically significant correlations between service quality and customer satisfaction. The trust may also be affected by other factors, such as the quality of the service provided. According to research by (Najib and Sosianika, 2019), there is a strong correlation between the service quality and trust in the retail industry. Furthermore, a separate studyfoundsimilarfindingsforhomedeliveryser- vices (Chou, 2013). The quality of the service provided impacts not only customer satisfaction but also customer loyalty. According to studies cited by (Bawa et al., 2013), customers are more likely to remain loyal if they are satisfied with the service they receive. In light of this, the researcher has developed the following hypothesis:

H1 : There is a positive and significant effect of GEH clinic service quality on patient satisfaction for customer loyalty at GEH clinic services at Pandan Arang Hospital.

H2 : Service quality has a positive and significant effect on trust for customer loyalty in the G- EH clinic services at Pandan Arang Hospital.

H3 : Customer satisfaction mediates the effect of service quality on customer loyalty.

H4 : Trust mediates the effect of service quality on customer satisfaction.

H5 :Trustandcustomersatisfactionmediatetheef- fect of service quality and customer loyalty.

Experienceisthesubjectivereactionofcon- sumers directly or indirectly to the company (Me- yer and Schwager, 2007). Shaw (2004) stated that the consumer experience is an interaction between companies and consumers. The interaction can be physical or emotional. Customer experience regarding perceived services makes patients consider choosing a hospital at this time. Trust also affects the relationship between customers and the company (Morgan and Hunt, 1994). According to research (Moriuchi and Takahashi, 2016), a relatively significant positive correlation exists between customer experience and trust in e-comers. Then the same thing is also found in research (Rahmawati etal., 2019)intheculinaryfield. Additionally, cre- ating a feeling of satisfaction for customers can also increase the company's competitive advantage (Ridwan and Purwanto, 2021). (Felita and Japari- anto, 2015) a good customer experience will support customers to return and, in the end, will result in loyalty that keeps customers. Therefore, the re-

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87 searcher proposes the following hypothesis:

H6 : There is a positive and significant effect of customer experience on trust for customer lo- yalty in GEH clinic services at Pandan Arang Hospital.

H7 : Trust mediates the effect of customer experi- ence on customer satisfaction.

H8 :Trustandcustomersatisfactionmediatetheef- fect of customer experience on customer loyalty.

The term "customer perceived value" refers to the value that customers place on a product or service at different points in the buying cycle (Wo- odruff,1997).Researchmethodologybasedondis- tributionof responses (Zeithaml and Bitner, 2005) created a framework of six factors (physical state, competence, product/service quality, cost, emotional value, and social value) that influence whatis valued.Trustisbuiltwhenacustomerbegins feel- ingsafewithbusinessafterreceivingsomebenefit.

To thisend, onecould contendthat a customer's belief in a vendor's reliability is predicated on the perceived worth of a product or service (Singh and Sirdeshmukh, 2000). Eventhoughthisisapre-purchase scenario in which customer trust is an antecedent of value expectation, some authors argue for

a counterfactual causality in which customer trust is an antecedent of perceived post-purchase value (Sirdeshmukhetal,2002).PirzadandKarmi(2015) stated that the highest levels of perceived valueco- uldboosttrustafterapurchase,suggesting a positive relationship between the two concepts. When consumers report high contentment with particular brand, that brand's value rises (Prameka, 2016).

Furthermore, he also described how company co- uld increase customer satisfaction by focusing on value it is perceived to be providing to clients.

H9 : There is a positive and significant effect of customer perceived value on trust for customer loyalty in GEH clinic services at Pan- dan Arang Hospital.

H10 : There is a positive and significant effect of customer perceived value on customer satisfaction for customer loyalty at GEH clinic services at Pandan Arang Hospital.

H11 : Trust mediates the effect of customer percei- ved value on customer satisfaction.

H12 : Customer satisfaction mediates the effect of customer perceived value on customer loyalty.

H13 : Trust and customer satisfaction mediate the effect of customer perceived value on customer loyalty.

Figure 1. Framwork Model Service

Quality

Customer Satisfaction Trust

Customer Experience

Customer Perceived

Value Customer

Loyalty

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Trust is the degree to which a client is willing to rely on a business (Moorman et al., 1993).

Svensson et al. (2010) stated that there is a correlation between trust and manufacturer satisfaction, with manufacturers using trust components like c- redibility, fairness, and honesty to weigh the pros and cons of a business partnership. According to the previously mentioned studies, the most influe- ntial aspect of a customer's satisfaction is the company's ability to effectively meet the customer's n- eeds (Pavlou and Fygenson, 2006). Evidence from (Lie et al., 2019), For users of the Go-Jek app, the article examines how customer satisfaction affects service quality, price, trust, and loyalty. After put- ting the hypothesis to the test, we find that consumers' trust does lead to promising outcomes. The researcher has a hypothesis due to this fact:

H14 : There is a positive and significant effect of trust on customer satisfaction for customer loyalty in the GEH clinic services at Pandan Arang Hospital.

H15 : Customer satisfaction mediates the effect of trust on customer loyalty.

One of the main goals of a business is customer retention because loyal consumers are dedicated to being loyal and buying goods or services in the future (Ruswanti and Lestari, 2016). Satisfacti- on is one of the core concepts of marketing (Kot- ler, 2000), one of the concepts included in the affe- ctive loyalty component (Oliver, 2010). It has be- enwidelystudiedinmarketingoverthepastperiod (Tsiotsou, 2006). Curuana and Malta (2002) stated that consumer happiness greatly influences loyalty.Sofromthisstatement, theauthorshypothesize:

H16 : Customer satisfaction has a positive effect

on loyalty.

METHOD

Mix Methods Research, a hybrid of qualitative and quantitative approaches, was used to com- pilethedataforthisinvestigation(Sugiyono,2016). In this study, qualitative data collection comes first, followed by quantitative data at varying inter- vals and sequentially. The GEH Clinic at Pandan Arang Hospital is where the study is being cond- ucted. The research was carried out between May 2021 and March 2022. This study's data was col- lected through interviews with GEH clinic admini- strators and doctors, followed by the administration of questionnaires to GEH clinic patients; the sample size was calculated through a non-probabi- lity sampling strategy known as purposive sampling, and it was determined that 307 participants w- ould be included in the analysis. Patients at Pan- dan Arang Hospital's GEH Outpatient Installation were surveyed using questionnaires, and the hospital's administration and the Gastroentero Hepa- tology physician were interviewed for additional information. In addition, we drew upon secondary data sources, such as the results of other people's research, books, reports, and documents from affi- liated parties, and the Pandan Arang Hospital web- site, to fill in the gaps in our primary data set. In- terviews and questionnaires as methods for gather- ing information. Smart PLS software, used in the quantitative method of data analysis, consists of t- wo analyses: the outer model and the inner model.

In contrast, qualitative approaches to data analysis involve activities like a literature review and pilot studies, data grouping and reduction, data presen- tation, and conclusion drawing.

Table 3. Indicators and Statements of Customer Loyalty

Indicator Statement

Repeat the purchase 1. I always use the services of the Pandan Arang Hospital regarding Gastroentero Hepatology cases because the doctor's diagnosis is correct.

Retention 1. I will continue to use the services of the Gastroentero Hepatology clinic at Pandan Arang Hospital, even though there are other hospitals.

Referrals 1. I will share a good impression with others if I get health services at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

2. I will recommend the services of the Gastroentero Hepatology clinic at Pandan Arang Hospital to others.

Source: Kotler and Keller (2009) and Abou-Shouk and Soliman (2021)

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89 Table 4. Indicators and Statements of Trust

Integrity 1. Agreements made by Gastroentero Hepatology clinic doctors tend to be reliable.

2. I do not doubt the advice of a subspecialist in Gastroentero Hepatology.

3. I hope doctors can keep their promises, like coming according to operating hours.

4. I hope that the advice from the subspecialist doctor of Gastroentero Hepatology is the result of their best consideration.

5. I believe that the subspecialist Gastroentero Hepatology doctor at Pandan Arang Hospital serves his patients sincerely.

Benevolence 1. I hope the doctor is ready and willing to help and support my recovery.

2. I hope the Gastroentero Hepatology doctor has good intentions toward me.

3. I hope the doctor assistant nurse at doctor Gastroentero Hepatology clinic has good intentions toward me.

4. I hope that both doctors and nursing assistants of Gastroentero Hepatology doctors put the patient's interests above their own.

5. I hope doctor Gastroentero Hepatology means well.

Ability 1. Gastroentero Hepatology Doctor at Pandan Arang Hospital is competent.

2. Gastroentero Hepatology Doctors at Pandan Arang Hospital understand the target patients where they work.

3. The Gastroentero Hepatologist at Pandan Arang Hospital understands and can communicate my illness well.

4. Doctors of Gastroentero Hepatology at Pandan Arang Hospital know how to provide the best service.

Source: Mayer and Davis (1995) and Gefen (2002)

Table 5. Indicators and Statements of Customer Satisfaction

Satisfaction as pleasure (appearance of goods/services)

1. I feel comfortable with the order examination room of the Gastroentro Hepatology clinic at Pandan Arang Hospital.

2. I am satisfied with the services of the Gastroentro Hepatology Clinic at Pandan Arang Hospital because it is supported by modern and

sophisticated equipment.

Satisfaction as fulfillment 1. I am satisfied with the overall services offered by the Gastroentro Hepatology clinic of RSUD Pandan Arang.

2. I am satisfied with the performance of the nurse assistant at the Gastroentro Hepatology Clinic at Pandan Arang Hospital.

Satisfaction as ambivalence 1. I feel comfortable coming to Pandan Arang Hospital.

Source: Arnould and Zinkhan (2003), Almubayed and Kahwaji (2016), and Ali, Kim, Li, and Jeon (2016)

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Table 6. Indicators and Statements of Customer Perceived Value

Emotional Value 1. I feel comfortable using the services of Gastroentero Hepatology at Pandan Arang Hospital.

2. I feel that there is progress after checking at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

3. I am happy with the services provided at the Gastroentero Hepatology clinic at Pandan Arang Hospital because the doctors are experienced.

4. Gastroentero Hepatology Clinic at Pandan Arang Hospital is one of my choices when I need medical treatment.

5. A conducive examination queue arrangement in accordance with health protocols during the Covid-19 pandemic did not make me afraid to come to the Gastroentero Hepatology clinic of Pandan Arang Hospital.

Quality/Performance 1. Gastroentero Hepatology Clinic of Pandan Arang Hospital consistently provides the best service for its patients regarding facilities/equipment and the services of doctors and nurse assistants.

2. The quality of services provided by the subspecialist Gastroentero Hepatology doctor has met the standard.

3. The doctor's nurse assistant is always friendly with the patient.

4. The doctor of the Gastroentero Hepatology Clinic at the Pandan Arang Hospital came not according to the operating hours. (*)

5. Doctors are always in a hurry when treating patients. (*)

Social Value 1. I feel well accepted when I get treatment at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

2. Gastroentero Hepatology Services Pandan Arang Hospital has a good reputation in the community.

3. Checking at the Gastroentero Hepatology Clinic at Pandan Arang Hospital will improve how the public perceives me.

4. I will make a good impression on others regarding the services at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

Price/Value of Money 1. The patient can reach the cost of the Gastroentero Hepatology clinic at the Pandan Arang Hospital.

2. The prices offered by Pandan Arang Hospital are in accordance with the services I received.

3. Overall, with affordable rates, the Gastroentero Hepatology clinic of Pandan Arang Hospital can provide satisfactory services.

4. Gastroentero Hepatology clinic services at Pandan Arang Hospital are quite economical.

Source: Sweeney and Soutar (2001)

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91 Table 7. Indicators and Statements of Service quality

Tangible 1. Access to Gastroentero Hepatology clinic facilities at Pandan Arang Hospital is easy.

2. The waiting room for the Gastroentero Hepatology clinic at the Pandan Arang Hospital is kept clean.

3. Gastroentero Hepatology Clinic at Pandan Arang Hospital has modern equipment.

4. The Gastroentero Hepatology Clinic at Pandan Arang Hospital provides comfortable operating hours.

Reliability 1. Examination at the Gastroentero Hepatology clinic of Pandan Arang Hospital was carried out according to the promised schedule.

2. The administrative staff at the Gastroentero Hepatology clinic of RSUD Pandan Arang gave me information about when the service would be done.

3. The inspection fee in connection with the service I received was too high. (*)

4. The facilities at the Gastroentero Hepatology clinic of the Pandan Arang Hospital provide services as promised. Such as the availability of advanced equipment and methods, including endoscopy, colonoscopy, fibroscan, and hemorrhoid ligation.

Responsiveness 1. The Gastroentero Hepatology clinic doctor at Pandan Arang Hospital is willing to listen to my questions.

2. The Gastroentero Hepatology clinic doctor at Pandan Arang Hospital responded effectively to my questions regarding the patient's health status.

Assurance 1. The nurse assistant of the Gastroentero Hepatology clinic at the Pandan Arang Hospital is polite.

2. I feel safe in the hands of the Gastroentero Hepatology doctor at Pandan Arang Hospital, who examines me.

3. I will entrust the future to the same doctor for the case of Gastroentero Hepatology.

4. The examination time at the Gastroentero Hepatology clinic of the Pandan Arang Hospital is quite efficient, following health protocol standards during the Covid-19 pandemic.

Empathy 1. The process for scheduling an examination at the Gastroentero Hepatology clinic at the Pandan Arang Hospital is comfortable.

2. The waiting time for examination at the Gastroentero Hepatology clinic of Pandan Arang Hospital is short because the service is fast.

3. I participate in decision-making regarding my medical care.

4. The doctor at the Gastroentero Hepatology clinic at Pandan Arang Hospital understood my needs.

5. The assistant nurse at the Gastroentero Hepatology Clinic at the Pandan Arang Hospital respects my feelings.

Source: Margaritis, E., Katharaki, M., and Katharakis, G. (2012)

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Table 8. Indicators and Statements of Customer Experience

Think 1, My curiosity arose when the doctor explained my illness.

2. When the doctor diagnoses, I feel my knowledge is increasing.

3. I am involved in the thought process when the doctor diagnoses.

Feel 1, Sometimes I feel disappointed with the attitude of the doctor's nurse assistant at the Gastroentero Hepatology clinic at Pandan Arang Hospital. (*)

2. Sometimes, I get tired of waiting in the long check queue. (*) 3. Sometimes, I can't wait for many check queues. (*)

4. Sometimes, I am angry that I have not been treated fairly by other patients by the Gastroentero Hepatology clinic doctor. (*)

Act 1. I tend to review my examination schedule/control schedule.

2. I actively follow the doctor's advice for my recovery.

3. I look for the latest service information at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

Sense 1. I feel comfortable seeing the order of the waiting room, which is neat and clean.

2. I feel that the air circulation in the Gastroentero Hepatology clinic of Pandan Arang Hospital is smooth.

3. I feel calm when I do the examination at the Gastroentero Hepatology clinic at Pandan Arang Hospital because it is far from noise.

Relate 1. I feel important to the medical staff, doctors, and nurse assistants, at the Gastroentero Hepatology clinic at Pandan Arang Hospital.

2. I adjust myself to other patients in the Gastroentero Hepatology clinic at Pandan Aran Hospital.

Source: Schmitt (1999) and Rajaobelina (2017) RESULTS

Qualitative Research

From the results of interviews with the management of Pandan Arang Hospital and the doct- or in charge of the GEH clinic regarding the general conditions and strategies carried out for the Out- patient Installation and GEH clinic during the Co- vid-19 pandemic and the JKN era, it is as follows:

Theme 1: The General Condition of the Outpatient Installation at Pandan Arang Hospital in the JKN Era and the Covid-19 Pandemic. The government appointed Pandan Arang Hospital as a second-line referral hospital for managing the Covid-19 patients in Boyolali Regency. After going through thecredential process from BPJS, the Pandan Arang Hospital was administratively officially class B in March 2021. The transition

period of hospital status and Covid-19 pandemic caused a significant decrease in the number of patient visits, especially patients with BPJS guarantees, because of the tiered referral system and the fear of people going to the hospital. It causes patient visits to fall by more than 50% daily. As described by one of the participants, as follows:

“The number of outpatient visits was first affected by the Covid-19 pandemic, from 700 patients to around 500 patients per day, then followed by a change in hospital class from C to B, causing the number of patient visits to drop to 200-300 per day as a result of BPJS rules. Require tiered referrals” (He- ad of Nursing Installation for Outpatient Pandan Arang Hospital).

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93 The same thing was also conveyed by other

management, including the Director, Head of Ge- neral Affairs, Head of Service, Head of Outpatient Installation, and Coordinator of Outpatient Patient Registration (TPPRJ), that there was a decrease in the number of patient visits at outpatientpolyclin- ics.Tomaintainthecontinuityofoutpatient services in the JKN era and during the pandemic, Pan- dan Arang Hospital has prepared facilities and infrastructure as well as service flow according to the recommendations of WHO and the Ministry of H- ealth, including the policy of separating Covid-19 and Non-Covid19 services from patients entering the hospital until patients leaving the hospital, separating the areas summarized in one service man- ual document and complementing human resources for more complex cases, as explained by the director of Pandan Arang Hospital.

“[…] The hospital's strategy to deal with Covid-19 first separates Covid-19 and non- covid-19 services from admission, ER/outpatient services, inpatient services until dis- charge, and higher hospital referral services until the patient dies. It is summarized in a single document of service guidelines and standard operating procedures. Regarding the increase in a hospital class, as a type b hospital, we must prepare facilities and infrastructure and more competent human resources to receive referral patients for difficult cases that are not handled in type C and type D hospitals” (Director, Pandan Arang Hospital).

Then from another point of view, the thing that needs to be considered regarding the decrease in the number of patient visits at the outpatient installation of Pandan Arang Hospital is the availability of specialist and subspecialist doctor services so as not to lose market share. It was conveyed as follows:

“The presence of a Gastroenterohepatology consultant causes outpatient visits at the internal medicineclinictoremainquitehigh, especiallythe GEH clinic, because it catch- es referrals for sub-specialist cases from ne- arby hospitals […]” (The doctor in charge of the Gastroentero clinic Hepatology, Pan-

dan Arang Hospital).

Theme2:InfrastructureFacilitiesattheOut- patient InstallationofPandanArangHospitaland theGastroentero Hepatology clinic. Pandan Arang Hospital provides online registration services (B- APER application), medical records using ERM, and drug delivery services in collaboration with Grab. GEH services include ultrasound, fibroscan, endoscopy,colonoscopy,andhemorrhoidligation.

As described as follows:

“Outpatient facilities and infrastructure include digital medical records (ERM), access for disabled and non-disabled patients according to accreditation standards and the Ministry of Health, drug delivery services via grab” (Director of Pandan Arang Hospi- tal).

“Thereisstillalotthatneedstobeupgraded.

The improvement target for facilities and infrastructure is already more than 50%. I think it has exceeded the target” (Head of the Outpatient InstallationatPandanArang Hospital).

"Thereisa BAPER application (online queue booking) which contains service facilities, tariffs, and is also connected to the BPJS system and several insurances” (Head of General Section of Pandan Arang Hospital).

"The facilities and infrastructure are complete and adjusted to standards" (Head of Ser- vices at Pandan Arang Hospital).

“Types of gastroentero hepatology subspecialty services include endoscopy, hepatology examination consisting of ultrasound, supporting laboratories, biopsy equipment, and fibro scene. In the future, it will be equi- pped with THTP so that gallstones can be takenwithoutsurgery[…]”(Doctorinchar- ge of the Gastroentero Hepatology clinic).

Theme 3: Weaknesses of the Outpatient In- stallation and Gastroentero Hepatology Clinic at Pandan Arang Hospital. HR is the main weakness factor, according to the management of Pandan

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Arang Hospital. The problem lies in changing the mindset to be more advanced and better. In addition, the quantity of human resources competent in GEH services is still lacking. As stated by the following informant:

"The weakness in patient care following hospital class B policies is the competence of human resources, and this becomes management resistance in realizing the hospital's vision and mission” (Director ofPan- danArangHospital).

"The perceived weakness is HR. It needs regeneration and regeneration so that it can improve services and not rely on one per- son” (Doctor in charge of the GEH clinic).

"From the officer's perspective, understand- ing of the flow has begun to increase, but sometimes the officers forget the schedule of the doctor in charge of the patient” (Head of Outpatient Nursing Installation at Pandan Arang Hospital).

However, on the other hand, others think that they do not feel any weakness in the Outpati- ent Installation of Pandan Arang Hospital. The following is an excerpt:

"I don't think there are any weaknesses"

(Coordinator for Outpatient Registration (TPPRJ)).

Theme 4: Opportunity factors for Outpatie- nt Installation and Gastroentero Hepatology Clinic at Pandan Arang Hospital. Changing the hospital class to type B is an effective opportunity to ex- plore more comprehensive services with larger buildings, providing comfort to patients. Pandan Arang Hospital was appointed as a referral hospital for Hepatitis C services. Another opportunity is cooperation with insurance other than BPJS. The following is an explanation from the interviewees:

“To develop class B hospital services, the opportunity is wide enough. Some of the infrastructure facilities are already available.

It's just a matter of improving the competence of human resources" (Director of Pandan Arang Hospital).

“The outpatient polyclinic building is adequate, the number of examination rooms is sufficientandcomfortable, thewaitingroom is spacious, complete facilities and infrastructure, so that it supports its main services in the Pandemic era to carry out physical distancing” (Head of Outpatient Installation at Pandan Arang Hospital).

“It is necessary to increase cooperation with other insurance companies besides BPJS and add sub-specialists who do not yet exist in lower type hospitals so that theycanalso acceptpatientsfromareasoutsideBoyolali because there are not many type B hospitals intheSoloRayaarea”(HeadofServicesat Pandan Arang Hospital).

"The opportunity factor for Gastroentero Hepatology clinics is to provide complete services for patients with hepatitis B and hepatitis C, related to the national hepatitis eradication program. Also, the opportunity for plenary services for degenerative diseas- esisincreasing,suchasgastrointestinalcan- cer. For this reason, the presence of oncolo- gy and digestive surgeons is essential to work together for Gastrointestinal Hepatology services” (Doctor in charge of Gastroentero Hepatology clinic).

Theme 5: Threat factors felt by the Outpa- tient Installation of Pandan Arang Hospital and the Gastroentero Hepatology Clinic. The existence of a tiered referral system and the increase in private hospitals in the Boyolali area have caused a decrease in the patient visits, especially among BPJS patients. It is as conveyed by the informantasfol- lows:

“Theautomatictieredsystem is a threat to reduce the number of hospitals outpatient visits” (Director of Pandan Arang Hospi- tal).

“There are many new hospitals in the Bo- yolali district, so the Pandan Arang Hospital must improve its quality to maintain patient loyalty” (Head of Nursing Installation for OutpatientHospital).

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"The free trade era allows foreign doctors to enter the Boyolali area for Human Resource Boyolali Hospital needs to improvecomp- etencesothatit isnotinferior" (Doctor in charge of Gastroentero Hepatology clinic).

Theme 6: marketing strategy and marketing media at Pandan Arang Hospital Hospital. Mana- gement conducts round table discussions either through social media, zoom, or through limiteddis- cussions,activepromotionbyinvolving stakeholders, especially from district government, by mov- ing the referral system so that puskesmas, hospitals, as well as the private clinics in Boyolali know that the Pandan Arang Hospital there is a comprehensive Gastroentro Hepatology service, so there is no need to refer outside of Boyolali, and through counseling at the polyclinic so that we can provide information about this service to hospital visitors.

The marketing media of the Pandan Arang Hospi- tal carries out advertising mainly using social media, leaflets, radio, and online under the responsib- ility of the Public Relations section. The informant conveyed the following:

"Inviting stakeholders to be active in movi- ng the referral system, conducting round table discussions through social media zoom and outpatient polyclinic counseling to pro- videinformationaboutGEHservices"(Doc- tor in charge of the Gastroentero Hepatolo- gy clinic at Pandan Arang Hospital).

"The marketing team of Pandan Arang Hos- pital uploaded the recording of activities on social media" (Director of Pandan Arang Hospital).

“Service marketing is carried out through thewebsite,theBAPERapplication,andthe most effective way is through WhatsApp group” (Head of General Section of Pandan ArangHospital).

“Putupbannersinfrontoftheoutpatient clinic room to inform the type of service” (He- ad of Outpatient Installation at Pandan Ara- ng Hospital).

“RSUD Pandan Arang conducts advertising

mainly using social media and online under theresponsibilityofPublicRelations. What isconveyed is the type of service, service flow, and service rates” (Head of Service Division at Pandan Arang Hospital).

"Health promotion is also carried out through distributing leaflets that include service information"(CoordinatorofOutpatientRe- gistration Place (TPPRJ)).

Theme 7: Evaluation of customer satisfaction at Pandan Arang. Hospital Pandan Arang Hos- pital evaluates customersevery6monthsthrough theIKMsurvey (Community Satisfaction Index), and in BAPER application, patients can submit criticism and suggestions at any time. There is a sug- gestion box, and there is an SMS complaint. Thus the patient can submit criticism and suggestions at any time. As stated by the following informant:

"The evaluation isinthe formof apatient satisfactionsurveybyassessing the community satisfaction index (IKM), distributed every 6 months" (Head of Outpatient Nurs- ing Installation at Pandan Arang Hospital).

"Service evaluation using the criticism and suggestions column in the BAPER application and SMS complaints"(Coordinatorof OutpatientPatientRegistration (TPPRJ)).

Participant and Measurement Model

Characteristics of respondents most of the respondents are male (54.4%), age of respondents above 50 years (57.6%), whose most recent education is high school (44.3%), are old patients (64.4

%), with the most type of guarantor being BPJS (87.9%). Data is processed and tested using Smart PLS 3.0 software, including outer and inner mode- ls then the analysis continues to the hypothesis testing phase. The primary purpose of the outer model is to identify the connections between latent variables and the indicators they produce. PLS Algo- rithm is used for testing the external model proce- dure. Validity and reliability testing for a mirrored PLS SEM measurement model. Convergent validity and discriminant validity are the two types of validity in PLS-SEM. A set of indicators must be able to represent and explain a single latent varia-

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ble jointly to have convergent validity. If the outer loading value is 0.7 and the average variance extr-

acted is 0.5, then PLS-SEM model is valid and can meet convergent validity.

Table 9. Average Variable Extracted (AVE)

Cronbach's

Alpha rho_A Composite

Reliability

Average Variance Extracted (AVE)

Assurance 0.839 0.839 0.892 0.674

Customer Experience 0.945 0.946 0.951 0.566

Customer Loyalty 0.879 0.879 0.917 0.734

Customer Perceived Value 0.952 0.953 0.957 0.553

Customer Satisfaction 0.910 0.911 0.933 0.736

Empathy 0.881 0.882 0.913 0.677

Reliability 0.842 0.846 0.894 0.679

Responsiveness 0.769 0.769 0.896 0.812

Service Quality 0.953 0.954 0.958 0.544

Tangible 0.900 0.900 0.930 0.769

Trust 0.945 0.946 0.951 0.582

Table 10. Fornell-Larcker

Assurance Customer Experience Customer Loyalty Customer Perceived Value Customer Satisfaction Empathy Reliability Responsiveness Service Quality Tangible Trust

Assurance 0.821

Customer Experience 0.632 0.752

Customer Loyalty 0.574 0.572 0.857 Customer Perceived

Value 0.638 0.647 0.597 0.743 Customer Satisfaction 0.634 0.650 0.763 0.687 0.858 Empathy 0.729 0.645 0.564 0.610 0.617 0.823 Reliability 0.676 0.589 0.577 0.537 0.591 0.713 0.824 Responsiveness 0.710 0.598 0.514 0.619 0.590 0.677 0.704 0.901

Service Quality 0.719 0.649 0.696 0.710 0.738

Tangible 0.728 0.662 0.585 0.643 0.655 0.674 0.729 0.684 0.877 Trust 0.658 0.723 0.677 0.740 0.746 0.666 0.607 0.630 0.748 0.691 0.763 Source: Data processed using SmartPLS 3.0 (2022)

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97 The indicators on thequestionnaireinthis

studycanbeextractedperfectly and have a loading factor value > 0.7. Then table 9 explains the AVE value. The AVE value in this study shows that all variables are valid because they have a value above 0.5. Discriminant validity is an additional con- cept that means two conceptually different concepts must show adequate differences. It means that if a set of indicators is combined, it is hoped that it will not be unidimensional. Measurement of discriminant validity using Fornell-Larcker and Crossloadings. Discriminant validity is said to be high if the construct'srootAVE is greater than the correlation of the construct with other latent variables, as measured by the Fornell-Larcker criterion test. The results of this study are summarized

in Table 10, which shows that all variables are satisfactory as long as the correlation value of any given variable to any other variable is greater than the correlation value of the other variables. Each indicator's 'loading' should be greater than its 'cross-loading,' which is the second criterion for the discriminant validity. The 'cross-loading' can oc- cur at the indicator level if the Fornell-Larcker criterion evaluates discriminant validityatthe con- structlevel(latentvariable). All of the survey questions in this research can be considered valid because the loading value of a given construct exceeds the loading value of all other constructs. All the study's variables pass the reliability test based on the Cronbach's Alpha, with a composite reliability value of over 0.7 and an Alpha of over 0.6.

Full Structural Model and Hypothesis Testing

Table 11. Path Coefficient

Assurance Customer Experience Customer Loyalty Customer Perceived Value Customer Satisfaction Empathy Reliability Responsiveness Service Quality Tangible Trust

Assurance

Customer Experience 0.279

Customer Loyalty Customer Perceived

Value 0.213 0.345

Customer Satisfaction 0.763

Empathy Reliability Responsiveness

Service Quality 0.881 0.275 0.885 0.874 0.833 0.882 0.306 Tangible

Trust 0.383

Source: Data processed using SmartPLS 3.0 (2022)

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The inner model or measurement of the inside is also known as a structural model. The structural model is a model that connects latent variables. The first step is to evaluate the structural model by looking at the significant relationship between theconstructsorvariables.Itcanusethepath coefficient to describe the strength of the relationship between constructs. Table 11 showed that the trust variable has a 0.383 path coefficient value on thecustomersatisfactionvariable, whiletheeffects of service quality and perceived value are 0.275 and 0.213, respectively. At 0.345, customer perceived value has the most significant impact on the trust variable, followed by 0.306 for service quality and 0.279forcustomerexperience.Thecorrela- tion between the customer satisfaction variable and the loyalty of existing customers is 0.763%.

The Path Coefficient also reveals the relative im- portance of five different aspects of service quality: empathy (0.885), tangibles (0.882), assurance (0.881), reliability (0.874), and responsiveness (0.833). Allvariables in this model have positive

pathcoefficients,asshownbytheresultsdescribed above. A higher path coefficient indicates a stro- nger relationship between the independent and de- pendent variables. Research using a modified ver- sion of the R-squared statistic reveals a 62.7% impact of Service Quality, Customer Experience, and Customer Perceived Value on the Customer Satis- faction. Conversely, there is a 58.3 percent correlation between satisfied customers and repeat business. ForthelatentvariableofendogenousTrust, thevalue of Q2 predictive relevance is 0.384, whi- le the values for CustomerSatisfaction(0.452)and CustomerLoyalty (0.421) are similar. If the value of Q2, which measures the predictive relevance of the three endogenous latent variables, is greater than zero, then it can be concluded that the model has predictive relevance. The overall model is ve- rified by calculating its goodness of fit. The high value of 0.598 for the GoF in this study indicates that the research model is robust and has a substa- ntial GoF. Small GoF = 0.1, moderate GoF = 0.25

%, and large GoF = 0.36%. (large GoF).

Hypothesis Test Using Bootstrapping

Table 12. Direct Effects Using Bootstrapping

Original

Sample (O)

Sample Mean (M)

Standard Deviation (STDEV)

T Statistics

(|O/STDEV|) P Values Customer Experience -> Trust 0.279 0.283 0.069 4.058 0.000 Customer Perceived Value ->

Customer Satisfaction 0.213 0.220 0.084 2.533 0.012

Customer Perceived Value ->

Trust 0.345 0.347 0.066 5.214 0.000

Customer Satisfaction ->

Customer Loyalty 0.763 0.760 0.036 20.972 0.000

Service Quality -> Customer

Satisfaction 0.275 0.273 0.070 3.959 0.000

Service Quality -> Trust 0.306 0.299 0.079 3.894 0.000

Trust -> Customer Satisfaction 0.383 0.378 0.088 4.329 0.000 Source: Data processed using SmartPLS 3.0 (2022)

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99 Figure 2. Model T Values

Table 13. Testing The Mediation (Specific Indirect) Effects Using Bootstrapping

Original

Sample (O)

Sample Mean (M)

Standard Deviation (STDEV)

T Statistics

(|O/STDEV|) P Values Customer Perceived Value -> Customer

Satisfaction -> Customer Loyalty 0.162 0.167 0.065 2.502 0.013 Service Quality -> Customer Satisfaction ->

Customer Loyalty 0.210 0.208 0.055 3.794 0.000

Customer Experience -> Trust -> Customer

Satisfaction -> Customer Loyalty 0.082 0.082 0.030 2.723 0.007 Customer Perceived Value -> Trust ->

Customer Satisfaction -> Customer Loyalty 0.101 0.100 0.031 3.272 0.001 Trust -> Customer Satisfaction -> Customer

Loyalty 0.292 0.287 0.068 4.299 0.000

Service Quality -> Trust -> Customer

Satisfaction -> Customer Loyalty 0.089 0.085 0.030 2.940 0.003 Customer Experience -> Trust -> Customer

Satisfaction 0.107 0.108 0.039 2.737 0.006

Customer Perceived Value -> Trust ->

Customer Satisfaction 0.132 0.131 0.041 3.252 0.001

Service Quality -> Trust -> Customer

Satisfaction 0.117 0.112 0.039 3.021 0.003

Source: Data processed using SmartPLS 3.0 (2022) Reliability

0,764

Responsiveness 0,693

Empathy 0,784 Assurance

0,775

Service Quality

Tangible 0,778

Customer Experience

Customer Perceived Value

Trust Customer

Satisfaction

Customer Satisfaction 0,38

3 0,83

3

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Hypothesis Testing

The t statistic value of 3.959 or greater than t table = 1.96 and the p-value of 0.006 or less than 0.05 indicate that Service Quality has a positive and significant effect on Customer Satisfaction for Customer Loyalty at GEH clinic services at Pand- an Arang Hospital. The obtained data supports the acceptance of H1a as a working hypothesis. The t statistic value of 3.894 is greater than the t table = 1.96,andthep-valueof0.009islessthan0.05,in- dicatingthatthequalityofservicesprovidedbythe GEH clinic at Pandan Arang Hospital has a positive and significant effect on trust and customer loyalty. It follows from the obtained data that H2a is accepted. Service quality significantly positively affectscustomer loyalty through customer satisfaction because the t-count value is 3.794, which is greater than 1.96. Also, the p-value is 0.000 or less than 0.05. Therefore customer satisfaction mediates the effect of service quality on customer loyalty. So, H3a accepted. Service quality significantly positivelyaffectsthecustomersatisfactionthrough trust because the t-count value is 3.021, which is greater than 1.96. Also, the p-value is 0.003 or less than 0.05. Therefore trust mediates the effect of service quality on customer satisfaction. So, H4a is accepted. Service quality has a significant positive effect on customer loyalty through trust and satisfaction because the t-value is 2,940, greater than 1.96. Also, the p-value is 0.003 or less than 0.05. Therefore the trust and customer satisfaction mediate the effect of service quality and customer loyalty. So, H5a was accepted. The t statistic value of 4.058 or greater than t table = 1.96 and the p- value of 0.000 or less than 0.05 indicate that Cus- tomer Experience has a positive and significant effect on Trust for Customer Loyalty at GEH clinic services at Pandan Arang Hospital. The obtained data support the conclusion that H6a is true. Cus- tomer experience has a significant positive effect on customer satisfaction through trust because the t-count value is 2.737, greater than 1.96, and the p-value is 0.006 or less than 0.05. Therefore, trust mediates the effect of customer experience on customer satisfaction. So, H7a is accepted. Customer experience significantly positively affects customer loyalty through trust and customer satisfaction because the t-count value is 2.723, which is greater than 1.96. Also, the p-value is 0.007 or less than 0.05. Therefore the trust and customer satisfaction

mediate the effect of customer experience on customer loyalty. So, H8a accepted. The t statistic value of 5.214 or greater than t table = 1.96 and the p-value of 0.000 or less than 0.05 indicate that the Customer Perceived Value has a positive and significant effect on Trust for the customer loyalty at GEH clinic services at the Pandan Arang Hospital.

The data support the hypothesis, so we can say that H9a is true. A t-statistic of 2.533 or greater than t table = 1.96 and p-value of 0.012 or less than 0.05 indicate that customers' perceptions of value have a positive and statistically significant impact on their satisfaction with the GEH clinic services provided by Pandan Arang Hospital. The obtained data supports the acceptance of H10a as a working hypothesis. Customer perceived value has a significant positive effect on customer satisfaction through trust because the t-value is 3.252, greater than 1.96, and the p-value is 0.001 or less than 0.05.

Therefore, trust mediates the effect of customer p- erceived value on customer satisfaction. So, H11a was accepted. Customer perceived value has a significant positive effect on customer loyalty through customer satisfaction because the t-count value is 2.502, greater than 1.96, and the p-value values of 0.013 or less than 0.05. Therefore, customer satisfaction mediates the effect of customer perceived value on customer loyalty. So, H12a was accepted. Customerperceivedvaluehasasignificantpo- sitive effect on customer loyalty through trust and satisfaction because the t-count value is 3.272, w- hich is greater than 1.96. Also, the p-value is 0.001 or less than 0.05. Therefore, trust and customer satisfaction mediates the effect of customer perceived value on customer loyalty. So, H13a was appro- ved. The t statistic value of 4.329 or greater than t table = 1.96 and the p-value of 0.000 or less than 0.05 demonstrate that trust has a positive and significant effect on customer satisfaction, as measured by loyalty to the GEH clinic services by Pan- dan Arang Hospital. Results from the hypothesis testing lead us to accept H14a. Trust has a significant positive effect on customer loyalty through customer satisfaction because the t-value is 4.299, greater than 1.96, and the p-value is 0.000 or less than 0.05. Therefore, customer satisfaction mediates the effect of trust on the customer loyalty. So, H15a was accepted. The t statistic value of 20.972 or greater than t table = 1.96 and also the p-value of 0.000 or less than 0.05 indicate that customer