Inpatient Satisfaction To Attribute of Health Service Quality Dimensions in Hospitals in Indonesian

The hospital is one of the health service facilities that play a very important role in providing health services to the community. To increase patient satisfaction in the hospital, it is necessary to evaluate the quality of existing health services both from a technical and administrative perspective. This study aims to describe inpatient satisfaction with the attributes of the health services quality dimension in hospitals in Indonesia. This study used secondary data with a cross-sectional design based on Risnakes data in 2017. The sample used is samples of Risnakes in hospitals in 2017 after deducting missing data, namely 7,287 inpatients from 380 hospitals in Indonesia. Data analysis used univariate analysis. Results of this study showed that the level of inpatient satisfaction to the attribute of health service quality dimensions in private hospitals was better than in government hospitals. In the tangible dimension of the various attributes studied, there are 5 attributes still below the standard of patient satisfaction (90%), while for the reliability dimension there are 2 attributes, the responsiveness dimension 5 attributes, the assurance dimension 2 attributes, and empathy dimensions 3 attributes. To improve the quality of health services, the management of all hospitals in Indonesia needs to routinely evaluate all of the attributes of health service quality dimensions in the hospital.


INTRODUCTION
In realizing the goal of health development, the hospital is one of the health facilities that play a very important role in providing health services to the community to improve the highest possible health status to create a better quality of life. 1 As a health facility which is the first place of reference, the hospital should be able to run health care quality and affordable for all communities, especially for inpatient services. 2 Thus every hospital must always evaluate the quality of existing services both from a technical and administrative point of view because the quality of service provided will greatly affect the level of patient satisfaction of the hospital. 3 Patient satisfaction is the main objective of every hospital and becomes the main criteria in natural assessing the quality of health services. 4 Patient satisfaction can be interpreted as the level of patient feelings that arise as a result of the performance of health services obtained after the patient compares what is expected with what has been received regarding existing services. 5 It can only be realized if a hospital has succeeded in fulfilling all the needs of patients in obtaining a quality, fair and equitable service. 1,6 Based on data of the Global Health Index followed by the Banyuwangi District Health Office, the health level of the Indonesian state is in the 101st position of 149 countries in the world, and based on the results of the Community Satisfaction Index Survey Report conducted by the Indonesian Ministry of Health 2018 shows that the Patient Satisfaction Index at Hasan Sadikin Hospital is 78.74%; Fatmawati Hospital 78.23%; Marzoeki Mahdi Hospital 79, 95% and Persahabatan Hospital 78.99%. 7 Based on this fact, it shows that patient satisfaction in Indonesia is still below the customer satisfaction standard set by the Indonesian Ministry of Health, namely > 90%. 8 Based on these facts, the problem of patient satisfaction must be considered and overcome seriously, because patient satisfaction will affect patient loyalty to existing services in the hospital, even patient satisfaction is related to the image of the hospital. To overcome this problem, the health service quality in the hospital must be continuously improved, it is necessary to conduct an assessment or measurement of patient satisfaction to the quality of existing health services.
Methods commonly used to measure patient satisfaction is the SERVQUAL method to look at the quality of service of five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. 9,10 This study aims to describe inpatient satisfaction with the attributes of the health services quality dimension in hospitals in Indonesia.

METHOD
This research is a quantitative study with a cross-sectional study design based on secondary data from the Workforce Research in the Health Sector (Risnakes) in 2017 that obtained from the Indonesian Ministry of Health's laboratory. The sample used is samples of Risnakes in hospitals in 2017. From 9,605 samples obtained, after deducting missing data only 7,287 inpatients can be a sample in this study.
The samples come from 380 selected hospitals in Indonesia, both public and private hospitals that were successfully interviewed by the Risnakes team in 2017. In Risnakes 2017 the sample is selected by proportional random sampling. 11 The independent variable in this study is the dimension of tangible, reliability, responsiveness, assurance, and empathy, while patient satisfaction acts as the dependent variable. Furthermore, the data were analyzed using the SPSS program with univariate analysis because this study only wanted to describe inpatient satisfaction to the attributes of the health services quality dimensions in hospitals in Indonesia. Categorizing satisfied and not satisfied based on the value of the mean of respondents' answers on each question, if the attribute score above the mean of the respondents considered satisfied but if the attribute score below the mean of the respondents considered not satisfied. The results of data analysis are presented in the form of tables and descriptions.

RESULTS
The univariate analysis aims to explain or describe the frequency distribution of respondents based on respondent characteristics, independent variables, and dependent variables. In this study, the univariate analysis explains the frequency distribution of respondents based on patient satisfaction with the attributes of the dimensions of health services in hospitals in Indonesia. The results of the univariate analysis are presented as follows: Based on table 4, it can be seen that of the nine attributes of the assurance dimension studied, inpatients were satisfied with the seven attributes. The highest percentage of satisfaction is in the attributes of inpatient service officers serving friendly and polite, and officers providing the information needed by patients clearly, which is 99.6% and the lowest is in the attributes of health workers storing patient health information (medical history) as confidential, which is equal 73.5%.

DISCUSSION
Inpatient services are one of the existing forms of service in hospitals that are provided to patients to occupy a bed due to the needs of observation, diagnostics, therapy, rehabilitation, medication, and other medical services with certain medical conditions that require daily medical care. 12 Inpatient services show an interaction between patients and health workers, both doctors and nurses, for a long time while the patient is treated. According to Supriyanto and Wulandari (2011), inpatient services involve a sensitive relationship between patients, doctors, and hospital nurses while the patient is treated so that it is related to patient satisfaction and the quality of existing services. 12 For this reason, the hospital must always provide quality services to realize patient satisfaction.
Bitner and Zeithaml (1996) describe patient satisfaction as a specific evaluation effort for all services provided by service providers to customers where measurement of customer response is carried out directly so that customer satisfaction can only be assessed based on the experience felt during the service delivery process. 13 Based on this, it can be said that patient satisfaction is a form of feeling or direct patient assessment of the quality of all health services they have received while being treated in the hospital. Assessment of patient satisfaction on the quality of health care can be measured by the overall dimensions of service quality attributes which include the dimensions of tangible, reliability, responsiveness, assurance, and empathy

Tangible (Dimensions of Physical Evidence)
The dimension of tangible is the appearance of the hospital that can be seen directly and becomes a reference for the first-morning assessment of patients who will receive service. Physical evidence (tangible) includes physical appearance. can be in the form of facilities and infrastructure including ready-to-use tools and staff appearance. 14 The availability of buildings and rooms with attractive interiors, neatly arranged and ready-to-use medical and non-medical equipment, the comfort and cleanliness of the rooms that are maintained, and the appearance of attractive officers. The patient's expectations of physical evidence are the patient's beliefs before receiving services which will later be used as a standard or reference in assessing services. 15 Patient satisfaction with the dimensions of tangible is the response or level of patient feelings to the attributes of physical evidence that appear after the patient sees and feels the service while the patient is hospitalized. In this study, an assessment of inpatient satisfaction was carried out on the 12 attributes of the dimensions of physical evidence as can be seen in Table 1 According to Pohan (2007), several elements can affect the satisfaction of inpatients at the hospital where they are treated, including the inpatient room which is neat, clean, and comfortable. 12 Environmental conditions were arranged neatly, coexist and beautiful will make patients and families who take care of the patient are comfortable. Convenience is the dimension of the quality of services that are not directly related premises n effectiveness Vitas clinically but can affect patient satisfaction for re-use hospital services. 14 Recommendations that can be given regarding the patient's complaints above are that the hospital needs to provide a family waiting room and patient care room that is made to be as comfortable as possible with conditions that are always clean, adequate ventilation, adequate seating, availability of a place to wash hands and sufficient trash cans, and the availability of a bathroom/WC comfortable and did not smell, as well as necessary their role cleaning service that should always pay attention to and increase efforts to the maintenance of cleanliness, especially the cleanliness of the room shower/WC as well as the overall hospital hygiene.
In addition to the above complaints, the patients also feel dissatisfied with the attributes ' is not

Reliability
Reliability includes all the ability of service providers to provide immediate service in a timely, accurate, reliable, and satisfactory manner as promised. 9 This concerns the consistency of service providers in providing services, fulfilling existing promises, keeping accurate records, and serving correctly. Patient satisfaction with the reliability dimension is the patient's response or level of feeling to the reliability attributes that appear after the patient feels service while the patient is hospitalized. In this study, an inpatient satisfaction assessment was carried out on 9 attributes of reliability dimensions such as which can be seen in table 2.
Based on table 2 above can be seen that the level of satisfaction of patients in private hospitals is better than the government hospital because private hospital patient satisfaction for all dimensions of quality attributes of reliability (reliability) meets the standards of customer satisfaction has been set at> 90%. However, even so, private hospitals must continue to improve the quality of the reliability dimension attributes so that no more patients feel dissatisfied. For both public and private hospitals, there is one attribute that shows the level of patient satisfaction reaching 100%, this means that all patients who are hospitalized in hospitals in Indonesia are satisfied with these attributes, namely all hospitals always carry out laboratory examinations or other medical support examinations (X-rays, ultrasound, MRI, etc.) of hospitalized patients.
All of the attributes of the reliability dimension studied, in government hospitals, 2 attributes indicate the level of patient satisfaction is low or below the customer satisfaction standard set by the Ministry of Health of the Republic of Indonesia (> 90%). This means that patients feel dissatisfied with the service dimension of reliability of the available hospital where they were treated so that it can be a problem in hospital health care quality. The attributes are 1) all the drugs prescribed are available, and 2) There is no additional charge for all services received. being hospitalized. This is not following the theory of "Excellent Service Joints" as followed by Warella (1997) states that the criteria for quality public services include: clarity and certainty regarding service procedures or procedures, and openness in service procedure. 17 Recommendations that can be given for this problem are that the hospital must provide clear information about all the medical costs required for the actions given to treat the disease suffered by the patient before the treatment is carried out so that the patient and family can prepare all the costs needed.
Hospitals can maximize frontline functions that are already available and apply the implementation of SIMRS online so it is expected to control the symptoms.

Responsiveness
Responsiveness is the willingness of officers to assist customers in dealing with complaints and provide services quickly and soon. This dimension focuses on the attention and speed of officers in responding to requests, complaints, and problems faced by consumers. 18 Patient satisfaction with the dimension of responsiveness is the response or level of patient feelings to the attributes of responsiveness that appear after the patient feels service while the patient is hospitalized. In this study, an assessment of the satisfaction of inpatients was carried out on the 7 attributes of the response dimensions as can be seen in Table 2. with requests, complaints, and problems of the patients. 14 Recommendations that can be given to overcome all the complaints above are that there is a need for personality training for health workers so that in providing services to patients they can be as much as possible by not intervening or hindering patients from choosing the treatment or treatment they want. Besides, the hospital also needs to deal with patient complaints about the difficulty of obtaining inpatient rooms and services for selected doctors/nurses/health workers by helping to simplify the administrative process for admission to inpatients, and it is better if a doctor's schedule should be arranged so that doctors are always available when needed.
Apart from the complaints above, the patient also fell dissatisfied because the doctor/nurse/other health worker did not involve the patient in deciding how to treat and examine according to what the patient wanted. Whereas, according to research on patient characteristics and dimensions of health service quality in Sweden, it is stated that patient participation in medical decision making has a positive correlation with patient satisfaction. 19 Recommendations that can be given for this complaint are important for the hospital to always involve the patient and his family in determining how to treat or treat the patient according to the wishes of the patient so that they do not regret whatever has happened to all the actions taken, and the patient will feel satisfied. for the services provided.

Assurance
Assurance (Assurance) is a measure of the ability and knowledge of personnel to fully be trusted without hesitation as reliable professionalism, failure to assure patients will result in the patient's concern for receiving help. 15 For this reason, the hospital must provide a guaranteed dimension of service with good quality so that patients feel satisfied, confident, and believe that they will be cured for treatment at the hospital.
Patient satisfaction with the dimension of assurance (assurance) is the response or level of patient feelings to the assurance attributes that appear after the patient feels service while the patient is hospitalized. In this study, an inpatient satisfaction assessment was carried out on the 9 attributes of the guarantee dimensions as can be seen in Table 4 In government hospitals or private, the patient was not satisfied because it is based on table 4 above in mind that although health workers have been maintaining privacy during the examination, they do not store health information (medical history) patients in secret for patients treated so that patients feel no safe with the behavior of health workers at the hospital. This is not following the theory which reveals that the dimensions of assurance include knowledge, ethics, politeness, friendliness, the ability and skills of officers to generate customer trust and confidence. 9,20 Although in terms of courtesy and friendliness of the staff is good, patients still feel insecure because patient confidentiality is not properly maintained, even though in principle this dimension ensures that patients are free from all dangers, risks, and doubts.
Recommendations can be given to this complaint is the need for evaluation or briefing on all officers periodically on actions taken and need their personality training for health workers Hospital to provide service with a friendly and courteous and can maintain the confidentiality of the patient so that the patient and family feel confident, trusting and safe treatment in the hospital because of things this will greatly affect the assessment of patient satisfaction on the quality of the health services in the hospital.
On the dimension of this guarantee, the patients were also dissatisfied because although the health workers provide clear information about the care and treatment of patients, the clerk did not provide information about the cost of the treatment clearly and in detail. So that many patients have to pay additional costs for actions that have been taken related to the treatment of their disease. This makes patients and their families object to having to incur costs beyond their expectations, and automatically this greatly affects patient satisfaction with the services available at the hospital.
Gaspersz (1997) states that the quality dimension must pay attention to service accuracy related to service reliability and error-free. 14 This means that the hospital must provide accurate information about everything related to the care or treatment of patients before the procedure is carried out so that all actions will be free of errors. The recommendation for this problem is that health workers must provide clear and detailed information on all matters relating to patient treatment, including all costs involved. Officers must explain in clear language that can be understood by the patient and family. 21

Empathy
Empathy is individual care and attention from officers to customers, providing convenience and good communication in making relationships when customers need help, and understanding customer needs. 9,10 To the satisfaction of patients to the dimensions of empathy (empathy ) are a response or the patient's level of feeling against the attributes of empathy that is obtained after the patient feels the service for the patient to be hospitalized. In this study, an assessment of inpatient satisfaction was carried out on the 8 attributes of the empathy dimension as can be seen in Table 5.
Based on the table above, if we compare the level of patient satisfaction on the empathy dimension, it is better for private hospitals than government hospitals. In government hospitals, the level of patient satisfaction on the attributes of the empathy dimension that is below the customer satisfaction standard (> 90) is more than that of private hospitals, namely 3 attributes at government hospitals and 2 attributes at private hospitals. In both government and private hospitals, patients feel dissatisfied with the same attributes, but in private hospitals, except for the attributes of time to wait for the results of laboratory examinations or other medical supporting examinations (X-rays, USG, MRI, etc.), it is not long.
The first complaint, the patient is not satisfied with the attribute ' w time waiting for inpatient admission process is not long ' because the patient feels time wait that long, either because the administrative process cumbersome and because of the full treatment rooms. Second, patients were also dissatisfied because the time waiting for results of laboratory tests or other medical investigations (Xray, ultrasound, MRI, etc.) felt old. Third, the patients are not satisfied with service quality dimensions of empathy in the hospital where they were treated for patients find it difficult to obtain a permit for family and friends to serve the personal needs of patients such as bringing kan favorite foods and everyday needs of the patient. This is not in line with the meaning and understanding of the existing dimensions of empathy, namely, empathy is the willingness of health workers to give personal/individual attention or care to customers, in this case, the patient, which is a combination of aspects of access and understanding the customer. 22 Access is the ease of making contact or communication and easy to reach, for example, services are easily accessible via telephone, service waiting time is not long, locations are easily accessible. Meanwhile, understanding the customer is an attitude that always tries to understand the wants and needs of consumers. 21 Recommendations can be given to all the complaints above are the saki home should be able to ensure that every officer in the hospital can provide service excellence with an attitude of care and concern that better individually and understand the need for patients. The health workforce on duty can assist patients in preparing the administration needed for hospitalization, the results of laboratory examinations and other medical support are sought to be released as quickly as possible considering the need for immediate testing of patients, and officers are expected to be able to permit for families to fulfill patient needs and able to provide understanding to the patient's family so that they can follow the applicable visiting hour regulations so that other patients do not feel disturbed.

CONCLUSIONS AND SUGGESTIONS
Based on the results of the study and discussion, it can be seen that the level of patient satisfaction in public and private hospitals is not much different, although patient satisfaction in private hospitals is better than patient satisfaction in government hospitals. For the management of all hospitals in Indonesia, it is necessary to routinely evaluate existing services to maintain the attributes that have been assessed as good by patients and improve the quality of attributes that are still considered poor in every dimension of service quality by following the Minimum Service Standards. in hospitals that have been designated by the Ministry of Health of the Republic of Indonesia so that the quality of health services in the hospital will be better and patient satisfaction will increase. For the relevant government having authority to carry out a revision of the related policies Minimum Service Standards RS following the progress of science and technology.