Analysis of Factors Affecting Patient Loyalty in Bandung General Hospital in Medan

Patient loyalty greatly affects the survival of a hospital, because loyal patients not only make repeated visits but can act as loyalty advocators. In the last five years, there has been a decrease in the number of inpatient visits at RSU (Regional General Hospital) Bandung Medan, an average of 8.79% so that research is needed to determine the factors that affect patient loyalty. The study was conducted by cross sectional, using a questionnaire that has been tested valid and reliable. The research variables were service quality, patient satisfaction, and patient loyalty. The number of samples was 100 patients who met the criteria. Data were analyzed using SEM-PLS method. The results: service quality has a significant effect on patient satisfaction, patient satisfaction has a significant effect on patient loyalty, and service quality has a significant effect on patient loyalty. Patient loyalty at RSU Bandung Medan is significantly influenced by service quality factors and patient satisfaction factors. Regarding the service quality variable, 20% of respondents did not agree that nurses recorded accurately. In the patient satisfaction variable, 20% of respondents were dissatisfied with the cleanliness of the room, 20% of respondents were not satisfied with the food served, and 15% of respondents were dissatisfied with the results of the treatment. In the patient loyalty variable, 15% of respondents disagreed with giving positive responses to the relationship about the performance of the Bandung Hospital, and 15% of respondents would move to another hospital if they got a discount.


Introduction
Patient loyalty has a huge influence on the survival of a hospital. Because loyal patients do not only make repeated visits, but can also act as loyalty advocators, namely patients who voluntarily recommend hospital products or services to friends, relatives, and other community groups, although they may not necessarily become repeat visitors (Supriyanto & Ernawati). , 2010). Loyal consumers not only increase value in business, but can also attract new customers, so that loyal patients can increase the number of patient visits and have an effect on hospital income Saragih et al., 2017).
Several previous studies stated that there are several factors that influence patient loyalty in the hospital. One of them is research by Zhou et al (2017) which states that loyal patients are influenced by patient satisfaction, service quality, value, hospital image, trust, commitment, and community habits. Research by Rif'adarajad et al (2017) found that the variables of service quality, patient satisfaction, hospital image and value had a significant effect on patient loyalty at the Buton District General Hospital. Research by  found that service quality variables have a significant effect on patient satisfaction. Service quality has a Abdurrouf & Puspitasari's research (2017) also obtained the same results, namely the quality of service has a significant positive relationship with patient loyalty. Dewi's research (2017) found that service quality variables have a positive and significant effect on patient satisfaction, service quality variables have a positive and significant effect on patient loyalty, and patient satisfaction variables have a positive and significant effect on patient loyalty.
Bandung General Hospital (RSU) is one of the public hospitals located in Medan City. The results of the preliminary survey on inpatient visit data in 2015 -2019 showed a decrease in the number of inpatient visits each year, with an average decrease of 8.79% per year.
The results of previous research and initial survey data made researchers interested in conducting research on the factors that affect patient loyalty in Bandung Hospital in Medan. It is hoped that knowing the factors that affect patient loyalty will have an impact on the increase in the number of loyal patients and the increase in the number of patient visits in the future.

Methods
This research is an analytic study with cross sectional method. The study was conducted at Regional General Hospital (RSU) Bandung Medan, on March 5, 2020 to April 30, 2020. The total sample size was 100 respondents and met several criteria, namely: adult patients, aged ≥ 17 years, cooperative patients, not illiterate, not prison patients. ), is not a VIP class and 1 class hospitalized patient, and is an inpatient with a minimum of 3 days of care.
This study uses a questionnaire measuring tool that has been tested valid and reliable. Prior to conducting the research, the questionnaire was tested at Mitra Medika Amplas Hospital, with 20 samples having the same criteria as the research to be conducted. The research variables consisted of 3, namely: service quality (Q), patient satisfaction (S), and patient loyalty (L). The variable service quality is assessed through indicators of reliability (reliability), responsiveness (responsiveness), empathy (empathy), assurance (assurance), and tangibles (physical evidence). The patient satisfaction variable is assessed through performance theory, fulfillment theory, expectancy-disconfirmation theory, and social-equity theory. Patient loyalty is assessed through indicators of rebuy, retention, and referrals. Furthermore, the data were analyzed using the SEM-PLS method.

Univariate Analysis
The characteristics of the respondents in this study were obtained as follows: The table of characteristics of the respondents above can be concluded that the majority are female (63%), the majority are 20-30 years old (48%), the majority have an undergraduate degree (60%), the majority have private jobs (46%), and the majority use services at RSU Bandung (44%).
The results of research on the service quality variable (Q) can be seen in the table below: From the table above, it appears that each indicator in the service quality variable (Q) has a mean value above 3, which means that the service quality variable is considered good by the majority of respondents. The table above also shows that 20% of respondents disagreed that inpatients recorded accurately without errors.
The results of research on the patient satisfaction variable (S) can be seen in the table below: From the table above, it appears that each indicator on the patient satisfaction variable (S) has a mean value above 3, which means that the patient satisfaction variable is considered good / satisfied by the majority of respondents. In the table above, it also appears that 20% of respondents are not satisfied with the cleanliness of the inpatient rooms, 20% of respondents are not satisfied with the food menu served, 15% of respondents are not satisfied with the results of treatment. The results of research on the patient loyalty variable (L) can be seen in the table below: From the table above, it appears that each indicator on the patient loyalty variable (L) has a mean value above 3, which means that the patient loyalty variable is considered good / loyal by the majority of respondents. The table above also shows that 15% of respondents disagreed with giving positive responses regarding the performance of the Bandung Hospital, and 15% of respondents would move to another hospital if they got a discount from the hospital.

Multivariate Analysis
The multivariate analysis in this study uses the SEM-PLS method, which begins with testing the outer model and inner model, which is then carried out by testing the hypothesis. The path image in this study can be seen as follows: Testing the inner model by looking at the value of R square and Q square. In this study, the Q square value was 0.89 which means that the model has a fairly good predictive relevance. Furthermore, hypothesis testing is carried out, the following results are obtained: a. The variable of Service Quality (Q) is totally significant towards the Patient Satisfaction variable (S) with a p-value of 0.0001 b. Patient Satisfaction Variable (S) is totally significant towards Patient Loyalty variable (L) with p-value 0.0001 c. Service Quality variable (Q) is totally significant towards Patient Loyalty variable (L) with p-value 0.0001

Relationship Quality of Service to Patient Satisfaction
The results of path analysis using the SmarPLS application obtained the results, namely: there is a significant influence of service quality on patient satisfaction variables in a positive direction, with a p-value of 0.0001 and t-statistic of 25.288. The results of this study are in accordance with research conducted by , Dewi (2016), Sumitro & Wahjono (2018), Sharon & Santosa (2017),  which states that there is an effect of service quality on patient satisfaction significantly.
Quality service is a service that must be in accordance with the expectations desired by every consumer. Service quality must start with customer needs and end with customer satisfaction and positive perceptions of the quality of service . Customer satisfaction is generally known as the result of service quality, which means that it has a positive relationship to the quality of services provided to consumers. The level of patient satisfaction is believed to be in line with the level of service quality that is felt after consumption (Sharon & Santosa, 2017).
Research by Meesala & Paul (2018) in an article entitled "Service Quality, Consumer Satisfaction and Loyalty in Hospitals: Thinking for the Future" states that service quality that affects patient satisfaction is Reliability and Responsiveness. The study states that the most important things in service quality are: (1) speed in providing services, (2) attentive officers, (3) accuracy of billing (calculation), (4) good communication when providing services, (5) timeliness services, and (6) the officers' willingness to provide assistance. The measure of quality health services refers to the application of only good standards and professional code of ethics, which basically includes an assessment of patient satisfaction regarding the doctor- The results of this study are in accordance with research conducted by , Dewi (2016), Sharon & Santosa (2017), Rif'adarajad (2017), , Lestariningsih et al (2018), who states that there is a significant relationship between patient satisfaction and patient loyalty.
Satisfaction can provide several benefits including the relationship between the hospital and the patient being harmonious which is the basis for deciding on repeat purchases and creating patient loyalty and word of mouth recommendations that benefit the hospital. The relationship between patient satisfaction and patient loyalty is a relationship where consumers reach the highest value for satisfaction which causes strong emotional bonds and has a long-term commitment to the hospital (Hidayat et al., 2018).
Patient satisfaction is a measure of the level of quality of health services, besides patient satisfaction is an important element in evaluating service quality by measuring the extent to which patients respond after receiving services. Patient satisfaction is related as a form of overall satisfaction with the aim of recommending the hospital to others (Sumitro, 2018). Mortazavi S research, et al. in an article entitled "The Relationship between Patient Satisfaction and Loyalty in The Private Hospital Industry" states that: overall patient satisfaction is influenced by nurse services, rooms, service when received and administration, as well as responsiveness. The findings of this study can be concluded that satisfaction and patient loyalty are positively related, so that one of these factors can increase patient satisfaction and further increase patient loyalty as well (Mortazavi et al., 2009).
Those who need health services will definitely look for good health care providers who can provide them with satisfaction. Health service providers must be able to provide information and patient needs so that patient desires can be fulfilled and increase patient satisfaction. By achieving maximum customer satisfaction, a company will be able to achieve customer loyalty (Dewi, 2017). Loyal patients are not necessarily satisfied patients, but satisfied patients tend to be loyal (Sofia et al., 2018).

Relationship of Quality of Service to Patient Loyalty
The results of the data analysis of this study state that the third hypothesis is also accepted, namely that there is a significant positive effect of service quality on patient loyalty, with a pvalue of 0.0001 and t-statistic of 18.966. This means that the higher the service quality of a hospital, the higher patient loyalty and vice versa.  (2017) , , which states that service quality has a significant relationship with patient loyalty.
Service quality is positively related to the interest in reusing customers, with high quality, customers will have an interest in reusing services from the same provider. One way to make Likewise in Lestariningsih's research (2018), which states that service quality does not have a significant effect on patient loyalty, where service quality has an effect on loyalty mediated by trust. Trust plays a very strong role as moderating which affects service quality towards loyalty.

Conclusion
Based on the overall results of the study, 20% of respondents disagreed that inpatient staff recorded accurately, 20% of respondents were dissatisfied with the cleanliness of inpatient rooms, 20% of respondents were dissatisfied with the food menu served, 15% of respondents were dissatisfied with the results of treatment, 15 % of respondents do not agree to give positive responses to friends and family about the performance of the Bandung Hospital, and 15% of respondents said they would move to another hospital if they got a discount. Some suggestions that can be conveyed to the management of the Bandung Medan Hospital include improving the accuracy of nurse records, improving the cleanliness of inpatient rooms, evaluating the performance of nutrition staff so that the food menu can satisfy patients, improving the quality of treatment results, and considering giving discounts.