The Effect of the Quality of Health Services on the Satisfaction of Patients at the East Langsa Community Health Center

Service quality and patient satisfaction are the two most important things in Community Health Center (puskesmas) services. This study aims to see the effect of the quality of health services on outpatient satisfaction at Langsa Timur Public Health Center, Langsa City in 2020. This type of research is a quantitative research which is an analytical survey with a cross sectional study approach. The population in this study were 2,116 people. A sample of 95 people using the Slovin formula. The analysis used is univariate analysis, bivariate analysis with chi-square test and multivariate analysis with linear regression test, measuring instruments used questionnaires and data processing using computerized with a significance level of P-Sign <0.05. The results of this study are based on the results of univariate analysis, as many as 64 people were dissatisfied and 31 people were satisfied. The results of multivariate analysis showed that physical evidence and responsiveness had an influence on patient satisfaction and physical evidence was dominant. The conclusion of this study is that there is an effect of physical evidence and responsiveness on outpatient satisfaction at Langsa Timur Public Health Center, Langsa City.


Introduction
Community Health Center (Puskesmas) is a health service unit which is the spearhead in the field of basic health. The use of health services at the health center demands quality services not only regarding recovery from physical illness but also regarding satisfaction with the attitudes, knowledge and skills of officers in providing services as well as the availability of adequate facilities and infrastructure that can provide comfort (Monicha, 2019).
On outpatients at the Puskesmas using health insurance, namely the Social Security Administrator (BPJS) for Health. The existence of the BPJS is expected to be able to achieve the universal coverange target by 2019. No later than January 1, 2019, all Indonesian residents have national health insurance to benefit from health care and protection in meeting their basic Patient satisfaction is a level of patient feeling that arises as a result of the performance of health services obtained after the patient compares it with what he expects (Amin & Lampung, 2017). The main determinant of customer satisfaction is the customer's perception of service quality. One of the service quality approaches is the Servqual (Service Quality) model developed by Parasuraman (Lupiyoadi, 2009: 181), which consists of the following five determinants of service quality, reliability, responsiveness, assurance, empathy and tangible (Zainafree, 2016).
Measuring customer satisfaction is an important element in providing better, efficient and more effective service. The level of customer satisfaction with service is an important factor that develops a service delivery system that is responsive to customer complaints, minimizes costs and time and maximizes the impact of service on patients (Munusamy et al., 2010;Angelova & Zekiri, 2011;Ulinuha, 2014). This dissatisfaction was caused by several things. Among them are the high cost of health services, the lack of service facilities, the length of service, the less satisfactory in providing services. Quality shows the perfection of an organization's performance in accordance with the code of ethics and standards, which can lead to satisfied patients. Satisfaction is a feeling of pleasure to the services provided where the service can match the expectations or even exceed the expectations of the patient (Milakovich & Blanch, 2005;Manu, 2011).
Community health Centers (Puskesmas) are expected to be able to carry out identification of patient needs and factors that affect patient expectations of the quality of service they receive, so that it can be seen a description of patient satisfaction with the services provided (Program et al., 2017).
Based on the results of observations, it turns out that patients at Puskesmas Langsa Timur are not satisfied with the services provided by officers and inadequate infrastructure, this is related to the quality of health services where there are several factors related to patient satisfaction which include: Tangibels (Physical Condition), Realibility (reliability), Responsiveiness (responsiveness), Assurance (Assurance), and the factor of Empathy (Empathy).
This study looked at the quality of health services and satisfaction of outpatients at Langsa Timur Public Health Center. The background of this study was to determine the assessment of outpatients at Langsa Timur Public Health Center about the quality of health services and the satisfaction they feel. This is important as a reference in improving services in order to provide patient satisfaction. This study aims to see the effect of health service quality on outpatient satisfaction at Langsa Timur Public Health Center, Langsa City in 2020.

Methods
This research is a quantitative research analytic survey with a cross sectional study approach which is intended to analyze the effect of health service quality on outpatient satisfaction at Langsa Timur Public Health Center, Langsa City, 2020 (Muhammad, 2017).
This research was conducted at the Langsa Timur Public Health Center, Langsa City. The reason for the writer took the location of this study with the consideration that after the initial survey, there were problems with the quality of health services, including patient complaints about the delay in when officers came to provide services and less friendly health workers when providing services.
When this research was conducted, it started from the stage of submitting the title of the proposal to the comprehensive examination. Population is a generational area consisting of subjects / objects that have certain qualities and characteristics set by the researcher for study and then draw conclusions (Muhammad, 2016). The population in this study included all outpatients who visited the Langsa Timur Public Health Center, Langsayang City, with an average monthly visit of 2,116 people.
The sample is part of the number and characteristics of the population. While sampling means taking a sample or taking part of the population or universe as a representative of the population or universe (Muhammad, 2017) From the above calculations, a sample of 95 respondents was obtained. The sampling technique used in this study was accidental sampling, namely sampling that was carried out by chance without being planned, whoever was an outpatient who visited could be sampled in this study.

Result and Discussion
After conducting research on the Effect of Health Service Quality on Outpatient Satisfaction at Langsa Timur Public Health Center, Langsa City in 2020. Based on the table above, it can be seen that of the 95 respondents who have the category of youth (17-25 years) as many as 23 people (24.2%), adults (26-45 years) as many as 45 people (47.4%) and the elderly (46 -65 years) as many as 27 people (28.4%).   Based on the table above, it can be seen that 9 respondents with primary education (9.5%), 13 junior high school (13.7%), 40 high school students (42.1%) and 33 undergraduate (34) , 7%). Based on the results of the respondents' answers from the questionnaire on the physical evidence statement, it can be seen that whether the nurses arrived on time who said Yes (24.2%) and No (75.8%), were the nurses at the health center during working hours who said Yes (31 , 6%) and No (68.4%), were the doctors always in the room saying Yes (24.2%) and No (75.8%), did the doctors come on time who said Yes (20%) ) and No (80%), Did the registration officer come on time saying Yes (34.7%) and No (65.3%).  Based on the results of respondents' answers from the questionnaire statement of responsiveness, it can be seen that the ability of doctors to be responsive in resolving patient complaints who say Yes (46.3%) and No (53.7%), Is the procedure for delivering information easy to understand that says Yes (40 %) and No (60%), Does the officer provide information before the service action is carried out that says Yes (42.1%) and No (57.9%), Does the officer give a good response to patient complaints who say Yes (34, 7%) and No (65.3%). Based on the results of respondents' answers from the empathy question questionnaire, it can be seen that whether medical personnel pay good attention to patients who say Yes (47.4%) and No (52.6%), do the patient's communication with medical personnel go well who say Yes (32.6%) and No (67.4%), Did the doctor communicate that the patient could easily understand who said Yes (42.1%) and No (57.9%), Based on the results of the respondents' answers from the questionnaire on the patient's satisfaction statement, it can be seen that the majority of respondents who answered satisfied from statement no.9 were 41 people (43.2%) and the minority of respondents answered dissatisfied from statement No.1 as many as 3 people (3.2%) Based on the table above, it can be seen that of the 95 respondents who thought the quality of physical evidence service was good as many as 28 people (29.5%), and those who thought the quality of physical evidence service was not good were 67 people (70.5%). Based on the table above, it can be seen that of the 95 respondents who thought the quality of reliability service was good as many as 41 people (43.2%), and those who thought that the quality of service reliability was not good was 54 people (56.8%). Based on the table above, it can be seen that of the 95 respondents who thought the quality of guarantee service was good as many as 64 people (67.4%), and those who thought the quality of the guarantee service was not good were 31 people (32.6%). Based on the table above, it can be seen that of the 95 respondents who thought the quality of empathy service was good as many as 38 people (40%), and those who thought that the quality of service reliability was not good were 57 people (60%). Based on the table above, it can be seen that of the 95 respondents who thought that they were not satisfied with the health services provided as many as 64 people (67.4%) and who thought that they were satisfied with the health services provided were 31 people (32.6%).  17 it is known that from 95 respondents the majority of respondents thought the quality of physical evidence service was good as many as 67 people (70.5%) felt dissatisfied as many as 38 people (40%) and were satisfied as many as 29 (30.5%). While a minority of respondents thought that the quality of physical evidence service was not good as many as 28 people (29.5%) felt dissatisfied as many as 26 people (27.4%) and were satisfied as many as 2 (2.1%). The results of the Chi-Square test obtained a probability value (p-value) = 0.001 <0.05, this indicates that there is a relationship between physical evidence and satisfaction at the Langsa East Langsa Health Center, Langsa City in 2020. Based on table 18 it is known that from 95 respondents the majority of respondents thought that the quality of service reliability was not good as many as 54 people (57%) felt dissatisfied as many as 42 people (44.2%) and felt satisfied as many as 12 (12.7%). While a minority of respondents thought that the quality of service reliability was good as many as 41 people (43%) felt dissatisfied as many as 22 people (23.1%) and felt satisfied as many as 19 (20%). The results of the Chi-Square test obtained a probability value (p-value) = 0.016 <0.05, this indicates that there is a relationship between reliability and satisfaction at the Langsa East Langsa Health Center, Langsa City in 2020. , it is known that of the 95 respondents, the majority of respondents thought that the quality of service was not good as many as 49 people (51.6%) felt dissatisfied as many as 40 people (33%) and 9 (16%) felt satisfied. Meanwhile, a minority of respondents thought that the service quality was good as many as 46 people (48.4%) felt dissatisfied as many as 24 people (31%) and were satisfied as many as 22 (15%). The results of the Chi-Square test obtained a probability value (p-value) = 0.002 <0.05, this indicates that there is a relationship between responsiveness and satisfaction of the Langsa East Langsa Health Center, Langsa City in 2020. , it is known that from 95 respondents the majority of respondents thought the quality of the guarantee service was good as many as 64 people (64.7%) felt dissatisfied as many as 40 people (42.1%) and were satisfied as many as 24 (25.3%). While a minority of respondents thought that the quality of the guarantee service was not good, as many as 31 people (32.6%) felt dissatisfied by 24 people (25.3%) and 7 (7.4%) were satisfied. The results of the Chi-Square test obtained a probability value (p-value) = 0.110> 0.05, this indicates that there is no guarantee relationship with the satisfaction of Pasiendi at Langsa Timur Health Center, Langsa City in 2020.  Total  64  67,3  31  32,7  95  100  Based on table 21, it is known that from 95 respondents the majority of respondents thought the quality of empathy service was good as many as 57 people (60%) felt dissatisfied as many as 34 people (35.7%) and were satisfied as many as 23 (24.2%). While a minority of respondents thought the quality of empathy service was not good as many as 38 people (40%) felt dissatisfied as many as 30 people (31.6%) and were satisfied as many as 8 (8.4%). The results of the Chi-Square test obtained a probability value (p-value) = 0.039 <0.05, this indicates that there is a relationship between empathy and satisfaction at Langsa Timur Public Health Center, Langsa City in 2020.

Multivariate Analysis
Linear regression is a statistical tool used to determine the effect of one or more variables on one variable. Variables that influence are often called independent variables, independent variables or explanatory variables. An important measure and often used in regression analysis is the coefficient of determination or symbolized R. The coefficient of determination is useful for knowing how much variation in the dependent variable can be explained by the independent variable or in other words, R Square shows how far the independent variable can predict the dependent variable. R square the better / more precise the independent variable predicts the dependent variable. From Table  4:22 above, it can be seen that the coefficient of determination is 0.204, meaning that the regression line equation obtained can explain 20.4% of the variation in service quality to explain patient satisfaction. From Table 23 above, it can be seen that the p value <0.05, meaning that at α = 5% it can be concluded that the regression is fit (fit) with the data.  Table 4:24 above, a linear equation is obtained to predict patient satisfaction, namely: Satisfaction = -0.072 + 0.241 Physical Evidence + 0.214 Responsiveness With the equation model obtained, it can be predicted patient satisfaction using physical evidence and responsiveness variables. Beta Column can be used to find out which variable has the greatest role (influence) in determining the dependent variable (patient satisfaction). The greater the beta value the greater the influence In the results above, it means that the variable that has the greatest influence on determining patient satisfaction is the physical evidence variable.
Based on the bivariate results, it is known that of the 95 respondents (100%) who think that the quality of physical evidence service is good as many as 67 people (70.5%) about 38 people (40%) feel dissatisfied patient satisfaction and 29 (30%) feel satisfied. , 5%). While respondents who thought the quality of physical evidence service was not good were 28 people (29.5%) regarding patient satisfaction as many as 26 people (27.4%) and were satisfied as many as 2 (2.1%).
After doing the Chi-Square test with a confidence level of 95%, a significant value of 0.001 is obtained, which means it is smaller than (p-value) 0.05. Based on the results of this statistical test (p-value), it means that poor physical evidence will experience low patient satisfaction with health services, while good physical evidence can get good patient satisfaction as well. This shows that there is a relationship between physical evidence and satisfaction of the East Langsa Public Health Center Langsa City in 2020.
This research is in line with research conducted by Suryanti Kasim et al (2013) regarding time discipline at the Tataba Public Health Center, Kec. Buko, Banggai Kepulauan Regency, found that the number of health workers in good category was 12 health workers with a percentage of 37.5%, while health workers who were in poor category were 20 people (62.5%). this shows that the time discipline of health workers is still not good (Di et al., 2013).
Time discipline determines the quality of work in health care priorities. This will be a problem if the use of time is not appropriate, of course, the service will be delayed and reflects that health workers have not been as much as possible to help in the client's healing process (Di et al., 2013). This research is in line with research conducted by Nesia Dea Pradella (2017) regarding time discipline at the Tawangrejo Public Health Center in Madiun City. Based on the observation, it is known that there are 29 employees (37.7%) who are not on time and 48 employees (67.3%) are on time. It can be seen that there are still employees who come and go home not in accordance with the applicable regulations, there are still employees who do not immediately work or serve patients, instead stop at a shop, read the newspaper and chat (Pradella, 2017).
The statistical test results are based on the results of the chi-square test, but because the chisquare test requirements are not met, the value seen is fisher's exact, which is p = 0.000 because the p value <0.05, Ho is rejected and Ha is accepted. This means that there are factors that are related between the variable timeliness and satisfaction of BPJS patients at Paccerakang Puskesmas, Makassar City (Amelia, 2018).
In the bivariate analysis, the results showed that there is a relationship between the dimensions of quality reliability and patient satisfaction (p = 0.000), meaning that there is a relationship between the dimensions of quality reliability and patient satisfaction (Kurnia et al., 2017).
After doing the Chi-Square test with a confidence level of 95%, a significant value of 0.002 is obtained, which means it is smaller than (p-value) 0.05. Based on the results of this statistical test (p-value), it means that poor responsiveness will experience low patient satisfaction with health services, while good responsiveness can get good patient satisfaction as well. This shows that there is a relationship between responsiveness and satisfaction of the East Langsa Community Health Center Langsa City in 2020.
Quick response relates to the ability of health workers to provide services according to procedures and meet patient expectations. The better the responsiveness of health services provided to patients will increase the level of patient satisfaction (Journal & Sciences, 2019).
After doing the Chi-Square test with a confidence level of 95%, a significant value of 0.110 is obtained, which is greater than (p-value) 0.05. Based on the results of this statistical test (pvalue), this shows that there is no guaranteed relationship with the satisfaction of the Langsa East Langsa Health Center in 2020.
After doing the Chi-Square test with a confidence level of 95%, a significant value of 0.039 is obtained, which means it is smaller than (p-value) 0.05. Based on the results of this statistical test (p-value), it means that poor empathy will experience low patient satisfaction with health services while good empathy can get good patient satisfaction as well. This shows that there is a relationship between empathy and patient satisfaction at Langsa Timur Health Center, Langsa City in 2020.
Based on these results it can be concluded that the tangible factor (direct evidence) is related to the level of patient satisfaction, where they assume that the puskesmas officers are less disciplined when working hours are in progress, when the patient wants treatment sometimes the nurse is not in this room has a very negative impact on the satisfaction level of outpatients at Langsa Health Center. East. So that the better direct evidence of health care providers seen by patients, the better the level of satisfaction felt by patients.
Puskesmas Langsa Timur in terms of discipline, namely delays in health workers due to various reasons, including: other activities outside of service, busyness in managing the household, distance to live, and there has been no strict sanction for those who are late so that officers go around and go back to the puskesmas.
Researchers assume that consistent service is what patients want most in the sense that it must be reliable. Consistent service is a reliable service that contains elements: doing what has been promised to the patient, being professional in serving the patient and accuracy in providing information to the patient. If this can be given to patients, it can increase service satisfaction to patients.
In the explanation above, it can be seen that the importance of the reliability of an officer in providing services to patients who are not convoluted so that patients do not wait too long and immediately get services from doctors to overcome the disease they suffer, so that the quality of health center services is even better and patients want to do re-control at the puskesmas.
From the research results, assurance has no relationship with patient satisfaction. This is because there are other variables such as physical evidence and responsiveness that are more influential on patient satisfaction. The knowledge, ability, and politeness possessed by the health center officers creates patient satisfaction at the Puskesmas.
East Langsa Puskesmas officers do not differentiate between patients who use BPJS or the general public, they still serve patients well and remain friendly even though sometimes they don't explain to patients what to do.
The attitude of the officers has a positive attitude, for example, like today, during the Covid-19 pandemic, so officers always suspect patients who have complaints such as fever, coughs, shortness of breath, so officers are a little less willing to have direct contact with these patients so that patients feel unappreciated and less satisfied with the service provided by the officer.
Officers already have a confident attitude in dealing with patient complaints and provide suggestions or suggestions to patients without hesitation so that patients are sure of what the officer said. It's just that there is a lack of discipline at Puskesmas Langsa Timur which has been explained in the tangible variable.
Respondents considered that the service in the empathy dimension was not good, so that patients were not satisfied with the officers 'communication methods and the officers' ways of calming patients. Therefore, the puskesmas should continue to be able to improve on emphaty dimension services, so that patients are satisfied with the attention given.

Conclusion
There is an effect of tangible factors (physical evidence) on outpatient satisfaction at LangsaTimur Health Center. There is no effect of reliability factor on outpatient satisfaction at Puskesmas Langsa Timur. There is an influence of the responsiveness factor (responsiveness) on the satisfaction of outpatients at Langsa Timur Public Health Center. There is no effect of assurance factor (guarantee) on the satisfaction of outpatients at Langsa Timur Public Health Center. There is no influence of empathy factor (empathy) on outpatient satisfaction at Puskesmas Langsa Timur. Tangible factors (physical evidence) have a dominant influence on the satisfaction of outpatients at Langsa Timur Public Health Center.