Effect of Health Service Quality Toward Patients Satisfaction

The quality of service at the Community Health Center (Puskesmas) is an important factor in creating patient satisfaction. The results of measuring patient satisfaction that are objective and accurate can assist the health center in formulating a better form of service. The purpose of this study was to determine and analyze the effect of health service quality on outpatient satisfaction. This type of research is an analytic survey with a cross sectional approach using primary data with questionnaires and secondary data from Community Health Center (Puskesmas) reports. The population in this study were patients who had outpatient visits from January to July 2020 with a total sample of 99 people who were determined using the accidental sampling method. The analysis used univariate, bivariate and multivariate analysis. Chi square test results showed that technical competence (p = 0.001 <0.05), effectiveness (p = 0.002 <0.05), human relations (p = 0.000 <0.05), comfort (p = 0.099> 0, 05) and timeliness (p = 0.001 <0.05). The logistic regression test shows that the variable that most influences patient satisfaction is the relationship between humans with an Exp (B) value of 4.195. The conclusion of this research is that technical competence, effectiveness, human relations and timeliness have a relationship with patient satisfaction, while comfort has no relationship with patient satisfaction. Efforts are needed to improve the quality of outpatient services by establishing a harmonious relationship between health workers and patients in order to achieve services that are able to satisfy patients.


Introduction
The World Health Organization (WHO) has determined that health is an investment, right and obligation of every human being. The quotation is contained in Law No. 36 of 2009 concerning health stipulates that everyone has the right to health services. Therefore, every individual, family and community has the right to obtain protection for their health and the state is responsible for regulating the fulfillment of the right to healthy life for its residents, including for the poor and underprivileged, which is then realized through health insurance for all citizens (Lumban, 2017). Based on the local needs of the local community, but on the other hand it can also be a threat because of regional capabilities and various aspects that strongly influence the direction of the policy of a regional head with the autonomous authority he has (Rismayanti, Gunawan Bata Ilyas, 2017). The delivery of health services for the community at the basic level in Indonesia is through the Community Health Center (Puskesmas). The Puskesmas is the technical implementation unit of the district or city health office which is responsible for carrying out health development in a work area (Mernawati & Zainafree, 2016).
In the era of globalization, excellent service is the main element in health units (Deaton, 2004;Spiegel & Yassi, 2004;Raphael, 2009). Puskesmas are required to provide health services that meet optimal service standards. Puskesmas are declared successful, not only in the completeness of the superior facilities, but also the attitude and service of human resources which are elements that have a significant effect on the services produced and perceived by patients. If this element is neglected, in a short time, the Puskesmas will lose a lot of patients and be shunned by prospective patients. Patients will turn to hospitals or other health clinics that meet patient expectations, this is because patients are a very valuable asset in developing the Puskesmas industry (H et al., 2015).
The quality of service at the Puskesmas is an important factor in creating patient satisfaction. Quality service in the context of service at the health center is to provide services to patients and their families according to quality standards to meet their needs and desires, so that they can get satisfaction that can increase the trust of patients and their families in the Puskesmas (Amelia, 2018).
The very heavy function of the Puskesmas in providing services to the community is faced with several challenges in terms of human resources and increasingly sophisticated health equipment, but must still provide the best service (Etlidawati, 2017).
Service Quality (quality of service) health is a health service that can satisfy every user of health services in accordance with professional standards and can make good use of existing resources, so that all customer needs and goals to achieve an optimal degree of health can be achieved. (Ajmain, 2016) There are eight dimensions of health service quality, namely the dimensions of technical competence, the dimensions of affordability, dimensions of effectiveness, dimensions of efficiency, dimensions of service continuity, dimensions of convenience, dimensions of timeliness, and dimensions of human relations (Wibawani Yunestri Mukti, Asiah Hamzah , 2013).
Quality which is considered as the key in differentiation and service excellence is a source of sustainable potential so that measurement and improvement of quality levels are very important. The quality of health services at puskesmas is strongly influenced by the quality of physical facilities, the types of personnel available, medicines and medical devices, and the process of service delivery. This situation can create real satisfaction in the customer (Burhanuddin et al., 2016).
Good service quality will lead to satisfaction of customers or service users (patients). Customer satisfaction is the main indicator of the standard of a health facility. The measure of service quality, low customer satisfaction will have an impact on the number of visits which will affect the provitability of these health facilities. (Kurnia et al., 2017).
The results of measuring customer satisfaction that are objective and accurate can help health centers in formulating better forms of service (Setia et al., 2016). Patient satisfaction basically satisfies the patient with expectations and understands the patient's needs. Most of the puskesmas services are still very limited, both in terms of personnel, facilities and infrastructure, availability of drugs, facilities, costs and medical services (Astuti, 2017). Patients will be satisfied if the services they get are at least the same or exceed patient expectations. Meanwhile, dissatisfaction will arise if the outcome does not meet the patient's expectations (Djeinne Thresye Pangerapan, Ora Et Labora I. Palandeng, 2018).

Methods
This type of research is quantitative research, namely research methods that are more directed towards measuring aspects objectively to social phenomena. This research is an analytical survey with a cross sectional study approach. Analytical survey is research which tries to explore how and why this phenomenon occurs. Cross sectional study is a study that studies the dynamics of the relationship or correlation between risk factors by observing or collecting data at a certain time which aims to analyze the effect of Health Service Quality on Patient Satisfaction at Langsa Baro Public Health Center, Langsa City in 2020. As for The population selection in this study included all 68,433 patients who visited Langsa Baro Health Center, Langsa City from January to July 2020. From the calculation of Sovin, above, the sample obtained is 99 respondents. The sample was obtained through the sampling technique by accidental sampling, namely sampling that was carried out accidentally without being planned, whoever the outpatients who visited could be sampled in this study.

Education
The results of the univariate analysis of the characteristics of respondents based on education can be seen in the table below. Based on the table above, it can be seen that the respondents with the latest elementary education were 9 people (9.1%), junior high school as many as 13 people (13.1%), high school as many as 42 people (42.4%) and college as many as 35 people (35 , 4%).

Employment
The results of the univariate analysis of the characteristics of respondents based on occupation can be seen in the table below. Based on table 4.3 it can be seen that the respondents who are still as students are 9 people (9.1%), respondents who work as civil servants are 20 people (20.2%), private employees are 23 people (23.2%) , self-employed as many as 23 people (23.2%), and not working as many as 24 people (24.2%).

Age
The results of the univariate analysis of the characteristics of respondents based on age can be seen in the table below.  Based on the table above, it can be seen that of the 99 respondents who thought that the effectiveness of services at Langsa Baro Health Center was not good, there were 53 people (53.5%), and those who thought that the effectiveness of services at Langsa Baro Health Center was good as many as 46 people (46.5%). Based on the table above, it can be seen that of the 99 respondents who thought that the relationship between people at Langsa Baro Health Center was not good as many as 49 people (49.5%) and who thought that human relations at Langsa Baro Health Center were good as many as 50 people (50.5%) .  Based on the table above, it can be seen that of the 99 respondents who were not satisfied with the health services provided by the Langsa Baro Health Center as many as 54 people (54.5%) and those who thought that were satisfied with the health services provided by the Langsa Baro Health Center as many as 45 people (45.5 %).

Technical Competence
The results of the bivariate analysis of technical competency variables can be seen in the table below.

Effectiveness
The results of the bivariate analysis of the effectiveness variable can be seen in the table below. Chi-Square test results obtained probability value (p-value) = 0.002 <0.05, this shows that there is a relationship between effectiveness and patient satisfaction at Langsa Baro Public Health Center, Langsa City in 2020.

Human relationship
The results of the bivariate analysis of the human relationship variables can be seen in the table below. The results of the Chi-Square test obtained a probability value (p-value) = 0.000 <0.05, this indicates that there is a relationship between human relations and patient satisfaction at Langsa Baro Public Health Center, Langsa City in 2020.

Convenience
The results of the bivariate analysis of the comfort variable can be seen in the table below. Chi-Square test results obtained probability value (p-value) = 0.001 <0.05, this indicates that there is a relationship between timeliness and patient satisfaction at Langsa Baro Public Health Center, Langsa City in 2020.
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 technical competence will result in low patient satisfaction with health services, while good technical competence can get good patient satisfaction as well. This shows that there is a relationship between technical competence and patient satisfaction at Langsa Baro Public Health Center, Langsa City in 2020. However, in the multivariate test, it was found that the technical competence variable had no (dominant) effect on patient satisfaction. This can happen because there are other variables that have a more dominant influence on patient satisfaction.
The results of this study are in line with the research conducted by Az-zahroh (2017) entitled "The Effect of Health Service Quality on the Satisfaction Level of Inpatients in the General Adult Room of Hospital X Gresik Regency" which shows that the better the technical competence of health workers will feel more satisfied with the health services provided (Az-Zhroh, 2017).
Technical competence concerns the skills and abilities of service providers at the puskesmas. Technical competence is knowledge, skills, ability and responsibility in providing services that satisfy patients and their families as long as they receive services provided by health workers according to patient needs (Amelia, 2018).
This research shows that the dimensions of technical competence relate to how the knowledge, skills, responsiveness and responsibility of the health service providers provided are in accordance with agreed health service standards. Failure to fulfill the dimensions of technical competence can result in a variety of things, from minor deviations to health service standards, to fatal errors that can reduce the quality of health services and endanger the lives of patients. Therefore, services must be provided optimally.
This study shows that the dimensions of effectiveness related to the services provided pay attention to the needs and respect of patients, clarity in service procedures, accuracy in providing health services and the appropriate number of personnel in providing services have a relationship with patient satisfaction. Effectiveness in providing services is an important thing that can affect patient satisfaction. Health services that are provided effectively need to be implemented continuously so that the quality of service can always be maintained.
Human-to-human relationships are concerned with the interactions between health care workers and patients, managers and staff, and between the health team and the community. Good human relationships instill trust and credibility with a friendly attitude, keep secrets, respect, are responsive, pay attention, listen to complaints and communicate well. The personal attention factor is able to make an effective contribution or the biggest contribution to increasing patient loyalty. The personal attention factor is thought to be closely related to the level of customer satisfaction with all facilities and the quality of service they have received from all parties, including medical personnel. Therefore, the personal attention factor plays an important role in achieving customer satisfaction (Wibawani Yunestri Mukti, Asiah Hamzah, 2013).
This study shows that the dimensions of human relationships which involve communication, friendly attitude, care and confidentiality are shown by health professionals in providing services to patients and have a relationship with patient satisfaction. Where the patient considers that the patient feels satisfied if there is a good relationship between the patient and health workers through communication using language that is easy to understand, a friendly attitude, caring and keeping patient secrets.
The fact that the researchers found when conducting research, the relationship between humans that existed in the community health center was still not good, this can be seen from health workers who were less friendly to patients, when patients came to visit the puskesmas, they did not always get a good response from health workers. . The contribution of human relationships can create patient satisfaction. This is because patients want a good relationship between patients and health workers such as a friendly attitude, attention, use of language that is easy to understand and a good response to patient complaints is considered important by patients in receiving services from health workers.
The results of this study are in accordance with Lori Di Prete Brown's theory which states that good human relationships instill trust and credibility by respecting, keeping secrets, respecting, being responsive and paying attention. Listening to complaints and communicating effectively are also important. Patients who are treated poorly tend to ignore the advice and advice of health workers, or do not want to go to that place (Amelia, 2018).
Comfort is a condition after the fulfillment of basic human needs, namely the need for tranquility and satisfaction which improves daily performance. The comfort dimension can encourage patients to come for treatment back to the service place, so that comfort can lead to patient confidence in health service organizations (Amelia, 2018).
This study shows that the dimensions of comfort regarding a clean environment, healthy air, good lighting and good appearance of health care providers have no relationship with patient satisfaction. This is because there are other things that are more important for patients in creating satisfaction, including a well-established relationship between patients and health workers, the effectiveness of the services provided, the technical competence of health workers and the timeliness of receiving services. The perfection felt by patients in undergoing treatment can certainly affect patient satisfaction and their willingness to return to health facilities for further services.
This study shows that the punctuality of service opening and closing times, time discipline in polyclinic services, staff arrival time, drug service time and overall patient service waiting time from initial registration to receiving medication at the pharmacy have a relationship with patient satisfaction. Patients feel satisfied if the treatment does not wait too long (appropriate time).

Conclusion
Based on the results show that effectiveness, human relations, competence have an influence, while comfort, timeliness have no effect on patient satisfaction. the effectiveness of puskesmas services is still not good, this can be seen when in providing services, there are still many health workers who do not explain the service procedures performed. So that patients do not get clear information about the services they receive. Based on the relationship between people at Langsa Baro Public Health Center, Langsa City is still not good, this is because there are still health workers who are unfriendly / indifferent and lack