THE MEDIATING EFFECT OF PATIENT SATISFACTION ON THE RELATIONSHIP BETWEEN SERVICE QUALITY, HOSPITAL IMAGE, TRUST AND PATIENT LOYALTY: EVIDENCE FROM INDONESIA

The development of healthcare industry in Indonesia has become very potential market and faced keen competition. One of marketing strategy to win the high competition is to createpatient satisfaction.The purpose of this study wasto examine the mediating effect patient satisfaction on the relationship between service quality, hospital image, patient trust and patient loyalty. The primary data for the study were collected from a selfadministered mail survey of 337 questionnaires from the hospital patients resulting in a sample of 214 usable responses being returned. The results showed that service quality and hospital image had significant effect on patient satisfaction and loyalty, while patient trust did not affect significantly patient satisfaction and loyalty. In addition, the variable of patient satisfaction was found to have positive effect on patient loyalty. Specifically, patient satisfaction mediated the relationship between service quality, hospital image and patient loyalty. However, it did not mediate the relationship between patient trust and patient loyalty. Introduction Nowadays, the increase of medical care services has become a major concern of every patient. Providing the health facilities and infrastructure are one of the main requirements in efforts toimprove the community health. These health facilities could consist of hospitals and community health centers (Ministry of Health of the Republic of Indonesia, 2008). The rapid technological developments have led to increased public knowledge of the health so that people are more selective in choosing health care facilities. Thus, every hospital is required to be able to provide the best health services to patients compared to its competitors. One marketing strategy to win competition is through the creation of consumer loyalty, which in this case is named by patient. Kotler and Keller (2014) conceptualize consumer loyalty is a commitment to to provide services based on a positive attitude and is reflected in the repeated and consistent use of services. In general, patient satisfaction has been recognized as the determinants of customer loyalty. Patient satisfaction is conceptualized as a comparison between perceived expectations and reality (Kotler& Keller, 2014). According to Rust and Oliver (1994), satisfaction is based on service quality; thus, the greater the service quality felt by patients, the more likely they will feel satisfied. On the other hand, variables of service quality, hospital image and patient trust were found as antecedents of customer satisfaction. Service quality has been recognized as a key element that affects customer satisfaction. Patient services quality is an effort to meet the needs and desires of patients as well as the accuracy of delivery in balancing patient expectations (Parasuramanet al, 1990). Hospital image is the perceptions of a hospital in patient memory (Keller, 1993). In fact, a good image helps organizations to enter into new markets faster, enhance ability to expand services (Ruyter & Wetzels, 2000), attract efficient staff, build reputation, promote services (Alves & Raposo, 2010), give positive feelings to consumers and differentiate the brand (Aaker,1991). Another variable that has the potential to influence patient satisfaction and patient loyalty is patient trust which is defined as a patient’s belief that the physician will act in the patient’s best interest and will provide appropriate treatment and medical care (Anderson & Dedrick, 1990; Thom & Campbell, 1997). [Sefnedi* et al., 7(2): February, 2020] ISSN: 2349-5197 Impact Factor: 3.765 INTERNATIONAL JOURNAL OF RESEARCH SCIENCE & MANAGEMENT http: // www.ijrsm. com © International Journal of Research Science & Management [41] Literature review Determinants of Patient Loyalty Patient loyalty is another terminology of customer loyalty. Oliver (1999) defines customer loyalty as a commitment to repeat purchases or subscribe to products or services consistently in the future. As the practitioner interest in patient satisfaction with physicians has increased, so have the number of empirical and theoretical publications. There have been a number of studies focusing on the link between patient satisfaction and loyalty. Previous research has found that patient satisfaction significantly predicted patient loyalty (Gabel et al, 1993; Lai et al, 2009; Juhana et al, 2015). Other studies found determinants of loyalty are service quality (Aliman & Muhamad, 2005; Sefnedi, 2019), hospital image (Allison et al, 2004; Rai &Srivastava, 2013; Shpetim, 2012), and patient trust (Moreira & Silva, 2015). Therefore, this study developed hypotheses as follow: H1 : Patient satisfaction significantly affect patient loyalty. H2 : Service quality significantly affect patient loyalty. H3 : Hospital image significantly affect patient loyalty. H4 : Patient trust significantly affect patient loyalty. Antecedents of Patient Satisfaction Customers or patient are either satisfied or disappointed based on a comparison made between their perception and service outcome expectation (Kotler & Keller, 2014). Patient satisfaction is among the most extensively researched constructs owing to its importance to hospital success. Conceptually, it has been defined as the feeling patients experience from their purchase (Oliver, 1999). Jahng et al (2005) claim that satisfaction is a critical issue in the marketing field since satisfied customers or patients turn into loyalty and ensure profitability, which is crucial for most businesses. Several empirical studies displayed the determinants of customer or patient satisfaction namely, service quality (Caruana, 2002; Mira & Sefnedi, 2019; Taqdees et al, 2018), hospital image (Silva & Alwi, 2003; Chahal&Bala, 2012), and patient trust (Moreira & Silva, 2015). Based on the previous findings, , this study developed hypotheses bellow: H5 : Service quality significantly affect patient satisfaction. H6 : Hospital image significantly affect patient satisfaction. H7 : Patient trust significantly affect patient satisfaction. Patient Satisfaction as Mediator It is true that there were no one previous researchers who examined the role of patient satisfaction as a mediator between service quality, hospital image, patient trust and patient loyalty simultaneously. Partially, Caruana (2002) found that customer satisfaction mediated the relationship between service quality and customer loyalty. Therefore, this study developed hypotheses bellow: H8 : Patient satisfaction mediated the relationship between service quality and patient loyalty H9 : Patient satisfaction mediated the relationship between hospital image and patient loyalty H8 : Patient satisfaction mediated the relationship between patient trust and patient loyalty Methodology This study was based on an empirical investigation of hospital patients in provinces of West Sumatera, Indonesia. The questionnaire was developed and pretested using a small sample of patients, with the final instrument in English and a Indonesian language equivalent with a covering letter and instructions that was drop and pick to a random sample that included 251 questionnaires and yielding 204 usable questionnaires’ being returned, accounting for an effective response rate of 81.3% and considered to be acceptable. In accordance with the research objectives, this study adopted a questionnaire-based quantitative approach, which was developed by extensively reviewing the literature on service quality, image, trust, satisfaction, and loyalty to identify reliable measured used in previous studies. Service quality was measured using five dimensions namely tangibles, empathy, reliability, responsiveness, and assurance. The five dimension were [Sefnedi* et al., 7(2): February, 2020] ISSN: 2349-5197 Impact Factor: 3.765 INTERNATIONAL JOURNAL OF RESEARCH SCIENCE & MANAGEMENT http: // www.ijrsm. com © International Journal of Research Science & Management [42] measured by 22 items (Parasuraman et al, 1990). Hospital image was measured using six items (Engel et al, 1995) namely: location, nature and quality of diversity, price, advertising and promotion, personal sales, and physical attributes. Patient trust was conceptualized as a patient’s belief that the physician will act in the patient’s best interest and will provide appropriate treatment and medical care (Th om & Campbell, 1997). This variable was measured with four item that adapted from McKnight et al (2002) namely plays a good role, competent,capable and proficient, and knowledgeable. Patient satisfaction was measured by seven items (Wu et al, 2010) that consist of good treatment, satisfied experience, making the right choice in using services, enjoying using the service, not regretting using the service, exceeded expectations, and satisfied with the service received. In addition, patient loyalty would be measured by twelve items (Caruana, 2002) namely (1) say positive things about hospital to other people, (2) intend to continue doing business with hospital, (3) encourage friends and relatives to do business with hospital, (4) seldom consider switching away from hospital, (5) doubt that I would switch, (6) really like doing business with hospital, (7) hospital is clearly the best to do business with, (8) believe this hospital is good, (9) try to use hospital every time I need service, (10) consider this hospital as my primary, (11) first choice when I need hospital service, and (12) primary place when I consider when I want to use hospital services. Results and discussion Next, some descriptive statistics of the sample is provided. A profile of the private university participating in the study is presented in Table 1. Table 1.The Profile of Participating Respondents (n = 214) Data Demograpy Categories Frequency (%) Gender Male 96 44,9 Female 118 55,1 Age 17-27 years 27 12,6 28-38 years 38 17,8 39-49 years 61 28,5 50-60 years 88 41,1 Formal Education Junior High School 41 19,2 Senior