Prediction of Inpatient Satisfaction with Service Quality with SEM

Method

Maria Sinaga, Chrismis Novalinda Ginting, Ali Napiah Nasution, Ermi Girsang

Department Magister of Public Health, Faculty of Medicine, University of Prima Indonesia.

Keywords: Service Quality, Inpatient Satisfaction.

Abstract: Patient satisfaction is an indicator of the hospital services quality. In fact, hospital services often make patients

dissatisfied like convoluted, boring, inhospitable, and less dexterous. This is allegedly because the provided

quality services is out of the patient expectations. The purpose of this study is to model the relationship

between service quality and inpatient satisfaction, which can then be used to predict satisfaction with various

variables. Modeling was conducted on questionnaire measurement data from 2,071 respondents with 250

samples. Analysis of questionnaire data was processed using univariate, bivariate with chi-square tests, and

multivariate with multiple logistic regression at 95% confidence level ( = 0.05). The modeling accuracy

above 90% was obtained with an input and output relationships in the form of satisfaction. Statistically there

was a relationship between physical evidence, reliability, quick response, and empathy with inpatient

satisfaction, p <0.05. The most significant variable related to inpatient satisfaction was reliability, where

patients who state good reliability will be satisfied with hospital services by 7.6 times higher than those that

are less good.

1 INTRODUCTION

Inpatient services in hospitals often cause satisfaction

and dissatisfaction felt by patients and families.

Dissatisfaction most frequently expressed in relation

to the attitudes and behavior of health workers,

among others: delays in the service of doctors and

nurses, difficult to find, less communicative and

informative, length of admission and order and

cleanliness of the hospital environment that indicate

that the quality of hospital services is still necessary

improved (Rahmawati, Febriana, & Stefanus, 2013).

Health services in hospitals are basically intended

to provide satisfaction to patients. According to

Parasuraman, the services provided by hospitals must

be quality and meet five main quality dimensions,

namely: tangibles, reliability, responsiveness,

assurance, and empathy (Tjiptono & Chandra, 2015).

Robbins and Luthan in (Warda, Junaid, &

Fachlevy, 2016) stated that for users of health

services, the quality of service is more related to the

responsiveness of officers to meet patient needs and

the smooth communication between officers and

patients. Patients as users of hospital services demand

services in accordance with their rights, that is,

quality and perfect services.

Fatas research conducted at Boyayali Hidayah

Hospital showed that the results of the analysis with

Cartesian diagram showed two attributes included in

quadrant a, first, doctors and nurses were quick in

providing the services needed, both doctors and

nurses patiently listened to patient complaints (Fatas,

2017). Rosjid's research at Nirmala Suri Sukoharjo

Hospital found that all service quality variables

included in the five dimensions of Servqual stand

alone or simultaneously, had a close correlation with

customer satisfaction. So that the Servqual method

can be applied in hospitals to measure patient

satisfaction with service quality (Rosjid, 2012).

Arwani's research at PKU Muhammadiyah Gubug

Hospital in 2011 concerning a decrease in the number

of patients showed that consumer satisfaction could

not be fulfilled. Some complaints felt by consumers

are related to tariffs that are not in accordance with

services provided by hospitals and hospital facilities

that are still not good (Arwani, 2011).

The better socio-economic condition of the

community so that in getting services at the hospital

also demands more quality service. This fact should

be of particular concern to the hospital to further

improve its services. But in reality some hospitals still

ignore the importance of customer/ patient

126

Sinaga, M., Ginting, C., Nasution, A. and Girsang, E.

Prediction of Inpatient Satisfaction with Service Quality with SEM Method.

DOI: 10.5220/0010291301260132

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 126-132

ISBN: 978-989-758-500-5

satisfaction by providing poor service. For example

health care for patients who are convoluted, boring,

less dexterous, patient care rooms that do not meet

health requirements and others. If this is not resolved

it can result in a decrease in the quality of hospital

services themselves (Sakti, 2009, Turnip et al, 2018).

Patient satisfaction surveys about the presence of

officers who are unprofessional in providing health

services include complaints that will be heard from

officers who are not friendly and indifferent to the

complaints of their patients. Two directions with

doctors, which reflects how weak the position of

patients as recipients of health services (Isnindar, et

al, 2013; Turnip et al, 2020; Wijaya et al, 2019).

Stella Maris Hospital in Medan is a specialized

hospital that provides services for maternal and child

health. Stella Maris Medan Women's and Children's

Hospital has several integrated polyclinics that can

help serve family health. By presenting the best

doctors, as well as medical services provided, as a

form of commitment of Stella Maris Medan Women's

and Children's Hospital to reliable health services for

all maternal and child health problems. Based on the

performance indicators achieved by the Stella Maris

Hospital in Medan in 2017, the Bed Occupancy Rate

(BOR) is 80.2%, the Average Length of Stay (ALOS)

is 2.7 days and the Turn Over Interval (TOI) is 1 day

whereas in 2018, the number of BOR was 72.9%,

ALOS was 2.8 days and TOI was 0.6 days (RSIA

Stella Maris, 2019). The ideal BOR parameter value

is 60-85%, the ALOS value is between 6-9 days, the

TOI value is in the range of 1-3 days (MOH RI,

2005).

The latest data that researchers obtained from the

Stella Maris Mother and Child Hospital Medan that

the number of inpatient visits during the last 3 months

was June 2019 as many as 2140 visits, as of July 2019

as many as 2151 visits, and as of August 2019 as

many as 2071 visits. Fluctuations have been seen over

the past 3 months, and in August 2019 the lowest

compared to June 2019 and July 2019. The decline is

presumably due to patients feeling less satisfied with

inpatient care.

Structural Equation Model (SEM), an analysis of

variance-based structural equations designed to solve

multiple regressions when 25 specific problems occur

in data such as relatively small sample sizes, missing

or abnormal data and multicollinearity that aims to

predict relationships between constructs and explain

the theoretical relationship between these constructs

(Ghozali & Laten, 2015; Kusumandari et al, 2018;

Turnip et al, 2018).

A preliminary survey that researchers conducted

by interviewing 10 inpatients about the satisfaction

felt during treatment. As many as 5 people expressed

satisfaction, while 2 others stated that they were quite

satisfied, and 3 people stated that they were not

satisfied. Patient dissatisfaction is usually caused by

doctors and nurses who are less friendly, less

responsive when asked for help, and others. In this

study, predictions of inpatient satisfaction with

service quality with the Structural Equation Modeling

(SEM) method were developed.

2 METHOD

This type of research is a quantitative analytic study

with a cross sectional study design. The research was

conducted at the Stella Maris Hospital in Medan in

November 2019. The study population was all

inpatients as many as 2,071 people, and samples were

obtained as many as 250 respondents. Univariate data

analysis, bivariate using chi-square test, and

multivariate using multiple logistic regression tests

with a confidence level of 95% ( = 0.05).

Analysis techniques were used to interpret and

analyze data. In accordance with the model developed

in this study, the data analysis tool used was SEM,

which is operated through the AMOS 16.0 program

(Hair et al, 1998; Ferdinand, 2006). Using the stages

of modeling and analysis of structural equations into

7 steps, namely: theoretical model development;

Arrange path diagram; Turn a path diagram into a

structural equation; Choose an input matrix for data

analysis; Assessing model identification; Assessing

Goodness-of-Fit Criteria; Model estimation

interpretation.

The use of SEM can expand the ability to explain

with the existence of statistical efficiency as a model

that tests the method thoroughly. Hypothesis testing

is done using a structural equation model using

AMOS software. For the purpose of rejecting or

accepting a hypothesis, a significance level of P <0.05

was used. After the raw data has been collected, the

data are then presented in various forms: (i)

Presentation of the results of the initial analysis. (ii)

Presentation of SEM analysis. (iii) Testing and

research hypotheses based on the results of data

processing.

3 RESULTS AND DISCUSSIONS

Characteristics of respondents ie most respondents

aged <40 years were 58.0%. Based on gender, all

respondents involved were female. Based on

Prediction of Inpatient Satisfaction with Service Quality with SEM Method

127

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education, the majority of respondents had a diploma

education of 49.6%, a small proportion had a high

school education of 20.0%. Based on work, most

respondents were housewives as much as 38.8%, a

small proportion of respondents worked as

entrepreneurs as much as 36.0%. Based on the length

of stay, the majority of respondents had been treated

for 2 days as much as 49.2%, a small portion had been

treated for 5 days as much as 2.8%.

Based on the results of bivariate analysis, all

independent variables were found to be significantly

related to inpatient satisfaction (p = 0,000). The

complete Chi-Square statistical test results can be

seen in Table 1.

Table 1: Relationship of Each Independent and Dependent

Variable.

The results of multivariate analysis (Table 2) with

multiple logistic regression tests showed that of the 5

variables as model candidates, 4 variables were

obtained that affected maternal satisfaction, namely

tangible, reliability, responsiveness, and empathy.

The most influential variable in this study was the

responsiveness variable which has a value of Exp (B)

/ OR = 7.985 meaning that mothers who state good

hospital responsiveness, have the opportunity to feel

satisfied with pregnancy and childbirth services by

7.9 times higher.

Table 2: Multiple Logistic Regression Test Results.

Variables B Sig. Exp (B)

95% CI for

Exp(B)

Tangible

Reliability

Responsiveness

Empathy

Constant

1,166

2,035

1,904

1,832

-1,524

0,013

0,000

3,209

7,656

6,715

6,246

1,279-8,052

3,013-19,453

2,536-17,782

2,490-15,667

3.1 Tangible Factors

Based on the results of the study showed that there

was a relationship of physical evidence with inpatient

satisfaction, p = 0.013 <0.05. Variable physical

evidence that has a value of Exp (B) / OR = 3.209

means that patients who state good physical evidence,

have the opportunity to feel satisfied with hospital

services by 3.2 times higher than patients who claim

physical evidence is not good.

This study is in line with research conducted by

Burhanuddin (2016) to get the result that there is a

relationship between the quality of health services

based on the dimensions of physical evidence and

patient satisfaction of BPJS participants. Research

conducted by Nova (2015) that examined the effect

of service quality on inpatient satisfaction stated that

the greatest influence was the variable of

manifestation or physical evidence (5,191). Based on

the results of research conducted by Winarno (2015)

that from the test results, the first hypothesis can be

explained through the sign parameter b1 in the

regression equation, which in this study is positive,

namely (+ 0.165) and t test where tcount (1,914)> t

table (1,660 ), then H0 is rejected and Ha is accepted.

This means that there is a positive and significant

influence of tangibles variable on service user

satisfaction. Physical manifestations include the

appearance and completeness of physical facilities

such as treatment rooms, buildings, and the

availability of clean parking lots, neatness, and

comfort of waiting rooms and examination rooms, the

completeness of communication and appearance

equipment (Tjiptono & Chandra, 2015). Everyone

wants service satisfaction so they can feel the

importance of the physical evidence presented by the

developer.

The results prove that physical evidence was

significantly related to inpatient satisfaction. Patients

who state that good physical evidence tends to be

satisfied with the services provided. Everyone's

satisfaction is actually very relative, depending on

their perceptions and social status. Hospital physical

evidence makes inpatients feel satisfied with regard

to comfort, cleanliness, neatness, and appearance.

This makes the patient feel satisfied with the services

related to tangible.

3.2 Reliability Factors

The results showed that there was a relationship of

reliability with inpatient satisfaction, p = 0,000 <0.05.

The reliability variable has a value of Exp (B) / OR =

7.656, meaning that patients who state good

reliability, have the opportunity to feel satisfied with

hospital services at 7.6 times higher. Fatas research

(2017) states that the results of the analysis with

Cartesian diagrams show two attributes included in

quadrant A, firstly doctors and nurses are quick in

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providing the services needed, both doctors and

nurses patiently listen to patient complaints. The

results of Triwahyuni's research (2015) show that

perceptions about the quality of reliable doctor

services have an influence on the satisfaction of

inpatients. Winarno's research results (2015) get

results that prove that there is a positive and

significant influence of the reliability variable on

service user satisfaction.

The reliability dimension shows the ability to

provide services according to the promises offered.

The assessment is related to the timeliness of service

at registration, the time of treatment / examination,

the suitability between expectations and the

realization of time for patients (Tjiptono & Chandra,

2015). The demand for reliability of health workers in

providing fast, appropriate, easy and smooth services

is a condition for patient evaluation in showing the

actualization of the work of health workers. The

satisfaction of these patients in the assessment of

reliability is the ability of health workers to provide

services immediately and satisfactorily as desired by

patients and families (Azwar, 2016).

The results of this study prove that the reliability

variable of health workers was related to the

satisfaction felt by hospitalized patients. The

reliability variable is the most related to inpatient

satisfaction. The services provided can be relied upon

if it is in accordance with the wishes of the consumers

related to the speed of service time and accuracy in

providing services which will ultimately have an

impact on the achievement of customer satisfaction.

The reliability of health workers can be seen from the

ability of health workers (doctors and nurses) who are

professional in providing services to patients and

families. Health workers check the condition of

patients from morning to night on a regular basis,

nurses pay attention to the cleanliness of the patient's

body being treated, control the infusion that is

installed, as well as provide counseling or health

education in accordance with the illness suffered by

the patient so that it can add insight into the

knowledge of the patient and family.

3.3 Responsiveness Factors

The results showed that there was a fast response

relationship with inpatient satisfaction, p = 0,000

<0.05. The variable rapid response has a value of Exp

(B) / OR = 6,715 meaning that patients who state

good hospital responsiveness are good, have the

opportunity to feel satisfied with hospital services by

6.7 times higher. Rosjid's research results (2016)

found that all service quality variables included in the

five dimensions of Servqual stand alone or

simultaneously, have a pretty close correlation with

customer satisfaction, especially the variable

responsiveness. Research conducted by Mukti,

Hamzah, & Nyorong (2015) shows that the results of

statistical tests using the chi square test obtained p

value = 0.002. This means that there is an effect of

responsiveness or timeliness on patient satisfaction.

The results showed that 63.6% of respondents said

they were dissatisfied with hospital staff who were

not responsive or not on time.

Quick response or timeliness in service was the

ability of the hospital to provide services as promised,

which includes the speed and accuracy of officers in

providing services include: accuracy in procedures

for patient acceptance, registration, speed of health

workers when asked for help, when examined and

diagnosing the disease and healing of diseases

(Azwar, 2016).

The results of this study prove that the

responsiveness of health workers was significantly

related to the satisfaction felt by inpatients. Patients

who claim that health workers are responsive in

providing services tend to feel satisfied. This is

related to the speed of the nurse if called by the patient

or family in less than 5 minutes, the nurse is

responsive in helping to meet the needs of eating /

drinking when the patient cannot do it himself,

doctors and nurses always check the condition after

taking action to see reaction from the actions taken,

health workers show readiness and always be willing

to help if requested by patients and families. In

addition, doctors and nurses also explained further

care at home in accordance with the conditions of the

illness experienced.

3.4. Empathy Factors

The results showed that there was an empathy

relationship with inpatient satisfaction, p = 0,000

<0.05. Empathy variable which has a value of Exp (B)

/ OR = 6.246 means that patients who state good

hospital empathy, have the opportunity to feel

satisfied with hospital services by 6.2 times higher.

Empathy is an important variable in increasing the

satisfaction of inpatients.

Based on research conducted by Prabowo, Noer;

aini, & Supriyadi (2016) shows that most respondents

have satisfied empathy (71.9%). There is a

relationship between the quality of service

dimensions of empathy with insurance patient

satisfaction. This is also in line with the study of

Winarno (2015) which found that there was a positive

and significant influence of empathy variables on

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service user satisfaction. Research conducted by

Immas, Saryadi, & Dewi, (2015) found that there was

a significant influence between empathy on patient

satisfaction. Where the better the empathy is given,

the higher the customer satisfaction.

Empathy is one of the factors driving the progress

of the hospital. Because empathy is needed by people

who are sick or who are being treated. If the empathy

given is not appropriate then the patient will not use

services at the hospital let alone recommend to others.

Factors of empathy or personal attention can make an

effective contribution or the greatest 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.

The results of this study prove that empathy is

significantly related to the satisfaction of inpatients.

Empathy is shown by health workers (doctors and

nurses) by communicating well with patients with

sympathy, giving more attention to patients that

patients do need attention both physically and

psychologically, health workers always seek approval

when taking action or doing examination. Likewise,

manners and manners are shown by health workers

when they take action. In addition, health workers

provide the opportunity for patients to express

feelings or complaints that are felt. Health workers

explain care and treatment procedures using language

that is easy to understand.

To facilitate management and make decisions

regarding variables that are considered to have a large

role, modeling using SEM methods is carried out. The

results of testing the structural model to test the

relationship of service quality, satisfaction and trust

are presented in Figure 1 through the model's

Goodness of Fit test. The model suitability test results

on the full SEM model show the results of the

evaluation of the model suitability for the full SEM

model. Of the eight criteria, only two criteria meet the

Goodness of Fit value, namely CMIN / DF with a

value of 0.871 (cut-off value <2.00) and RMSEA

with a value of 0.030 (cut-off value <0.08). The

parsimony principle and the rule of thumb say that the

model can be said to be fit or meet if there are at least

one or two goodness of fit criteria that meet (Rinaldo,

2009). Referring to the principle of parsimony and

rule of tumb, it can be concluded that the model built

is good and acceptable.

Figure 1: Model design using the SS method

Table 3: Effect of service quality on loyalty of Inpatients

The results of the calculation of hypothesis testing

between variables can be seen in Table 3. From the

hypothesis testing Table 3 can be explained as

follows: Hypothesis 1: Reliability significantly

influences the satisfaction of inpatients at the

hospital. The standardized regression weight between

reliability and patient satisfaction is 1,676 with a t /

C.R. = 1,239 (Probability = 0.215). Thus it can be said

that the influence is positive and significant. These

results provide support for the first hypothesis.

Hypothesis 2: Tangiable has a significant effect on

inpatient satisfaction. The standardized regression

weight between reliability and patient satisfaction is

0.346 with a t / C.R value. was 0.838 (Probability was

0.249) thus it can be said that in order to achieve

inpatient satisfaction one of the aspects required is

tangiable. The effect is positive and significant. These

results provide support for the selected hypothesis.

Hypothesis 3: Responsiveness significantly

influences inpatient satisfaction. The standardized

regression weight between reliability and patient

satisfaction is -0.592 with a t / C.R value. was -0.630

(Probability was -0.592). Thus it can be said that

Responsiveness is a very influential factor to achieve

patient satisfaction where the effect is positive and

significant to further provide support for hypothesis

3. Hypothesis 4: Health insurance does not

significantly influence patient satisfaction. The

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standardized regression weight between reliability

and patient satisfaction is -0.592 with a t / C.R value.

was -0.630 (Probability was 0.351). Thus it can be

said that Empathy is one of the factors that has a

significant influence on achieving patient

satisfaction. Hypothesis 5: Empathy has a significant

effect on patient satisfaction. The standardized

regression weight between reliability and patient

satisfaction is 1,556 with a t / C.R value. was 0.932

(Probability was 0.529). Thus it can be said that

health insurance is one of the factors that does not

have a significant influence on achieving patient

satisfaction. This is evidenced by the positive value

shown by the standardized regression weight.

Table 4: Effect of service on satisfaction.

From Table 4 it can be concluded that

responsiveness, empathy, reliability, tangiable have a

direct influence on inpatient satisfaction. Others with

health insurance that has a negative value indicates

that it does not have a positive direct effect that is too

influential on patient satisfaction. If seen from Table

4, the biggest factor for achieving inpatient

satisfaction in hospital was the responsiveness factor

with a total effect of 0.21 which means that the

percentage of satisfaction with responsiveness is

79%.

4 CONCLUSIONS

The results showed that all variables except collateral

affect the satisfaction of inpatients. The most related

variable is reliability which has an Exp (B) / OR value

= 7.656 meaning that patients who state the reliability

of health workers are good, have the opportunity to

feel satisfied with hospital services by 7.6 times

higher than patients who state the reliability of health

workers is not good. Using SEM method, the the

biggest factor for achieving inpatient satisfaction in

hospital was the responsiveness factor with a total

effect of 0.21 which means that the percentage of

satisfaction with responsiveness is 79%.

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