The Influence of Hospital Trust and Service Quality to Patient

Satisfaction and Loyalty

Wilujeng Puja Sari

, Naili Farida

and Sutopo Patria Jati

Student of Master’s Study Program in Public Health, Diponegoro University, Semarang, Indonesia

Teaching staff of Master’s Study Program in Public Health, Diponegoro University, Semarang, Indonesia

Keywords: Trust, Service Quality, Satisfaction, Loyalty.

Abstract: The purpose of this paper is to analyse how trust and service quality influence satisfaction that lead to patient

loyalty. This research used a quantitative methodology. In total, 100 patients participated from outpatient

departement in referal center hospital of Central Java, Semarang, Indonesia. The data was collected using a

survey method with a questionnaire. The data was analyzed using SEM with smartPLS3.0 software. The

reserach demonstrated that hospital trust has no significant impact on patient satisfaction. However, the result

also found that service quality has a positive influenced on patient satisfaction and patient satisfaction has a

positive influenced on loyalty. This research was performed only in one healthcare service provider in

Semarang so the result is less representative of the population in general. This study could be an input towards

hospital managers to generate effective strategies in their effors to improve patient satisfaction and loyalty.

1 INTRODUCTION

The presentation of high quality service is the key to

success in the service industry at this time. In an era

with a high level of competition, the efforts of the

monitoring and improvement of the quality of service

are required for improving efficiency as well as the

volume of business (Meesala and Paul, 2018). The

healthcare service is a vital sector that has great risks

in some potential cases so the ability to create trust in

the hospital rated extremely important. Trust in the

healthcare service determined by many factors such

as the customer's attitude toward the brand, perceived

quality, reputation and conduct of customer-oriented

staff (Khodadad Hosseini and Behboudi, 2017).

Service quality is an important determinant in

generating customer satisfaction and Word of Mouth

communications (Lang 2011). The dimensions of

service quality (SERVQUAL) includes tangible,

reliability, responsiveness, empathy and assurance

(Parasuraman, Berry, and Zeithaml, 1993). The

quality system based on these five dimensions has the

potential to increase functional quality and service

performance. Quality improvement is the main factor

that influences the level of customer satisfaction and

loyalty in service and manufacture marketing

(Meesala and Paul, 2018).

The purpose of delivering quality services as well

as creating trust is to result in patient satisfaction of a

healthcare service provider. Patient satisfaction is an

indicator of hospital success in providing medical

services. According to Wilson et al (2008) patient

satisfaction leads to customer loyalty, provide

recommendations to other people, as well as

purchases (Meesala and Paul, 2018).

1.1 Research Gaps

Patient satisfaction concept has taken a lot of

attention in the healthcare service industry. Some

prior studies bring up satisfaction as the main

construct such as: Amin and Nasharuddin (2013),

Elleuch (2008), Kessler and Mylod (2011). However,

researchers from previous study prioritizing service

performance as the construct to explain patient

satisfaction. Specifically, most previous research

shows that service quality has the biggest role in

explaining patient satisfaction (Meesala and Paul,

2018).

Hospital trust pointing the patient's belief in the

capability of a healthcare service provider. The

literature of marketing in healthcare industry indicate

trust as an important factor in determining loyalty

(Sumaedi et al., 2014). In healthcare service, trust has

been found as a fundamental factor in the decision-

Sari, W., Farida, N. and Jati, S.

The Inﬂuence of Hospital Trust and Service Quality to Patient Satisfaction and Loyalty.

DOI: 10.5220/0008429302030207

In Proceedings of the 2nd International Conference on Inclusive Business in the Changing World (ICIB 2019), pages 203-207

ISBN: 978-989-758-408-4

203

making process (Moliner, 2009). Refers to the

previous study, trust in healthcare provider has a

positive influence on patient satisfaction (Benkert et

al., 2006).

This review of the prior study concludes that

satisfaction is influenced by many factors and cannot

be determined merely through the construct of service

quality. Trust also seems to be a significant construct

in defining satisfaction that underlies patient loyalty

in the healthcare service provider. However, the

recent literature represents that there is a lack of study

in explaining relationship concurrently between trust,

service quality, satisfaction and loyalty based on the

patient evaluation.

2 HYPOTHESES

This paper focuses on the effect of hospital trust and

service quality on patient loyalty towards satisfaction.

The Following hypotheses based on a review of

previous literature that provides the scope of

marketing study. This research proposes hypotheses

as follows:

H1. Hospital trust has a positive impact on patient

satisfaction.

H2. Service quality has a positive impact on patient

satisfaction.

H3. Patient satisfaction has a positive impact on

patient loyalty.

3 RESEARCH METHOD

This research is an observational study with the cross

sectional approach. The population of this research

involved patients in the outpatient department of

referal center hospital of central java, Semarang,

Indonesia. Patients were selected based on purposive

sampling technique with several criteria, namely 17

years old and above, well communicate, has been

using the healthcare service more than once with a

different complaint, come for treatment in service

hours and using private payment. The sample size

was calculated using Slovin formula and obtained 100

respondents.

This research is using Structural Equation

Modeling (SEM) with two exogenous (independent)

variables i.e. trust (3 indicators) and the service

quality (5 indicators), whereas endogenous

(dependent) variables consists of satisfaction (5

indicators) and loyalty (3 indicators). The data

collection was executed through survey method by

using a five-point Likert scale questionnaire. The data

was analyzed using SEM with smartPLS 3.0

software.

3.1 Results

The characteristics of the research subject based on

demographic data consist of gender, age, occupation,

education, average monthly expenses, and the reason

for treatment.

Table 1: The characteristic of respondents.

Characteristic Percentage

Gender

Male 46,0

Female 54,0

Ages

18-23 YO 15,0

24-29 YO 12,0

30-35 YO 21,0

36-41 YO 17,0

42-47 YO 13,0

48-53 YO 10,0

≥54 YO 12,0

Education Backgrounds

Elementary School 10,0

Junior High School 15,0

Senior High School 40,0

Diploma/ Bachelor Degree 30,0

Post Graduate Program 5,0

Occupations

College Students 11,0

Official Employee 20,0

Entrepreneurship 30,0

Government Employee 5,0

Others 34,0

Average Monthly Expenses

<IDR 2,000,000 43,0

IDR 2,000,000-IDR 4,000,000 36,0

IDR 4,000,000-IDR 6,000,000 11,0

>IDR 6,000,000 10,0

Visitation Reasons

Their own accord 50,0

Recommendation from others 7,0

Reference from health workers 43,0

3.2 Partial Least Square – SEM

Analysis

3.2.1 Measurement Model

Evaluation of the outer model aims to determine the

goodness of fit by examining validity and reliability

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test of the indicators. The validity of the construct is

assesed based on convergent validity and

discriminant validity test to find out the accuracy of

the measurement model. Convergent validity testing

aims to determine the validity between item and

construct using outer loading score. Table 2 shows

that the outer loading score of all items was> 0.6

which is surpass the accepted value (Ghozali, 2014).

Other validity examination for contruct items using

discriminant validity test by comparing AVE score

and square root AVE of constructs. Tabel 2

demonstrates the result of discriminant validity test

based on Fornell and Larckers's (1981) criteria. All

constructs have AVE score higher than 0.5 and square

root AVE are greater than AVE score. Thus, the

discriminant validity test was accepted.

Reliability test was performed to explore

measurement model consistency. Tabel 2 shows that

all constructs have composite reliability (CR) score

>0.6, surpass the accepted value (Ghozali, 2014).

This result indicates the measurement model has

sufficient composite reliability, convergent validity

and discriminant validity (Ghozali, 2014).

The evaluation of the inner model aims to observe

the R-square score that indicates the predictive value

of a measurment model. Tabel 2 shows that patient

satisfaction has the R-square score 0.553 which

means exogenous constructs (trust and service

quality) affect satisfaction as much 55.3% whereas

about 44.7% of satisfaction was influenced by other

factors outside this study. Moreover, the R-square

score of loyalty is 0.340. This result explains that

patient satisfaction affects loyalty up to 34%, whereas

about 66% of loyalty construct was influenced by

other variables outside this study.

3.2.2 Structural Model

Analyzing the structural model was performed to

test the hypotesis of this study. The result was

examined using the bootstrapping technique with

1,000 resampling method to determine the path

coefficient's significance. The first hypothesis was

examined between hospital trust and patient

satisfaction. The result shows that hospital trust has a

positive (0.200) but not significant (t = 1,483) to

affect patient satisfaction. Thus, H1 was not

supported. Thereafter, we examined the second hypo-

Table 2: Validity and reliability test.

Variables

Outer

CR AVE Square root AVE R

Trust 0.891 0.731 0.855

Benevolence 0.810

Honesty 0.879

Competence 0.874

Service Quality 0.909 0.551 0.668 0.742

Reliability 0.822

Responsiveness 0.837

Assurance 0.853

Emphaty 0.846

Tangible 0.722

Satisfaction 0.859 0.668 0.820 0.734 0.818 0.553

Satis1 0.795

Satis2 0.769

Satis3 0.705

Satis4 0.727

Satis5 0.711

Loyalty 0.774 0.535 0.442 0.583 0.511 0.731 0.340

Loy1 0.684

Loy2 0.812

Loy3 0.691

*CR = Composite Reliability; AVE = Averange Variance Extracted

Table 3: Path coefficient test.

Hypotheses Original Sample (O) Sample Mean (M)

Standard Deviation

(STDEV)

T Statistics

(|O/STDEV|)

P Values

Hospital Trust-> Patient

Satisfaction

0.200 0.188 0.135 1.483 0.139

Service Quality-> Patient

Satisfaction

0.570 0.585 0.132 4.329 0.000

Patient Satisfaction-> Loyalty 0.583 0.593 0.063 9.197 0.000

The Inﬂuence of Hospital Trust and Service Quality to Patient Satisfaction and Loyalty

205

Figure 1: PLS output of hospital trust and service quality to patient satisfaction and loyalty.

tesis between service quality and patient satisfaction.

Tabel 3 shows that service quality has a positive

(0.570) and significant (t = 4.329) effect on patient

satisfaction. The third hypotesis was tested to

determine the relationship between patient

satisfaction and loyalty. The result indicates that

patient satisfaction has a positive (0.583) and

significant (t = 9.197) effect on patient loyalty. Both

second and third hypotesis was significant at p<0.05

thus, H2 and H3 were supported.

4 DISCUSSION

This research proposed a hierarchical model to find

out the relationship between trust, sevice quality,

patient satisfaction and loyalty. The Structural

Equational Model (SEM) was used to examine the

path model. The outcome confimed that hospital trust

has no significant impact on patient satisfaction.

Thus, H1 was rejected. This result indicates that

increasing hospital trust does not ensure a higher level

of satisfaction. According to this result, the prior

study suggested that trust has no influence on

satisfaction (Khodadad Hosseini and Behboudi,

2017; Laura, 2016).

Afterward, the result for the second hypotesis

demonstate that service quality has a positive and

significant effect on patient satisfaction. Thus, H2

was supported. This finding confirms the prevoious

study conducted by (Naidu, 2009). Similarly, Amin

(2013) has found that admission, medical service,

overal service, discharge, and social responsibility

have a significant impact on satisfaction. If a provider

could fullfill the expected service then the customer

would be satisfied (Parasuraman, Zeithaml, and

Berry, 1985).

Meanwhile, the third hypotesis stated that patient

satsfaction has a positive influnce on patient loyalty.

The outcome shows that H3 was supported. This

finding was suitable for previous research in which

satisfaction has an important role in patient loyalty

(Elleuch, 2008; Kessler and Mylod, 2011). If

satisfaction from the product or received service was

beyond expectation then customer tends to reuse the

same product or service (Lee and Kotler, 2009).

5 CONCLUSION

Patient satisfaction has already been discovered as the

main concept in the prior marketing study. Some

previous study concludes satisfaction was built from

service quality (Lang, 2011) (Amin and Zahora

Nasharuddin, 2013), whereas other literature declare

trust as an important construct in generating

satisfaction (Benkert et al., 2006) (Shan et al., 2016).

However, in this study trust has no significant

influence in resulting patient satisfaction to the

healthcare service provider. Moreover, the outcome

of this research shows that service quality has a

significant impact on patient satisfaction. Also patient

satisfaction has a positive influence on patient

loyalty.

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5.1 Implication

The outcome of this study has a strong implication for

hospital management. Particularly, the results offer a

new perspective for improving strategies in hospital

marketing for both patients and hospital managers. In

order to develop patient satisfaction and loyalty, this

literature suggests hospital managers consider patient

perspective in conducting routine evaluations of

service quality. Patient evaluations of service quality

could be an input toward management to revise

service sectors, which were yet infallible.

5.2 Limitation and Future Research

This study has several limitations. The data was

collected only in one healthcare service provider in

Semarang, Indonesia so the result may not represent

the population in general. Thus, the findings need to

be futher examined in other healthcare service

providers to confirm their constancy. Information

acheived from patients interview may not be free of

subjectivity.

REFERENCES

Amin, Muslim, and Siti Zahora Nasharuddin. 2013.

“Hospital Service Quality and Its Effects on Patient

Satisfaction and Behavioural Intention.” Clinical

Governance 18(3): 238–54.

Amin, Muslim, and Siti Zahora Nasharuddin. 2013.

“Hospital Service Quality and Its Effects on Patient

Satisfaction and Behavioural Intention.” Clinical

Governance: An International Journal 18(3): 238–54.

Benkert, Ramona, Rosalind M Peters, Rodney Clark, and

Kathryn Keves-Foster. 2006. “Effects of Perceived

Racism, Cultural Mistrust and Trust in Providers on

Satisfaction with Care.” Journal of the National

Medical Association 98(9): 1532–40.

Dachyar, M., and Muhammad Reyhan Siva. 2016. “Impact

of Service Quality on Customer Satisfaction in Low

Cost Airline Service in Indonesia.” Taylor & Francis

Group Journal 4(3): 1–6.

Elleuch, Amira. 2008. “Patient Satisfaction in Japan.”

International Journal of Health Care Quality

Assurance 21(7): 692–705.

Ghozali, Imam. 2014. Structural Equation Modeling

Metode Alternatif Dengan Partial Least Square (PLS).

4th ed. Semarang: Badan Penerbit Universitas

Diponegoro.

Kessler, Daniel P., and Deirdre Mylod. 2011. “Does Patient

Satisfaction Affect Patient Loyalty?” International

Journal of Health Care Quality Assurance 24(4): 266–

73.

Khodadad Hosseini, Sayed Hamid, and Leila Behboudi.

2017. “Brand Trust and Image: Effects on Customer

Satisfaction.” International Journal of Health Care

Quality Assurance 30(7): 580–90.

Kin, Nuryakin, and Naili Farida. 2016. “Effects of

Convenience Online Shopping and Satisfaction on

Repeat-Purchase Intention among Students of Higher

Institutions in Indonesia.” Journal of Internet Banking

and Commerce.

Kotler, Philip, and Kevin Lane Keller. 2009. Manajemen

Pemasaran. Jakarta: Penerbit Erlangga.

Lang, Bodo. 2011. “How Word of Mouth Communication

Varies across Service Encounters.” Managing Service

Quality: An International Journal 21(6): 583–98.

Laura, Netty. 2016. “The Effect Of Trust And Service

Quality Toward Patient Satisfaction With Customer

Value As Intervening Variable.” 7(August): 157–62.

Lee, Nancy R., and Philip Kotler. 2009. “Ending Poverty:

‘what’s Social Marketing Got to Do with It?’” Social

Marketing Quarterly.

Meesala, Appalayya, and Justin Paul. 2018. “Service

Quality, Consumer Satisfaction and Loyalty in

Hospitals: Thinking for the Future.” Journal of

Retailing and Consumer Services 40(November 2016):

261–69.

Moliner, Miguel A. 2009. “Loyalty, Perceived Value and

Relationship Quality in Healthcare Services.” Journal

of Service Management 20(1): 76–97.

Naidu, Aditi. 2009. “Factors Affecting Patient Satisfaction

and Healthcare Quality.” International Journal of

Health Care Quality Assurance 22(4): 366–81.

Parasuraman, A., Leonard L. Berry, and Valarie A.

Zeithaml. 1993. “More on Improving Service Quality

Measurement.” Journal of Retailing

69(1): 140–47.

Parasuraman, A., Valarie A. Zeithaml, and Leonard L.

Berry. 1985. “A Conceptual Model of Service Quality

and Its Implications for Future Research.” Journal of

Marketing 49(4): 41.

Shan, Linghan et al. 2016. “Patient Satisfaction with

Hospital Inpatient Care: Effects of Trust, Medical

Insurance and Perceived Quality of Care.” PLoS ONE

11(10): 1–18.

Sumaedi, Sik et al. 2014a. “The Empirical Study on Patient

Loyalty.” Clinical Governance 19(3): 269.

Wijaya, R., N. Farida, and Andriyansah. 2018.

“Determinants of Repurchase Intentions at Online

Stores in Indonesia.” International Journal of e-

Business Research.

The Inﬂuence of Hospital Trust and Service Quality to Patient Satisfaction and Loyalty

207