Determinants that Influence the Quality of Outstanding Services on Patient Satisfaction in dr. H. Moh. Anwar General Hospital Sumenep District

Quality hospital services are always a hope for every user of health services and along with the development of science and technology, people are increasingly critical in assessing health services. The purpose of this study was to analyze the effect of loyalty and response time on the quality of outpatient services and patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency. The design of this research is an observational quantitative study with a cross sectional approach with the focus of the research directed at analyzing the effect of loyalty and response time on the quality of outpatient services and patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency. The total population is 271 respondents and a sample of 109 respondents is taken by the Accidental Sampling technique. The findings showed that most of the respondents had sufficient category loyalty as many as 56 respondents (51.4%). Most of the respondents rated the response time in the medium category as many as 56 respondents (51.4%). Most of the respondents have a moderate category of service quality as many as 55 respondents (50.5%). Most respondentssatisfied as many as 65 respondents (59.6%). Based on the results of the Linear Regression analysis of the service quality variable on utilization, it shows that the p-value <0.05 then H0 is rejected and H1 is accepted, so it can be concluded that there is an influence of loyalty and response time on the quality of outpatient services and patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency. It is expected that respondents can provide constructive input and criticism so that the services provided can be in accordance with what is expected.

work units, and service units to achieve the set vision and mission and have responsibilities in managing quality improvement and patient safety, contract management, and resource management (KARS, 2017 ).
The quality of quality hospital services has always been a hope for every user of health services and along with the development of science and technology, people are increasingly critical in assessing health services. For this reason, hospitals must continue to improve the quality of services provided in accordance with the needs of health services and services related to patient needs, which are easily accessible, fast and accurate, quality services and of course at affordable costs (Bustami, 2011;Nursalam, 2011Nursalam, ). 2015.
The quality of services at home must of course be supported through 3 aspects, namely through: structure/input, namely all resources needed to carry out activities (human, physical and financial resources), process, namely all professional interactions between service providers and recipients of health services ( service process), and the output is the result of health services (aspects of medical services, efficiency, service coverage, and patient safety) and the final result produces an outcome in the form of patient satisfaction (Nursalam, 2015). Improving patient satisfaction can be done by applying the Professional Nursing Care Method (MAKP) with the team method. Previous studies explained the importance of team methods but focused on strategic management (Yudianto & Meirawaty, 2019).
One form of nursing services in order to improve service quality is to provide a higher sense of responsibility for nurses so that there is an increase in work performance and patient satisfaction. This nursing service will be more satisfying of course with the application of the professional nursing care model or MAKP because patient satisfaction is determined by one of them with optimal nursing services (Fisbach, 2011).
The application of the professional team nursing care model, if the responsibilities or roles of nurses both in terms of (documentation, weigh-in, pre post conference, nursing rounds, nursing supervision and drug centralization) are not carried out properly, which means that the work performance of nurses also decreases (Nursalam). , 2015). The decline in the work performance of nurses can result in low nursing care services and dissatisfied patients. If the patient is not satisfied, the number of patients (BOR), also decreases, which means a decrease in hospital income, and if this continues it will have an impact on the development of the hospital, which in the end also affects nurses in providing nursing care and also the rewards received. nurses, so nurses become lazy to work.
Health care standards are part of the health service itself and play an important role in overcoming the problem of the quality of health services. If a health care organization wants to provide quality health services in an obedient or consistent manner, this desire must be translated into a health service standard or operational procedural standard. Health service standards are an organizational tool to describe the quality of health services into operational terminology so that everyone involved in health services will be bound in a system, whether patients, health service providers, health care support, or the management of health service organizations, and will be responsible for accountability in carrying out their respective duties and roles (Imbalo, 2015).
Based on the above conditions, the authors are interested in researching the determinants that affect the quality of outpatient services on patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency.

MATERIALS AND METHODS
In this study, the researcher used an observational quantitative design with a cross sectional approach, which is a study to study the dynamics of the correlation between risk factors and effects, by approaching, observing or collecting data all at once (point time approach), that is, each subject The study was observed only once and measurements were made on the status of the character or variable of the subject at the time of examination. This does not mean that all research subjects are observed at the same time (Soekidjo, 2012). This research will analyzethe effect of loyalty and response time on the quality of outpatient services and patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency. The total population is 271 respondents and a sample of 109 respondents is taken by the Accidental Sampling technique. Data analysis using path analysis test. This research has gone through an ethical test with the number SK: 2309/KEPK/III/2021 Based on the results of the Linear Regression analysis of the service quality variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly influence response timeon the quality of outpatient services at General Hospital dr. H. Moh. Anwar, Sumenep Regency. c. The Effect of Loyalty through Service Quality on Satisfaction It is known that the direct influence given by loyalty to service quality is 0.533. While the indirect effect of loyalty through service quality on satisfaction is 0.120 x 0.667 = 0.080. Then the effect of total loyalty through service quality on satisfaction is 0.533 + 0.080 = 0.613. The total effect value is 0.613, so it can be concluded that there is an effect ofloyalty through the quality of outpatient services to patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency. d. The Effect of Response Time Through Service Quality on Satisfaction It is known that the direct effect given by the response time on the quality of service is 0.582. While the indirect effectresponse timethrough service quality to satisfaction is 0.881 x 0.667 = 0.588. So the effect of total response time through service quality on satisfaction is 0.582 + 0.588 = 1.170. The total effect value is 1.170 so it can be concluded that there is an effect of response time through the quality of outpatient services on patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency.

A. Outpatient Loyalty At Dr. H. Moh. Anwar General Hospital Sumenep Regency
The results showed that most of the respondents had sufficient category loyalty as many as 56 respondents (51.4%). In addition, a number of 29 respondents (26.6%) have good category loyalty. While a number of 24 respondents (22%) have low loyalty category. Sutisna (2011), said that loyalty is grouped into two groups, namely brand loyalty and store loyalty. Consumer loyalty can be defined as "a favorable attitude towards a brand that is represented in consistent purchases of that brand over time". Setiawan (2011), revealed that consumer loyalty is defined as a measure of customer loyalty in using a product brand or service brand at a certain time in a situation where there are many choices of products or services that can meet their needs and customers have the ability to get them. The level of consumer loyalty to a particular good or service depends on several factors, such as the cost of switching to another good or service, the similarity in quality, quantity or service of the type of substitute goods or services, the risk of changes in costs due to substitute goods or services. Odabası (2014), explains customer loyalty as a tendency, Existing research states that loyalty as a real behavior that is consistent over time. The approach to loyalty cannot be seen as a comprehensive thing about the factors that cause loyalty, but loyalty can be formed from behaviors. Over the past few decades, loyalty has been studied using an attitude approach, this is reflected in one of them by the desire to recommend service providers to others. However, with the passage of time and many studies, research with behavioral and attitude approaches to loyalty has developed, such as the elements of loyalty developed by Zeithaml, et al (2011), Aspects that affect patient loyalty are satisfaction, which is a comparison between expectations before performing with perceived performance, emotional bonding, where patients can be affected by a hospital name that has its own charm, so that patients can be identified in the hospital. a hospital name. Trust, namely the willingness of someone to entrust a company or a hospital name to perform and carry out a function, choice reduction anhabit (convenience), patients will feel comfortable with a hospital name when making transactions provides convenience, history with the company (experience with the company), namely the patient's experience with the company can shape behavior (Putri, 2010).
Based on the results of the study, it was found that most of the respondents had sufficient loyalty to the services provided by hospital health workers, where this was because patients believed that everything that health workers gave to patients was the best. So that patients follow all instructions given by officers and even patients are willing to queue because all patients must be served well when checking their illness. However, there are some respondents who have low loyalty where this is because they feel objected to having to wait a long time to queue for services and likewise doctors are less detailed in examining patient complaints.

B. Response TimeHealth Officer at Dr. H. Moh. Anwar General Hospital Sumenep Regency
The results showed that most of the respondents rated the response time in the medium category as many as 56 respondents (51.4%). In addition, a number of 27 respondents (24.8%)assess the response time category slow. Meanwhile, 26 respondents (23.9%) rated the response time in the fast category.
Waiting time is the time used by patients to get health services from the registration point to entering the doctor's examination room. Patient waiting time is one component that has the potential to cause dissatisfaction. The length of patient waiting time reflects how the hospital manages service components that are tailored to the patient's situation and expectations (Depkes RI, 2010).
The category of distance between waiting time and examination time which is estimated to be satisfactory or unsatisfactory for the patient, among others, is when the patient comes from registering to the counter, queuing and waiting for a call to the general polyclinic to be analyzed and examined by a doctor, nurse or midwife for more than 90 minutes ( old category), 30 -60 minutes (medium category) and 30 minutes (fast category). Waiting times in Indonesia are set by the Ministry of Health (Kemenkes) through minimum service standards. Each hospital or health center must follow the minimum service standards regarding this waiting time. The minimum service standard in outpatients based on the Ministry of Health Number 129/Menkes/SK/II/2008 is less or equal to 60 minutes (Kemenkes, 2013).
The speed and accuracy of the assistance given to patients who come to health facilities require standards according to their competence and ability so that they can guarantee a health treatment with a fast response time and appropriate treatment. This can be achieved by improving facilities, infrastructure, human resources and hospital management according to standards (Kepmenkes, 2009).
The Canadian of Association Emergency Physician (2012) wrote that the incidence of lack of stretchers for handling acute cases has a serious impact on the arrival of new patients who may be in very critical condition. The American College of Emergency Physician (2013) writes that in hospitals experiencing problems with the large number of patients who want to get services, placing a doctor in the triage area can speed up the process of discharge or discharge for minor patients and help start treatment for patients whose condition is more ill. . Green, et.al. (2014) which suggests that very small and simple changes in staffing have an impact on delays in handling.
From the results of the study, the researchers found that the response time given by health workers was overall in the fast category. This can happen because the management system applied in the hospital is well organized where the functional position is very professional. The response time tends to be faster in the morning while in the afternoon it is less fast due to the large queues of patients doing health checks. However, even though there are many patients queuing, all patients can be served in less than 60 minutes.

C. Quality of Outpatient Services at Dr. H. Moh. Anwar, General Hospital Sumenep Regency
The results showed that most of the respondents had a moderate category of service quality as many as 55 respondents (50.5%). In addition, a number of 29 respondents (26.6%) have a low service quality category. Meanwhile, a number of 25 respondents (22.9%) have a high service quality category.
Service is an activity or a series of tools that are invisible (cannot be touched), which occur due to interactions between consumers and employees or other things provided by service providers that are intended to solve consumer problems (Winarsih, 2015).
People as consumers certainly want quality services. Service quality is defined as the level of excellence expected and control over the level of excellence to meet customer desires. Service quality can be interpreted as an effort to fulfill consumer needs and desires as well as the accuracy of delivery in balancing consumer expectations (Oktafani, 2014).
One of the services that is widely used by the community is health services. Utilization of health services by using the service facilities provided either in the form of outpatient care, inpatient care, home visits by health workers or other forms of activity from the use of these services based on the availability and continuity of services, public acceptance and fairness, easily accessible by the community, affordable and quality (Anwar, 2014).
Good services are health services that are available to the community (acceptable) and sustainable (sustainable). This means that all types of health services needed by the community are found and their presence in the community is available at any time of need. Health services must be reasonable (appropriate) and acceptable (acceptable) by the community. This means that the health service can overcome the health problems faced, does not conflict with customs, culture, beliefs and beliefs of the community, and is unnatural, is not a condition of good health services.
The location angle is easily accessible by the community, so the distribution of health facilities is very important. Coverage of auxiliary facilities to determine effective demand. If the facility is easily accessible by using the available means of transportation, this facility will be widely used. Past user levels and trends are the best indicators of short and long term changes in future demand.
The services provided are affordable (affordable) by the community, where the cost of these services is sought in accordance with the economic capacity of the community. Expensive health services may only be enjoyed by some people. And shows the level of perfection of the health services provided (quality/quality) and shows the healing of diseases and the safety of actions that can satisfy service users in accordance with established standards.
From the results of the study, the researcher argues that health services must have various basic requirements, namely the basic requirements that influence the community in determining their choice to use health services. The services needed by the community in general are health services that are available in the community and sustainable, health services must be reasonable and acceptable to the community, locations are easily accessible by the community, the services provided are affordable and the perfection of health services provided. With good service, it will attract people to use health facilities properly and wisely.

D. Patient Satisfaction at Dr. H. Moh. Anwar, General Hospital Sumenep Regency
The results showed that most of the respondents were satisfied as many as 65 respondents (59.6%). Meanwhile, 44 respondents (40.4%) said they were not satisfied.
Understanding the patient's needs and desires is an important factor affecting patient satisfaction. Satisfied patients are a very valuable asset because if patients are satisfied they will continue to use the service of their choice, but if patients are not satisfied they will tell twice as much to others about their bad experience. To create patient satisfaction, health facilities must create and manage a system to obtain more patients and the ability to retain patients (Hendawan, 2015).
Patients are sick people who are treated by doctors and other health workers in practice (Yuwono, 2017). While satisfaction is a person's feeling of pleasure that comes from a comparison between the pleasure of an activity and a product with his expectations (Nursalam, 2016). Nursalam (2016) states that satisfaction is a person's feeling of pleasure or disappointment that arises after comparing his perception or impression of the performance or results of a product and his expectations. Tjiptono (2014) argues that customer satisfaction is an emotional response to experiences related to certain purchased products or services, retail outlets, or even behavioral patterns (such as shopping behavior and buyer behavior), as well as the market as a whole.
According to Yamit (2017), customer satisfaction is the result (outcome) that is felt on the use of products and services, equals or exceeds the desired expectations. Meanwhile, Pohan (2014) states that patient satisfaction is the level of patient feelings that arise as a result of the performance of the health services he gets, after the patient compares with what he expects. Another opinion of Mamik (2015) that patient satisfaction is an evaluation or assessment after using a service, that the selected service at least meets or exceeds expectations.
According to Wijono (2014) several things that affect patient satisfaction are the approach and behavior of officers, especially at the time of the first visit, the quality of the information provided, the appointment procedure, waiting time, health checks and taking drugs, public facilities in health facilities and the results of the treatment received. . Patient satisfaction is a benchmark that the services provided by health workers are good or not. Patient satisfaction is influenced by various things, namely the suitability between patient expectations and the reality that patients encounter in the field, the second form of service during the service process is provided by health workers, personal behavior of health workers to patients, atmosphere and physical conditions of the environment that are managed. by hospital staff, fees or prices to be paid by patients and promotions or advertisements that are in accordance with reality.
From the results of the study, the researchers argue that the cause of most patients being satisfied with the services provided by health workers in Indonesia hospitalbecause health workers are able to serve patients very well, health workers hear patient complaints and respond to them do not distinguish between JKN and non-JKN patients. In addition, the facilities and infrastructure available athospital very complete and has a clean environment.

E. The Effect of Loyalty on the Quality of Outpatient Services at Dr. H. Moh. Anwar, General Hospital Sumenep Regency
Based on the results of the Linear Regression analysis of the family support variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly influence loyalty to the quality of outpatient services at General Hospital dr. H. Moh. Anwar, Sumenep Regency.
People as consumers certainly want quality services. Service quality is defined as the level of excellence expected and control over the level of excellence to meet customer desires (Dimas and Oktafani, 2014). Service quality can be interpreted as an effort to fulfill consumer needs and desires as well as the accuracy of delivery in balancing consumer expectations (Dimas and Oktafani, 2014).
Good services are health services that are available to the community (acceptable) and sustainable (sustainable). This means that all types of health services needed by the community are found and their presence in the community is available at any time of need. Health services must be reasonable (appropriate) and acceptable (acceptable) by the community. This means that health services can overcome the health problems faced, do not conflict with customs, culture, beliefs and beliefs of the community, and are unnatural, not a condition of good health services (Suryono, 2013).
The goals of outpatient services include providing consultation to patients who need the opinion of a specialist doctor, with treatment or not and to provide follow-up for inpatients who have been allowed to go home but their health condition still needs to be controlled. Outpatient should have a comfortable and pleasant environment for the patient. This is important to note because it is from outpatient treatment that patients get the first impression about the hospital. A good outpatient environment should be spacious enough and have good air circulation, comfortable seating, attractive furniture and no disturbing sounds.
According to the researcher, several things that must be improved are related to the patient's confidence in the abilities of health workers, where most of the respondents do not believe in the abilities of health workers. This is also because officers are considered slow in responding to complaints made by patients. This causes the services provided are less in line with patient expectations.

F. The Effect of Response Time on the Quality of Outpatient Services at Dr. H. Moh. Anwar, General Hospital Sumenep Regency
Based on the results of the Linear Regression analysis of the service quality variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly influence response timeon the quality of outpatient services at General Hospital dr. H. Moh. Anwar, Sumenep Regency.
Hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services. To be able to provide excellent service to patients, hospitals are required to have effective leadership. This effective leadership is determined by a positive synergy between hospital owners, hospital directors, hospital leaders, and heads of service unit work units. Hospital directors collaboratively operate hospitals together with leaders, heads of work units, and service units to achieve the set vision and mission and have responsibilities in managing quality improvement and patient safety, contract management, and resource management (KARS, 2017 ).
The quality of quality hospital services has always been a hope for every user of health services and along with the development of science and technology, people are increasingly critical in assessing health services. For this reason, hospitals must continue to improve the quality of services provided in accordance with the needs of health services and services related to patient needs, which are easily accessible, fast and accurate, quality services and of course at affordable costs (Bustami, 2011;Nursalam, 2011Nursalam, ). 2015.
One form of nursing services in order to improve service quality is to provide a higher sense of responsibility for nurses so that there is an increase in work performance and patient satisfaction. This nursing service will be more satisfying of course with the application of the professional nursing care model or MAKP because patient satisfaction is determined by one of them with optimal nursing services (Fisbach, 2011).
Health care standards are part of the health service itself and play an important role in overcoming the problem of the quality of health services. If a health care organization wants to provide quality health services in an obedient or consistent manner, this desire must be translated into a health service standard or operational procedural standard. Health service standards are an organizational tool to describe the quality of health services into operational terminology so that everyone involved in health services will be bound in a system, whether patients, health service providers, health care support, or the management of health service organizations, and will be responsible for accountability in carrying out their respective duties and roles (Imbalo, 2015).
According to researchers, patients expect the best service, but the best service is often used by many people, causing patients who seek treatment at that place to be willing to queue up to get the health services they want. With this tendency to wait in line, patients often feel bored and tend to judge that health workers do not understand patients. Moreover, due to the large number of queues, patients are less well served. So that patients tend to judge that the services of health workers are not in line with expectations.

G. The Effect of Loyalty through the Quality of Outpatient Services on Patient Satisfaction in Dr. H. Moh. Anwar, General Hospital Sumenep Regency
It is known that the direct influence given by loyalty to service quality is 0.533. While the indirect effect of loyalty through service quality on satisfaction is 0.120 x 0.667 = 0.080. Then the effect of total loyalty through service quality on satisfaction is 0.533 + 0.080 = 0.613. The total effect value is 0.613, so it can be concluded that there is an effect ofloyalty through the quality of outpatient services to patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency.
Health services are an important factor in improving the health and welfare of every human being throughout the world. According to Law No. 36 of article 19 of 2009 concerning health, explains that everyone has the right to obtain health services and the government is responsible for the availability of all forms of quality, safe, efficient, and affordable health efforts by all levels of society. One of these efforts is to increase the availability and equity of basic health facilities such as puskesmas in each region (Bappenas, 2013).
Service quality (service quality) can be known by comparing the perceptions of consumers on the services they receive with the services they actually expect on the service attributes of a company. Service quality is perceived as good and satisfactory if the service received or perceived is as expected, if the service received exceeds consumer expectations, then the service quality is perceived as very good and of high quality. Service quality is perceived as bad if the service received is lower than expected (Amrizal, 2014). The quality of health services refers to the level of perfection in the appearance of health services that can satisfy every user of health services in accordance with the level of satisfaction of the average population.
The researcher believes that understanding the patient's needs and desires is an important thing that affects patient satisfaction. Satisfied patients are a very valuable asset because if patients are satisfied they will continue to use the service of their choice, but if patients are not satisfied they will tell twice as much to others about their bad experience. To create patient satisfaction, hospitals must create and manage a system to obtain more patients and the ability to retain patients. With a good arrangement, the hospital can provide services with accurate time and able to provide good service even though there are very many patients who come.

H. The Effect of Response Time through the Quality of Outpatient Services on Patient Satisfaction in Dr. H. Moh. Anwar, General Hospital Sumenep Regency
It is known that the direct effect given by the response time on the quality of service is 0.582. While the indirect effectresponse timethrough service quality to satisfaction is 0.881 x 0.667 = 0.588. So the effect of total response time through service quality on satisfaction is 0.582 + 0.588 = 1.170. The total effect value is 1.170 so it can be concluded that there is an effect of response time through the quality of outpatient services on patient satisfaction in General Hospital dr. H. Moh. Anwar, Sumenep Regency.
A person's satisfaction with services is related to the ability of the service provider to provide satisfaction. Consumer satisfaction can be defined as big quality or broad quality (wide satisfaction). This broad satisfaction is related to the overall quality of service quality, financing, distribution channels, guarantee of safe use and aspects of employee morality/performance of a health service organization. Community satisfaction in utilizing outpatient services is influenced by several factors, including the response time of health workers to patients (Depkes RI, 2018).
Ambulatory service is one form of existing medical services. In simple terms, outpatient services are medical services provided to patients not in the form of inpatient care. In the sense of outpatient this includes not only those organized by service facilities that are commonly known such as hospitals, health centers or clinics, but also those held at the patient's home (Depkes RI, 2018).
The hospital in carrying out its function as a health-oriented development center, community empowerment center, primary community health service center, and primary individual health service center, the hospital is obliged to provide hospital mandatory health efforts and development health efforts, including: Health Promotion Efforts, Health Efforts Environment, Maternal and Child Health Efforts and Family Planning, Nutrition Improvement Efforts, Infectious Disease Prevention and Eradication Efforts, and Treatment Efforts (Ministry of Health RI, 2017).
Health care standards are part of the health service itself and play an important role in overcoming the problem of the quality of health services. If a health care organization wants to provide quality health services in an obedient or consistent manner, this desire must be translated into a health service standard or operational procedural standard. Health service standards are an organizational tool to describe the quality of health services into operational terminology so that everyone involved in health services will be bound in a system, whether patients, health service providers, health care support, or the management of health service organizations, and will be responsible for accountability in carrying out their respective duties and roles (Imbalo, 2015).
Response Time (response time) is a service standard that must be owned by a health service. The researcher also concludes that Response Time is an element of Responsiveness which is one of the factors of patient satisfaction at the hospital. The achievement of the standard Response Time of nurses in hospital services is influenced by the availability of infrastructure, human resources and a good hospital management system. With a good arrangement, the hospital can provide services with accurate time and able to provide good service even though there are very many patients who come. And can give satisfaction to every patient who comes.
Determinants that Influence the Quality of Outstanding Services.....