PATIENT SATISFACTION AND INTENTION TO REVISIT OUTPATIENT SPECIALIST CLINIC AT XYZ HOSPITAL, BEKASI CITY

: This research was done as a response to the discrepancy between the target and the actual revisitations to the specialized outpatient clinic at XYZ Hospital in Bekasi City, then hoping to improve revisit intention at XYZ Hospital in Bekasi City. Several theories suggest that an increase in patient satisfaction leads to an increase in revisit intention. Patient satisfaction itself is related to hospital's physical environment, registration service, waiting time, doctor service, and nurse service. The aim of this study is to find out the positive impact of those variable towards patient satisfaction and then revisit intention. The model used in this study was adapted from previous research that was empirically tested on the population of patients at the specialized outpatient clinic at XYZ Hospital in Bekasi City. This study is a quantitative cross-sectional study. A questionnaire, made from prior interviews, was used to gauge hospital's physical environment, registration service, waiting time, doctor service, and nurse service. Respondent data were collected using purposive sampling with a total of 400 respondents. The data were analyzed using the PLS-SEM method. The results of the study showed that the hospital's physical environment, registration service, waiting time, doctor service, and nurse service have a positive influence on patient satisfaction. In addition, patient satisfaction also has a positive influence on revisit intention. In conclusion, this study proved that hospital’s physical environment, registration service, waiting time, doctor service, and nurse service have a positive impact on patient satisfaction which in turn had a positive impact on patient’s revisit intention.


INTRODUCTION
Healthcare services are one of the fastest growing service sectors in both developed and developing countries.The main purpose of healthcare services is to help improve the quality of people's daily lives.Patients are the primary focus of the healthcare system, and they are considered as customers, whom have various expectations and demands.One way to determine the effectiveness of healthcare services is by measuring patient satisfaction.Good service quality can be identified by greater patient satisfaction.According to Oliver (2010), satisfaction from the consumer's perspective is essential.From a marketing perspective, satisfaction can increase patient visits.Satisfied patients will be loyal, willing to revisit and recommend the service to others, which will increase patient visits.
There is a discrepancy between the target and actual number of visits for each month in the outpatient specialist clinic at XYZ Hospital in Bekasi City, based on the data of January-December 2021.The average total achievement is only 43% of the 100% target, indicating that the target was not met each month.The target number of visits set by XYZ Hospital in Bekasi City is the result of calculating 20% of the total revenue in 2020, which is then accumulated to determine the total number of visits that each specialist must achieve.The monthly targets vary because they are calculated based on the number of days in each month and adjusted according to the days when the specialists are available for consultations, as they may not be present every day.Due to this phenomenon, there is a need for management research at XYZ Hospital in Bekasi City to assess patient satisfaction to ensure the creation of revisit intention (return visits by patients).This is necessary to address the gap between the total visits and the target visits for the Specialist Clinic at XYZ Hospital in Bekasi City during the period from January to December 2021.Then an interview was conducted to 30 patients that are currently waiting for the specialized outpatient clinic at that time.The interview was made to find out what affected the decision to revisit a certain hospital.Thus, there is a need for management research in Private Hospital X in Bekasi to assess patient satisfaction and create revisit intentions, as there is a gap between the total and target visitation in the outpatient specialist clinic during the period of January-December 2021.
The relationship between patient satisfaction and the increase in revisit intention has been proven by several previous studies, such as Wandebori (2017) and Woo and Choi (2021).Based on this explanation, the aim of this study is to confirm the positive influence provided by doctor and nurse services, waiting time on patient satisfaction, and the influence of patient satisfaction on the intention to revisit outpatient patients.However, in the conceptual framework of Wandebori (2017) and Woo and Choi (2021), waiting time and registration service have not been given a role as other variables that affect patient satisfaction.Based on the conceptual framework by Hussain et al. (2019), this study's position is to conduct development by placing waiting time and registration service as variables that strengthen patient satisfaction.In addition, this study aims to prove the individual behavior resulting from patient satisfaction, namely the increase in revisit intention and to find out the positive impact of those variable towards patient satisfaction and then revisit intention.The expected results are as follows, all the hypothesis was accepted, and we found out there is a positive connection between patient satisfaction and revisit intention.
The problem formulation arises from the observed phenomenon of the unachieved target for specialist outpatient clinic visits at XYZ Hospital in Bekasi City during the period from January to December 2021.To address this issue, the researcher conducted a survey to identify the independent variables for the study.Consequently, the following research questions were formulated: Firstly, does the physical environment have a positive influence on patient satisfaction?Secondly, does the registration service significantly impact patient satisfaction?Thirdly, what is the effect of waiting time on patient satisfaction?Fourthly, does the doctor service play a role in influencing patient satisfaction?Fifthly, to what extent does the nurse service affect patient satisfaction?Lastly, does patient satisfaction exhibit a positive influence on revisit intention?These research questions aim to explore the interrelationships between the hospital's physical environment, registration service, waiting time, doctor service, nurse service, patient satisfaction, and revisit intention.Through the investigation and answering of these questions, this study seeks to shed light on the factors that contribute to patient satisfaction and their intention to revisit the hospital for specialized outpatient care, thereby providing valuable insights for potential improvements in the hospital's services.
patients expect administrative procedures that are easy to understand and not overly complicated when receiving care in hospitals.Research also indicates that complex administrative procedures can lead to disappointment and dissatisfaction among patients.Therefore, the quality of hospital administrative procedures has become an important indicator of service quality that must be improved to enhance patient satisfaction.This means that the efficiency and effectiveness of the registration service can influence the level of satisfaction that patients experience when receiving care in hospitals.By streamlining administrative procedures and ensuring that patients receive a smooth and hasslefree registration process, hospitals can improve patient satisfaction and ultimately enhance the overall quality of their services.Hussain et al. (2019) argue that waiting for medical treatment can be a crucial issue for patients.The time spent on administrative procedures and medical treatment, such as admission, discharge, and doctorpatient meetings in outpatient clinics, can play a role in influencing patient satisfaction.Delayed treatment of patients can often lead to dissatisfaction and even anger.Several studies have shown that patient wait time is associated with varying levels of patient dissatisfaction (Bar-Dayan et al. 2002;Camacho et al. 2006).Strategies to reduce wait time and improve patient satisfaction with care include improving scheduling systems and better workforce management.This means that reducing patient wait time can positively impact their overall satisfaction with the healthcare experience.By improving processes and optimizing resources, healthcare organizations can work to minimize wait times and enhance patient satisfaction.Kreps et al. (2001) argue that effective communication between doctors and patients is essential to achieving shared decision-making and ensuring effective healthcare services.Reliability and communication by doctors enhance patient satisfaction and the value of services.From research conducted by Chang et al. (2013) and Al-Abri et al. (2014), factors such as the quality-of-care patients receive and their overall satisfaction with the healthcare system are essential to the patient satisfaction.Doctor service refers to how patients evaluate the quality of services provided by a doctor directly.Patient satisfaction can be influenced by the quality of the relationship between the patient and the doctor, which requires special attention.To create a good relationship between patients and doctors, The purpose of this study is to answer the research questions mentioned above, which involve several key aspects of the hospital experience.Firstly, the study aims to test and analyse the positive influence of the hospital's physical environment on patient satisfaction.Secondly, it seeks to examine the impact of registration service on patient satisfaction.Thirdly, the study investigates the effect of waiting time on patient satisfaction.Additionally, the research evaluates the positive influence of doctor service and nurse service on patient satisfaction as separate factors.Furthermore, the study explores the link between patient satisfaction and their intention to revisit the hospital for future healthcare needs.By delving into these interconnected aspects, the research aims to provide valuable insights into the factors that contribute to patient satisfaction and how it, in turn, affects patients' willingness to return to the hospital.Understanding these relationships can potentially lead to improvements in various hospital services and ultimately enhance the overall patient experience in healthcare settings.

METHODS
In this study, the researchers used items from previous research on patient satisfaction and revisit intention, with some minor modifications.These items were adopted from various sources, including Woo and Choi (2021), Xie and Or (2017), Frichi et al. (2020), andStorm-Versloot et al. (2014).The data being collected using a standardized questionnaire is a quantitative data.Previous studies have shown that positive experiences with medical staff are closely related to patients' subjective evaluations of the quality of healthcare they receive during their hospital stay (Goel, 2014).Hospital facilities appear to be an area that needs more attention in efforts to improve patient satisfaction, in line with findings elsewhere (Grogan, 2000).It has been proposed that because patients cannot distinguish positive experiences with the physical environment from positive experiences with care, improving hospital environments focusing on patients with features such as noise reduction, increased natural light, visitor-friendly facilities, and well-decorated rooms can improve patient satisfaction (Siddiqui et al. 2015).Studer (2003) argues that organizations should learn from patient experiences to improve the quality of their services.This involves collecting information on staff performance and generating ideas for improving administrative procedures and services.In addition, indicated by multiple indicators, making it a powerful tool for this study.The analysis was conducted using 5,000 bootstrap subsamples to determine the statistical significance of the final results using path coefficients, Cronbach's alpha, Fornell-Lacker Criterion, and R-square values.The outer loading value was used to express the correlation between latent variables and their indicators.All indicators had an outer loading value greater than 0.7, indicating their contribution to defining their latent variable.The study concluded that all constructs were reliable and valid based on Cronbach's alpha, composite reliability, and AVE score.VIF was used to assess collinearity.R-square and Q-square were calculated to evaluate the model's ability to predict.
The hypothesis testing presented in Figure 1

Respondent Profile
In Table 1, it can be observed that the number of male respondents is smaller compared to females, with percentages of 44% and 56% respectively.Based on the gender data of the respondents, it can be concluded that the majority are females.Most respondents based on age fall within the 20-29 years range (46.3%), followed by the 30-39 years group (26%), then 40-49 years (15.3%),>50 years (6.5%), and the smallest group is <20 years (6.0%).In terms of educational level, the largest portion of respondents have a bachelor's degree (57.5%), followed by high school (18.5%), diploma (11.5%),Master's/Ph.D. (10.3%), and others (2.3%).Under the category of "others," there were respondents who had not attended school, completed primary school, and junior high school.
effective and accurate communication is crucial, including providing information about the patient's health condition (Hussain et al. 2019).In conclusion, effective communication and a good relationship between patients and doctors are essential for enhancing patient satisfaction and ensuring the value of healthcare services.A doctor's service quality is a significant factor in determining patient satisfaction, and addressing issues such as waiting time and administrative procedures can also improve patient satisfaction.
Satisfying healthcare service quality is an important factor in determining patient revisit intention.Kim et al. (2008) showed that the value of care has a significant influence on patient satisfaction and revisit intention at the hospital.Patient subjective evaluations are important criteria for evaluating healthcare service quality.Patient satisfaction can affect hospital profitability because it can trigger patient revisit intention.Revisit intention is defined as a patient's willingness to make repeated visits to the same hospital and is influenced by patient satisfaction with previous services.Therefore, it is important for management to pay attention to patient satisfaction in improving healthcare service quality and cultivating revisit intention.
The data for the study was collected through a two-part structured questionnaire.Part A contained demographic information, while Part B consisted of previously validated questions on various components.The responses to the questionnaire items were measured on a 5-point Likert scale, with options ranging from "strongly disagree" to "strongly agree".The study used a cross-sectional design with a non-probability sampling, purposive sampling.The inclusion criteria were outpatients of the specialist clinic at RS XYZ in Bekasi City who used non-BPJS or non-public insurance or corporate insurance and came for treatment with new complaints for the first time between March 27th and May 12th, 2023.The sample size for the study was calculated using the Cochrain formula (Sugiono, 2018) with a 95% confidence level and a margin of error of 5%.The minimum sample required was 384, but the study rounded up the sample size to 400.
The researchers utilized SEM in SmartPLS 4.0.9.2 software to analyze the data collected from the surveys.SEM is a statistical technique that is widely used for testing complex theories with empirical data.It can examine relationships between latent constructs

Measurement Model
The assessment of the measurement model focuses on the validity and reliability of construct measurements.The evaluation of validity includes convergent validity, which involves assessing reliability indicators and average variance extracted (AVE), as well as discriminant validity.According to Hair et al. (2018), a general guideline for reliability or outer loading indicators is that the outer loading value should be 0.708 or higher, and the AVE value should be 0.5 or higher.Additionally, internal consistency measurements were conducted by considering composite reliability.Hair et al. (2018) determined that the composite reliability value should be at least 0.7.
The outer loading values range from 0.653 to 0.910.However, according to Hair et al. (2018), items with outer loading values between 0.4 and 0.7 may be considered for deletion if their removal can increase the AVE value above 0.5.There are some items with outer loading values between 0,5 and 0.6 that were not deleted because in the following Table 2 AVE value exceeded 0.5.Additionally, the results of the composite reliability measurement for each construct in the following Table 3 ranging from 0.883 to 0.927, surpass the minimum requirement of 0.7.
The following Table 4 reveals the results of the discriminant validity measurement using the Fornell-Lacker Criterion approach.The correlation values between a variable and itself are higher than the correlations between variables.Additionally, the square root of Average Variance Extracted (AVE) values is greater than the correlations between constructs, indicating that the discriminant validity of all variables has been fulfilled.Table 5 provides an explanation of the collinearity between variables, and collinearity testing is useful in minimizing bias in research results.VIF values ranging from 5 to 10 indicate that the indicators have collinearity issues.The ideal VIF value is recommended to be less than 3.Here is the classification of VIF criteria according to Hair et al. (2018).In this study, it was found that all variables have VIF values less than 3. Therefore, it can be concluded that there is no multicollinearity issue in this study, and the independent variables are not correlated with each other.

Structural Model
In the inner model or structural model, the study examines the results of data collinearity statistics (VIF), the size and the coefficient of determination (R2), predictive relevance with Q square (Q2), f2 effect size and significance of path coefficients.Multicollinearity test is conducted to identify whether there is a linear relationship among the indicators used in the Partial Least Squares (PLS) model.Multicollinearity test can be detected using Variance Inflation Factor (VIF) as an evaluation method.In following Table 6 shows that Patient Satisfaction construct has a coefficient of determination (R2) of 0.710 and Revisit Intention construct construct has a coefficient of determination (R2) of 0.766.Hair et al. (2018) determined that the R2 values were 0.75, 0.50, and 0.25, respectively, in the substantial, moderate, and weak categories.In this study, the R2 satisfaction Patient Satisfaction construct was categorized as moderate.Meanwhile, the R2 of the 0.766 Revisit Intentionconstruct is in the Strong category.After evaluating the values of all endogenous constructs, if a model removes a specific exogenous construct, it can be used to evaluate the extent to which the removed construct influences the endogenous constructs.The measure used to describe the substantive impact of that construct is called effect size (f2) (Hair et al. 2018).Cohen (1988) classifies the size of into three categories: small (0.02), medium (0.15), and large (0.35) (Table 7).
The evaluation of the PLS model is also done using predictive relevance, which synthesizes cross-validation and fitting functions with predictions from observed variables and parameter estimates of the constructs.A higher value indicates a higher level of prediction accuracy.For specific endogenous constructs in the structural model, the value of Q2 should be greater than 0 to indicate good prediction accuracy (Table 8).Q2 values higher than 0, 0.25, and 0.50 depict small, medium, and large (Hair et al. 2018).
The analysis of the inner model in this study focuses on observing the significance values and coefficients in the relationships between variables present in the research model.The purpose of this significance test is to determine whether there is a significant influence between variables in the research model that can be generalized to the population level.Hair et al. (2018) explain that a hypothesis can be considered supported if its p-value is less than 0,05, assuming a significance level of 5%.
Based on the results from Table 9, it can be concluded that the influence of the Physical Environment variable on Patient Satisfaction is significant and positive.This can be seen from the p-value that is smaller than α (0.005 < 0.05).Therefore, it can be inferred that the Physical Environment variable has a positive and significant effect on the improvement of Patient Satisfaction.
Similarly, the influence of the Registration Service variable on Patient Satisfaction is also significant and positive.This can be observed from the p-value that is smaller than α (0.037 < 0.05).As a result, it can be concluded that the Registration Service variable has a positive and significant impact on the improvement of Patient Satisfaction.Furthermore, the influence of the Waiting Time variable on Patient Satisfaction is also significant and positive.This is evident from the p-value that is smaller than α (0.013 < 0.05).Therefore, it can be concluded that the Waiting Time variable has a positive and significant effect on the improvement of Patient Satisfaction.
Next, the influence of the Doctor Service variable on Patient Satisfaction is also significant and positive.This can be seen from the p-value that is smaller than α (0.000 < 0.05).As a result, it can be concluded that the Doctor Service variable has a positive and significant impact on the improvement of Patient Satisfaction.
Similarly, the influence of the Nurse Service variable on Patient Satisfaction is also significant and positive.This can be observed from the p-value that is smaller than α (0.000 < 0.05).Therefore, it can be concluded that the Nurse Service variable has a positive and significant effect on the improvement of Patient Satisfaction.Furthermore, the influence of the Patient Satisfaction variable on the Revisit Intention variable is also significant and positive.This can be seen from the p-value that is smaller than α (0.000 < 0.05).As a result, it can be concluded that the Patient Satisfaction variable has a positive and significant impact on the improvement of the Revisit Intention variable.as "keep up the good work."These variables need to be attended to and maintained to continue providing satisfactory performance.
The independent variables located in the low-low quadrant are considered unimportant and have poor performance.They can be categorized as "low priority."These variables can be ignored as they have low actual performance and are not highly expected by patients or customers.The independent variables located in the high-low quadrant are considered important but have unsatisfactory performance.They can be categorized as "Concentrate here."These variables require improvement to achieve the desired performance.The independent variables located in the low-high quadrant, or "Possible overkill," are considered unimportant but perform well.These variables may not require much further attention (Martilla & James, 1977).Based on the average indicators of variable importance (x) and performance (y) obtained in this study (0.736 and 72.354, respectively), the four quadrants can be determined using these coordinate values.However, it's important to note that the specific thresholds or criteria for defining the quadrants may vary depending on the context and specific requirements of the analysis.

Importance-Performance Map Analysis (IPMA)
The PLS-SEM analysis presents information about the relative importance of constructs in explaining other constructs within the context of the structural model.
Understanding the importance of these constructs is highly relevant for drawing conclusions from the findings.To extend the results of the PLS-SEM analysis, an Importance-Performance Map (IPM) is used, which considers the performance of each construct and its indicators.Accurately determining the Importance-Performance Map (IPM) has significant managerial implications as it can help guide strategies related to latent constructs or indicators.In this study, the IPMA utilized is unstandardized effects because it provides a ceteris paribus interpretation of the predecessor constructs on the target construct (Hair et al. 2018;Utami et al. 2022).
The Importance-Performance Map (IPM) is used to depict the performance or effectiveness of independent variables and their importance in influencing the dependent variable.In the IPMA, independent variables are placed on the X-axis (horizontal) and the dependent variable is placed on the Y-axis (vertical).Then, each independent variable is evaluated based on two dimensions: performance and importance.The IPM graph consists of four quadrants: high-high, lowlow, high-low, and low-high.The independent variables located in the high-high quadrant are considered important and perform well.They can be categorized In Figure 2

Conclusions
This study proved that hospital's physical environment, registration service, waiting time, doctor service, and nurse service have a positive impact on patient satisfaction.Patient satisfaction then in turn proven to have a positive impact on patient's revisit intention.These results may in turn be used by XYZ Hospital as a turning point for developing healthcare electronic application to be used inside the hospital.These results also shows that the model being demonstrated in this study is valid.

Recommendations
The suggestion for the next study is to use guided questionnaire for middle aged patients that cannot filled google form on their own.This study also used nonprobability sampling that may not fully represents the target population.

Managerial Implication
The findings of this study can be beneficial for XYZ Hospital in Bekasi to improve revisit intention and increase the number of visits to the specialist outpatient clinic.Based on the analysis of the importanceperformance map, it can be concluded that the performance of nurses in providing information to patients and the management's efforts to encourage patients to recommend XYZ Hospital in Bekasi need to be enhanced.Efforts can be made by providing communication training to the nurses in XYZ Hospital's specialist outpatient clinic, enabling them to actively communicate and provide information to patients.Additionally, all employees, including administrative staff, nurses, and doctors, can be encouraged to promote XYZ Hospital in Bekasi to patients as their preferred choice for medical treatment.
Certain aspects of service that have been deemed good by patients in XYZ Hospital's specialist outpatient clinic and need to be maintained include appropriate pricing for the services provided, satisfaction with consultation outcomes with doctors, Patient satisfaction with the decision to seek treatment at the specialist clinic of XYZ Hospital in Bekasi City, courteous behavior of nurses, and comfortable communication with nurses.
Based on the findings from the Inner Model, the highest value in the standardized path coefficient was found in doctor service, followed by nurse service in relation to patient satisfaction.
Based on these findings, a recommendation is made for the management of XYZ Hospital in Bekasi to focus on these two aspects with the aim of improving patient satisfaction.By increasing patient satisfaction, it is hoped that it will encourage patient loyalty.This will influence the patients' desire to revisit and recommend the services provided to them, ultimately leading to an increase in the number of patient visits.Overall, this study provides recommendations to the management of XYZ Hospital in Bekasi to improve the performance and service quality of doctors, as well as to pay special attention to the quality of nursing services, particularly in terms of informative communication.By making improvements in these areas, it is hoped that patient satisfaction, revisit intention, and the number of visits to the outpatient specialist clinic in XYZ Hospital in Bekasi can be increased.
, which captures the research framework, can be summarized as follows: H1: The physical environment has a positive influence on patient satisfaction.H2: Registration service has a positive influence on patient satisfaction.H3: Waiting time has a positive influence on patient satisfaction.H4: Doctor service has a positive influence on patient satisfaction.H5: Nurse service has a positive influence on patient satisfaction.H6: Patient satisfaction has a positive influence on revisit intention.

Figure 1 .
Figure 1.The research framework Figure 2. Importance-Performance Map target construct revisit intention

Table 1 .
Demographic characteristics of the respondents

Table 2 .
Result of convergent validity

Table 5 .
Result of inner VIF value

Table 7 .
Result of f 2 (effect size)

Table 8 .
Result of Q 2 (Predictive Relevance)Using the given averages, we can divide the quadrants as follows in Figure2: 1. High-High (Keep up the good work): Variables with both high importance (x > 0.736) and high performance (y > 72.354) would fall into this quadrant.These variables are considered important and exhibit good performance.2. Low-Low (Low priority): Variables with both low importance (x < 0.736) and low performance (y < 72.354) would be classified into this quadrant.These variables are deemed unimportant and have poor performance.3. High-Low (Concentrate here): Variables with high importance (x > 0.736) but low performance (y < 72.354) would be placed in this quadrant.These variables are considered important, but improvements are needed to achieve satisfactory performance.
Quadrant II (Low-High or "Possible Overkill"): In this quadrant, indicators with low importance but high performance are identified.Taking three examples from this quadrant, we have PE6 "The lighting in the waiting area of the specialist department is good," PE1 "The hospital's restroom is clean," and PE5 "The hospital corridors are clean."Indicators in this quadrant indicate that they are not highly important but perform well.4. Low-High (Possible overkill): Variables with low importance (x < 0.736) but high performance (y > 72.354) would fall into this quadrant.These variables may be performing well, but they are not considered important and may not require significant further attention.