PATIENT SATISFACTION ANALYSIS BASED ON SERVICE QUALITY ASSESSMENT AND TRUST IN HEALTH FACILITIES

Health centers have an important role to provide the best service to the community. One of the problems in the outpatient installation of the Tambelangan Health Center is the decrease in the number of patient visits. It is necessary to evaluate the quality of service so that patients put their trust and then reuse the service until they feel satisfied. The purpose of this study was to analyze the effect of service quality and trust on patient satisfaction. This research is included in the type of analytic observational using a cross-sectional approach. The sample size is 100 patients who seek treatment at the outpatient installation of the Tambelangan Health Center. The sampling technique was carried out by systematic random sampling. Data were obtained directly through the perception of the patient's assessment of the perceived service quality, their trust in the facilities and services received and including the satisfaction that the patient felt through the questionnaire instrument. The data obtained were then analyzed using binary logistic regression. The results showed that all patients (86%) stated that the overall dimensions of service quality were good, and almost all patients (81%) stated that they had believed and almost all respondents (84%) stated that they were satisfied with the service at the Outpatient Installation of the Tambelangan Health Center. Furthermore, service quality has a significant effect on patient satisfaction (p-value = 0.022) and trust has a significant effect on patient satisfaction (p-value = 0.006). The conclusion of the study shows that service quality and trust can affect patient satisfaction.


Introduction
Patient satisfaction is one indicator of the quality of services we provide and patient satisfaction is a capital to get more patients and to get loyal patients (Nursalam, 2014). Loyal patients will reuse the same health services when they need them again. It is even known that loyal patients will invite others to use the same health care facility. Yunus, et al. (2009) stated that services that are deemed unsatisfactory can lead to reduced customers or even loss because customers move to other services, so there is not the slightest doubt about the importance of quality service as the ultimate goal of service providers (Yunus, et al, 2020). Public Health Center provide services to the public by existing regulations. The service in question is an activity of direct interaction between a person and another person and provides customer satisfaction. Therefore, it cannot be denied that the quality of service is important.
Good service quality in five dimensions of SERVQUAL, namely: Tangibles, Reliability, Responsiveness, Assurance and Empathy (Kotler, 2010). Customer satisfaction will appear if the quality of service is good. Another factor that can affect the level of patient satisfaction is patient trust. Customer trust will arise because there is a belief that the parties involved in the exchange will provide consistent, honest, and responsible quality (Akbar & Noorjahan, 2009). Therefore, Public Health Center must start thinking about the importance of service to customers more maturely through service quality (Amelia, 2018).
The problem raised in this study is that one element of service at the Public Health Center, namely product specifications for the type of health service, gets a bad score when measuring the customer satisfaction index. Product specifications for the type of health service are the speed of officers in providing services to outpatients, and patient satisfaction in visits and repeat visits at the outpatient installation of the Tambelangan Health Center, Sampang (Kelmanutu, 2017); (Setiawan, 2019).
Based on the above background, the evaluation of service quality, trust instilled in patients and patient satisfaction is very necessary for Public Health Center to improve the quality of health services provided. If patients are not satisfied with health services, it can reduce trust with health service providers. Therefore, there is an evaluation related to the quality of service and trust in patient satisfaction so that it is by what the patient expects. The purpose of this study was to analyze the effect of service quality and trust on patient satisfaction.

Method
This research is included in the type of analytic observational, using a cross-sectional approach. The research location is in the Outpatient Installation of the Tambelangan Health Center, Sampang. The variables studied included service quality and trust and patient satisfaction. The quality of service studied includes the dimensions of Tangible, Reliability, Responsiveness, Assurance and Empathy (Li et al., 2018); (Munusamy, et al., 2010). The patient's trust studied includes the dimensions of Benevolence, Ability, and Integrity (Joseph & Rofiq, 2010). Meanwhile, patient satisfaction assessed includes the suitability of expectations, ease of obtaining services, and willingness to recommend to others (Hawkin & Lonney, 2010).
The population in this study were all patients who seek treatment at the Outpatient Installation. The sample in this study was 100 patients. Sampling in this study was carried out systematically random (Systematic Random Sampling). The primary data in this study were obtained using a questionnaire sheet, for the service quality variable with 24 statements, trust with 9 statements and patient satisfaction with 9 statements. Secondary data in this study was obtained from the Tambelangan Health Center in the form of patient satisfaction index data.
The questionnaire was tested for validity and reliability first. The data from the research were then tested descriptively using cross-tabulation and reading aids using the Pareto 80:20 concept. This means that descriptively, each indicator with a percentage value of >= 80% is included in the good category, and indicators with a percentage value of <= 80% are included in the poor category. Meanwhile, inferential analysis will show that there is an effect if the difference from the calculation of the percentage > 20% of each category on the service quality variable and trust on patient satisfaction occurs. In addition, the data will also be statistically analyzed to assess whether the effect is significant or not by using a binary logistic regression test.

Characteristics of Respondents
The characteristics of respondents in this study include gender, age, education, and occupation. Here are the full results. Respondents who are currently using health services at the Tambelangan Health Center have various individual characteristics. Based on these characters, respondents will have a variety of perceptions in assessing the quality of services provided by these health care facilities. According to Robbins (2009), individual characteristics can be seen from age, gender and education level (Robbins, 2001).
Based on Table 1 above, it can be informed that most of the respondents (52%) are male. a small proportion of respondents (24%) are in the range of 14-23 years or fall into the category of late adolescence (Depkes, 2009). This age group is the largest compared to other age groups. In addition, information was obtained that almost half of the respondents (39%) only received a basic education. Based on occupation, almost half of the respondents (47%) have jobs as farm workers and the least is as housewives (31%).

Service quality
Service quality consists of five dimensions, namely: Tangibles, Reliability, Responsiveness, Assurance and Empathy (Kotler, 2010). The results of respondents' assessment of service quality are presented in table 2 below. Based on the results of the study in Table 2, it can be informed that that most of the respondents (64%) stated that the overall dimensions of service quality in the aggregate were appropriate in the Outpatient Installation of the Tambelangan Health Center. If observed in detail, the management of the Public Health Center should make improvements to the tangible dimension so that the quality of service can gradually improve. Improvements that must be made are to increase comfort in the waiting room and registration room. Improvements in the reliability dimension also need to be made, namely the timeliness of doctors to examine patients does not match the specified time, registration officers and cashiers serve less quickly, so respondents wait too long. Although the assurance dimension looks good, there need to be improvements in the service, namely increasing the responsiveness or response of the staff when the patient comes.
In research on the quality of service at the Tambelangan Health Center, which includes the dimensions of tangible, reliability, responsiveness, assurance, empathy (Jumiani, et al., 2018), overall dimensions of service quality show in good condition. In Pareto principle, it can be seen that the overall dimensions of service quality in the aggregate are considered good because of the Pareto value above (>80%) so that the overall dimensions of the respondent's health service quality need to be maintained or improved by the management of the Tambelangan Health Center. However, it is still necessary to pay attention to small things and also make improvements immediately if there are complaints from patients. This strategy is an early prevention effort so that other problems do not arise so that it has an impact on decreasing patient satisfaction. This is an effect that the quality of service when it becomes bad will be able to affect patient satisfaction so that they refuse to use health services (Lestari & Hasanah, 2019;Sofia, 2015;Tores, 2015;Nanda, 2018;Aini, 2019;Ramadhan, Rahmiati and Maulana, 2019). Generally, a person will view a health facility initially from its physical condition. With a clean, neat and orderly physical condition. Patients will suspect that the health facility will carry out its functions properly.
The quality of service in the service sector is the service provided to the recipient of the service that will exceed the level of importance (Darmawansyah, et al., 2019). This emphasizes more on the advantages of the level of consumer interest as the core of service quality (Renjani, 2010). The existence of adequate service quality and by one's expectations will have an impact on achieving one's level of satisfaction (Masruri, 2014). Quality of service is very important for the health of patients.

Trust
Mula & Rofiq (2010) state that three factors shape a person's trust in a company's brand, namely Benevolence, Ability, and Integrity. The results of respondents' assessment of trust are presented in table 3 below (Mula & Rofiq, 2010). Based on the results of the study in Table 3, it can be informed that that most of the respondents (75%) stated that they believed, according to all indicators, in the Outpatient Installation of the Tambelangan Health Center. If observed in detail, then the management of the Public Health Center should make service improvements. In the dimension of benevolence, there is still an expression that Public Health Center do not always provide care to respondents who do not have the cost for treatment. Haekal & Widjajanta (2016) stated that the benevolence dimension is the ability of Public Health Center to provide mutually beneficial satisfaction between Public Health Center and patients. In general, the majority of patients believe in the kindness of the Public Health Center to patients who do not have the funds, so the trust of the respondents needs to be maintained or increased by the management of the Tambelangan Health Center (Haekal & Widjajanta, 2016).
In the dimension of ability, there is still an expression that outpatient installations do not always serve patients for 8 hours, and do not have adequate medical equipment. Dimensional ability refers to the competition and characteristics of Public Health Center in influencing patients to obtain guaranteed patient satisfaction and comfort during treatment at the Outpatient Installation so that health workers must be on standby during their working hours at the Tambelangan Health Center (Haekal & Widjajanta, 2016).
Meanwhile, in the dimension of integrity, there is still an expression that Public Health Center may commit malpractice when providing care or treatment services. The integrity dimension relates to how the behaviour of the officers who foster respondents' trust in the Public Health Center and Public Health Center can create a sense of security and comfort so that respondents who seek treatment at the Tambelangan Health Center's Outpatient Installation feel trust in patient satisfaction (Haekal & Widjajanta, 2016).
Trust has three dimensions, namely benevolence, integrity and ability (Nusiana, 2019). Positive trust will cause outpatients at the Tambelangan Health Center to be satisfied with the services of health workers. According to the Pareto principle, it can be seen that the overall trust in the aggregate is considered to have trusted because of the Pareto value mentioned above (>80%) so that the respondent's trust needs to be maintained or increased by the management of the Tambelangan Health Center. Trust can encourage the intention to buy or use the product by eliminating the doubts that the patient has been feeling (Aryani, 2010). Trust will always make customers remember repeatedly the services that have been provided by employees (Aini & Andari, 2016).

Patient Satisfaction
According to Hawkin & Lonney (2001), indicators forming customer satisfaction consist of conformity to expectations, ease of obtaining, and willingness to recommend to others. The results of the respondent's assessment of the level of satisfaction felt from the use of health services at the Public Health Center are presented in table 4 below (Hawkin & Lonney, 2010). Based on the results of the study in Table 4, it can be informed that that most of the respondents (73%) stated that they were satisfied, according to all indicators, with the Outpatient Installation of the Tambelangan Health Center. If observed in detail, then the management of the Public Health Center should make service improvements. In the aspect of convenience, respondents are still not satisfied with the administrative process which is not always easy and fast, thus making respondents wait for quite a long time. In terms of willingness to recommend, many patients are still dissatisfied as a result of poor service, plus the lack of facilities (outpatient rooms are not clean, toilets are not clean) and comfort in the waiting room (Darus, et al., 2018).
Assessment of patient satisfaction has three dimensions of satisfaction, namely the dimensions of conformity to expectations, ease of obtaining and dimensions of willingness to recommend. The results of the study generally show that the overall satisfaction dimension has been satisfied (Natassa, 2015). In the Pareto principle, it can be seen that the overall dimension of satisfaction in the aggregate is considered satisfied, because of the Pareto value mentioned above (>80%), so that the overall dimension of respondent satisfaction needs to be maintained or improved by the management of the Tambelangan Health Center. Aini & Andari (2016) stated that Public Health Center that do not provide services to patients will result in patient dissatisfaction when seeking treatment at the Public Health Center (Rizal, et al., 2017).

Quality of Service and Trust in Patient Satisfaction
The results of the assessment regarding the analysis of service quality and trust in patient satisfaction are presented in table 5, table 6 and  table 7.  Table 5 above shows that service quality and trust can be concluded together can affect patient satisfaction by 18.4%. When observed partially, each variable can significantly affect patient satisfaction (quality of service, p-value = 0.022 and trust, p-value = 0.006). Odds Ratio can be informed if the quality of service is getting better, then the patient will tend to be satisfied by 4.992 times compared to if the service quality is not good. As for trust, if the patient puts trust in the health center, the patient will tend to be satisfied by 5.736 times compared to patients who do not trust the health center. In more detail, each variable of service quality and trust in patient satisfaction can be seen in Table 5 and  Table 6 below. Based on Table 6, it can be informed that almost all respondents stated that the quality of service was good and satisfied at the Outpatient Installation of the Tambelangan Health Center (87.2%). Respondents at the Tambelangan Health Center Outpatient Installation were mostly satisfied because the quality of health services provided was good. The OR value indicates that if the quality of service provided is getting better, then it is likely that patient satisfaction will increase to 4.992 times compared to if the quality of service is not good.
The services provided by the Tambelangan Health Center are a very important factor as a basis for patients to take advantage of the services of the Public Health Center. Service quality is very important in today's highly competitive market competition (Adhi & Ernawati, 2012). Perceptions of good service quality will result in the emergence of customer satisfaction. Therefore, the better the quality of services provided by the Tambelangan Health Center; the more patients will feel satisfaction in utilizing existing services.
The results of the cross-tabulation are also statistically supported based on the fisher's exact test parameter which obtained a significance value of 0.046 (<0.05). These results conclude that statistically also shows there is a significant relationship between service quality and patient satisfaction at the Outpatient Installation of the Tambelangan Health Center. The strength of the relationship between variables can be seen in the Phi correlation value of 0.217 which means that there is a weak relationship between service quality and patient satisfaction at the Tambelangan Health Center Outpatient Installation. This means that the higher the quality of service, the higher the level of satisfaction of outpatients at the Tambelangan Health Center, on the other hand, the lower the quality of service, the lower the level of satisfaction of outpatients at the Tambelangan Health Center. Complementing the previous regression results, that if the independent variable has a strong relationship to the dependent variable, then the independent variable will also affect the dependent variable. Therefore, there is a strong relationship between service quality and patient satisfaction, so service quality will influence patient satisfaction.
The results of this study are in line with the research of Natassa (2015) which states that there is a significant influence between service quality and patient satisfaction. The results of this study are in line with the research of Aini & Andari (2016) at the Desa Pasir Utama Health Center which states that there is a significant influence between service quality and patient satisfaction. In addition, it is also in line with the research of Darus, et al. (2018) at the Dinoyo Health Center in Malang City which states that there is a significant influence between service quality and patient satisfaction (Darus, et al., 2018). The results of this study are also by the research of Rosiana Rizal, Muslim Suardi, and Yulihasri (2017) which states that service quality affects patient satisfaction (Rizal, et al., 2017;Novita, Erpidawati & Susanti, 2019;Ramadhan, et al., 2019;Adriansyah et al., 2020). Based on Table 7, it can be informed that almost all respondents stated that they believed and were satisfied with the Outpatient Installation of the Tambelangan Health Center (88.9%). This shows that the more a patient trusts in the services provided by the Health Center, the patient will give a satisfying response to the services he feels. The OR value indicates that if the patient puts trust in the Health Center, the patient will tend to be satisfied by 5.376 times compared to patients who do not trust the Health Center.
Trust is directly related to the patient's perception of the reputation of the Public Health Center. If the patient gets a service product that is in line with expectations, a pleasant service, the benefits of the service product can be felt, then the patient will give confidence to the Tambelangan Health Center (Adriansyah & Nadatien, 2019). This will make patients continue to use the services of the Tambelangan Health Center and in the end will recommend the Public Health Center to others because they are satisfied with the services provided (Afrizal & Suhardi, 2018).
The results of the cross-tabulation are also supported statistically based on Fisher's exact test parameters which obtained a significance value of 0.012 (<0.05). These results conclude that statistically also shows there is a significant relationship between trust and patient satisfaction at the Outpatient Installation of the Tambelangan Health Center. The strength of the relationship between variables can be seen in the Phi correlation value of 0.275, which means that there is a weak relationship between trust and patient satisfaction at the Tambelangan Health Center Outpatient Installation. This means that the higher the trust, the higher the level of satisfaction of inpatients at the Tambelangan Health Center. Conversely, the lower the trust, the lower the level of outpatient satisfaction at the Tambelangan Health Center (Ramadhan, et al., 2019). Complementing the previous regression results, that if the independent variable has a strong relationship to the dependent variable, then the independent variable will also affect the dependent variable. Therefore, there is a strong relationship between trust and patient satisfaction, so trust will influence patient satisfaction.
The results of this study are in line with the research of Pramana & Rastini which states that there is a significant influence between trust and satisfaction (Pramana & Rastini, 2016). The results of this study are in line with the research of Sudirman, Halim & Pinem which states that there is a significant influence between trust and satisfaction (Halim & Rahim, 2015). In addition, it is also in line with Simatupang (2017) which states that there is a significant influence between trust and patient satisfaction (Simatupang, 2017). The results of this study are also by research by Adhi & Ernawati (2012), namely trust has a positive and significant effect on patient satisfaction (Adhi & Ernawati, 2012). The results of this study provide important information that patients who seek treatment at a health center can feel much better satisfaction if they participate and give full trust to the health center and officers when providing health services. Meanwhile, the limitation of this study is that researchers often encounter respondents in the category of elderly patients who are difficult to communicate with in answering questions. Then, research during the COVID-19 pandemic made it quite difficult for researchers to get respondents.

Conclusion and Suggestion
Based on the results of the discussion above related to research on the Effect of Health Service Quality and Trust on Patient Satisfaction at the Outpatient Installation of the Tambelangan Health Center, it can be concluded that the results of this study indicate that almost all respondents (86%) stated that the quality of service was good, almost all respondents (81%) stated that the overall dimension of trust in the aggregate was trusted and almost all respondents (84%) stated that the overall dimension of satisfaction in the aggregate was satisfied with the service at the Outpatient Installation of the Tambelangan Health Center. Then there is a significant influence between service quality and trust on patient satisfaction at the Outpatient Installation of the Tambelangan Health Center, Sampang.
Researchers have suggestions that can be done for the problem improvement stage, namely that the Public Health Center is expected to improve the quality of service by adding several supporting facilities such as the number of patients waiting chairs, parking lots and room cleanliness, as well as increasing the friendliness of health workers when serving patients who seek treatment at the Tambelangan Health Center Outpatient Installation. Recommendations for future research are to examine aspects of service quality and trust and patient satisfaction with patient loyalty in utilizing health services.

Acknowledgments
We would like to express our gratitude to the Undergraduate Department of Public Health, LPPM and Universitas Nahdlatul Ulama Surabaya for the opportunity, support and motivation in publishing this scientific paper. As well as thanks to the respondents and RSI A. Yani who have provided the opportunity and research permission.