Analysis of the Quality of Health Services on Outpatient Satisfaction at the Outpatient Clinic of Kolodale Regional Hospital

: Health services have an important role in the implementation of health services in hospitals as a whole, especially nursing. Health services are considered good if the health services can create a feeling of satisfaction for each patient. Achieving a level of satisfaction with the services provided to patients, both the quality of health services and the health service system, means that patients will prefer quality health services that are quality, guaranteed, and affordable to patients, or in other words, consumers are one of the most important factors in achieving the level of satisfaction in a health service. This research aims to analyze the quality of health services on the satisfaction of outpatients at Kolonodale Hospital, North Morowali Regency. This research is a quantitative study that uses an analytical survey research method with a "cross-sectional study" design approach, sampling by accidental sampling with a sample size of 50 respondents taken from outpatients at the polyclinic. The instrument used was a test developed using a Likert scale, the data obtained was analyzed using descriptive and analytical statistical analysis, namely the chy square test with a significance level of 5 percent. The results of the research showed tangible values (p=0.000), reliability (p=0.000), responsiveness (p=0.000), assurance (p=0.000), and empathy (p=0.000) because the value ρ<α (0.05) so it can be said that there is a relationship between tangible, reliability, responsiveness, assurance and empathy on outpatient satisfaction in Kolonodale Regional Hospital, North Morowali Regency. Tangible and empathy variables have the strongest level of relationship with patient satisfaction. So it would be better for the hospital to provide a suggestion box, so that input from patients can be conveyed and can help improve the quality of the hospital in the future.


Introduction
Health services have an important role in the implementation of health services in hospitals as a whole, especially nursing.Health services are considered good if the health services can create a feeling of satisfaction for each patient.Achieving a level of satisfaction with the services provided to patients, both the quality of health services and the health service system, means that patients will prefer quality health services that are quality, guaranteed, and affordable to patients, or in other words, consumers are one of the most important factors in achieving the level of satisfaction in a health service.Patient satisfaction is a measure of the extent to which patients are satisfied with the health services they receive from health service providers.Patient satisfaction is one of the important factors that determines the success of a health service facility (Manzoor et al., 2019).
Measuring the quality and satisfaction of health services is an indispensable element for adequate management of resources and allows focusing on the preferences of its users, allowing them to build health services adapted to the needs and expectations of patients, patient satisfaction can be useful for building evaluations that refer to patient assessments hospitalization (Marley et al., 2004).Patient satisfaction is a well-known standard to evaluate the effectiveness of health services provided in hospitals.Patient satisfaction is an important benchmark for measuring health service delivery (Ganasegeran et al., 2015).
Improving patient service has become a priority for all health service providers with the optimal goal of achieving high levels of patient satisfaction (Lee et al., 2007).Satisfaction is one of the key factors related to government policy or business success which can only be maintained through providing good quality service to increase satisfaction.This improved provision requires effective service delivery, cost allocation, and management strategies (Sun et al., 2017).Patient opinions are becoming more important in the process of improving the healthcare delivery system.Patient satisfaction is a state of joy or happiness experienced by patients while using a health service.Thus, patient care is the basic function of every health service provider (Li et al., 2012).
The decrease in the number of patients is also an indication of patient dissatisfaction with hospital services, although it is not significant in proving patient satisfaction or dissatisfaction in the hospital, the quality policy in providing excellent service focuses on satisfaction, families, and employees.The hospital already has this policy, but in reality, there are still patients who complain about hospital services, especially outpatients who complain about health services.
The lack of patient satisfaction occurs because patient demands are increasing but are not accompanied by improvements in staff actions.Health services and patient satisfaction are indicators of the success of providing health services in hospitals.Patient satisfaction will be fulfilled if the service provided meets their expectations.If the service provided does not meet the patient's expectations, the patient will feel dissatisfied.Nurses must be able to provide optimal health services according to existing health service standards.This is because patient satisfaction is an indicator of the success of health services.Patient satisfaction is a reflection of the quality of health services they receive.Quality of health services refers to the level of perfection of health services in creating a sense of satisfaction in each patient.The more perfect the satisfaction, the better the quality of health services.However, relatively good service quality does not necessarily satisfy patients (Supartiningsih, 2017).Currently, patient opinion is considered a key factor in treatment decisions and healthcare delivery (Joosten et al., 2008).Therefore, the evaluation of health service delivery from the patient's perspective is receiving greater attention and has become a core attribute of any health system as it serves as a valuable indicator for measuring the success of service provision, especially in public sector hospitals (Mohd et al., 2014).
Government hospitals operate based on government policy because the government only funds government hospitals, while private sector organizations are formed as business organizations that can provide more effective care and services to their clients.Patients in private hospitals require higher costs to get the desired quality of service.Today, to meet patient needs, proper and complete details are required before availing of any service from a particular healthcare organization.Patients become more curious and expect additional services to get quality services beyond their expectations, as they pay more money for care, and any instances of dissatisfaction tend to force them to switch to another hospital (Dong et al., 2017).
Based on the results of initial observations, researchers obtained data on the number of patients who had received outpatient treatment at the Kolonodale Regional General Hospital (RSUD) with the number of outpatient visits in 2020 amounting to 15,415 visits with an average monthly visit of 1,284 visits while in 2021 there were 17,573 visits with an average monthly visit of 1,464 visits.This hospital is the only government-owned hospital in North Morowali Regency, making it a center for advanced health services.The quality of service is an indicator of increasing public visits to this hospital, not only because there are no other hospitals in North Morowali Regency.The government has made efforts to improve the structure of buildings and the service facilities provided to be more complete, therefore it is hoped that this service can increase the satisfaction of service recipients, in this case, people who seek treatment at hospitals.This research aims to analyze the quality of health services on the satisfaction of outpatients at the outpatient clinic at the Kolonodale Regional General Hospital (RSUD), North Morowali Regency.

Method
This research uses a "cross-sectional study" design (cross-sectional study), which is a type of research design that is analytical and is included in the Survey research design type (Timotius, 2016).This design is intended to study the dynamics and variations of the variables contained in the research title "analysis of the quality of health services on outpatient satisfaction at the outpatient clinic of Kolonodale Regional Hospital, North Morowali Regency".
The research was conducted at Kolonodale Regional Hospital, North Morowali Regency.This research lasted for 1 (month) starting from May to June 2022.The population in this study were all patients seeking treatment at the outpatient clinic of Kolonodale District Hospital.North Morowali as many as 50 people.By taking samples by accidental sampling, where samples are taken because they are in the place when the research takes place.The sample criteria used are Inclusion Criteria and Exclusion Criteria.By focusing on Patient Satisfaction, Quality, Responsiveness, Assurance, and Empathy.The instrument used for this research was a questionnaire with the Likert and Gutman scale types, for the Likert scale the highest answer was a score of 4 and the lowest answer was a score of 1.

Result and Discussion
This research was conducted in May 2022 at the Kolonodale Regional Hospital, North Morowali Regency with a sample size of 50 respondents and data collection was carried out through questionnaires to analyze the quality of health services on outpatient satisfaction at the Kolonodale Regional Hospital., North Morowali Regency.After the data is collected, it is edited, coded, and then tabulated.The research results can be seen in the following table and discussion.

Long-Term Care
From the table 1, it can be seen the characteristics of respondents based on the length of treatment where the majority of respondents received treatment >10 months as many as 31 respondents (62%), and the least received treatment <1 month as many as 2 respondents (4%).

Number of Visit
From the table 2, it can be seen the characteristics of respondents based on the number of visits where the majority of respondents received treatment >10 times as many as 33 respondents (66%) and the least duration of treatment was 6-10 times as many as 3 respondents (6%).

Univariate Analysis a) Tangible
The table 3 shows that of the 50 respondents, more than 30 respondents (60%) have quality in the tangible category compared to 20 respondents (40%) who have less.

b) Reability
The table 4 shows that of the 50 respondents, there are 33 respondents (66%) who have more quality in the category of proven reliability compared to 17 respondents (34%) who have less quality.

d) Assurance
The table 6 shows that of the 50 respondents, 33 respondents (66%) had more quality in the guaranteed assurance category compared to 17 respondents (34%) who had less.

e) Empathy
The table 7 shows that of the 50 respondents, more than 30 respondents (60%) have quality in the tangible category, compared to 20 respondents (40%) who have less.

Bivariate Analysis a) Tangible relationship with satisfaction
The table 9 shows that of the 27 respondents who said direct/tangible evidence was proven, there were 21 respondents (77.8%) who were satisfied and 6 respondents (22.2%) who were less satisfied, while 23 respondents who said direct/tangible evidence was lacking.respondents, there were 6 respondents (26.1%) who were satisfied and 17 respondents (73.9%) who were dissatisfied.The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.001.Because the p value < α=0.05, the alternative hypothesis is accepted.This means that there is a direct/tangible evidence relationship to the satisfaction of outpatients at Kolonodale District Hospital, North Morowali District.

b) The Relationship between reability and satisfaction
From the table 10, it shows that of the 27 respondents who said reliability/reliability was reliable, there were 21 respondents (77.8%) were satisfied, and 6 respondents (22.2%) were less satisfied, while the respondents who said reliability/Reability was less were 23 respondents.There were 6 respondents (26.1%) who were satisfied and 17 respondents (73.9%) who were dissatisfied.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.013.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a relationship between reliability and outpatient satisfaction at Kolonodale District Hospital, North Morowali District.

c) The Relationship between responsiveness and satisfaction
The table 11 shows that of the 39 respondents who said responsiveness was responsive, there were 25 respondents (64.1%) who were satisfied 14 respondents (35.9%) who were less satisfied, while 11 respondents said responsiveness/responsiveness was less.respondents, there were 2 respondents (18.2%) who were satisfied and 9 respondents (81.8%) who were less satisfied.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.018.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a relationship between responsiveness and satisfaction of outpatients at Kolonodale Hospital, North Morowali Regency.The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.005.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is an empathetic relationship with outpatient satisfaction at Kolonodale Regional Hospital, North Morowali Regency.e) The Relationship between emphaty and satisfaction The table 13 shows that of the 31 respondents who said they were empathetic, there were 23 respondents (74.2%) were satisfied, 8 respondents (25.8%) were less satisfied, while there were 19 respondents who said empathy was lacking, there were 4 respondents (21 .1%)were satisfied and 15 respondents (78.9%) were less satisfied.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.001.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is an empathetic relationship with the satisfaction of outpatients at Kolonodale District Hospital, North Morowali District.

Discussion
After the data is processed and tested, the results of the research are then discussed according to the variables studied.

1) Tangible relationship to patient satisfaction
The table above shows that of the 27 respondents who said direct/tangible evidence was proven, there were 21 respondents (77.8%) were satisfied, and 6 respondents (22.2%) were less satisfied, this was because even though the hospital had a building that was it is clean and well maintained and the staff are neat, but it does not have an adequate waiting room to accommodate patients who come almost at the same time, so sometimes patients don't get a seat while waiting in line.
Meanwhile, 23 respondents said direct/tangible evidence was lacking, there were 6 respondents (26.1%) were satisfied, and 17 respondents (73.9%) were dissatisfied, this was because, apart from the capacity of the waiting room, it was sometimes still insufficient.The patient did not get the appropriate medicine as prescribed from the beginning by the doctor because the medicine in the pharmacy was empty so the doctor replaced the type of medicine given with a similar medicine.Sometimes patients also get copies of prescriptions to buy empty medicines at pharmacies outside the hospital.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.001.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a direct/tangible evidence relationship to the satisfaction of outpatients at Kolonodale Hospital, North Morowali Regency.This research is in line with research conducted by Alim et al. (2019) with the title The Relationship between the Quality of Health Services and the Satisfaction of Outpatients at Makassar District Hospital, which states that there is a relationship between physical Evidence and outpatient satisfaction (p=0.000).
This research is in line with the theory carried out by Parasuraman (2014) that the dimensions of direct evidence (tangibility) include the appearance of physical facilities such as buildings and rooms, availability of parking, cleanliness, tidiness and comfort of rooms, completeness of communication equipment and employee appearance.Physical evidence (tangibles), relating to the attractiveness of the physical facilities, equipment, and materials used by the Kolonodale Regional General Hospital, North Morowali Regency, as well as the appearance of health service personnel at the hospital, which often have a direct and significant influence on community satisfaction as service users service.
Aspects of the existing facilities and infrastructure in a hospital greatly influence the level of patient satisfaction, even though the hospital building, whether the facilities inside it, are not functioning properly, for example, a toilet that is not clean or perhaps an inadequate waiting room, will be a separate assessment by the patient as a facility user.Resource factors which include human resources and infrastructure, to optimize internal and external commitment and support including community support and budgeting support in improving the quality of health services (Arrohmah et al., 2023).Research examining patient safety, satisfaction, and service quality hospitals: using a crosssectional survey of nurses and patients in 12 countries in Europe and the United States, the results showed that nursing care and the environment were the main factors influencing patient satisfaction (Aiken et al., 2012).

2) The relationship between reliability and patient satisfaction
The table above shows that of the 27 respondents who said reliability was reliable, there were 21 respondents (77.8%) were satisfied, and 6 respondents (22.2%) were dissatisfied, this was because even though patients were satisfied with the existing services, they felt that there were several things that were uncomfortable for the patient, for example, during an examination by a doctor, they were only interviewed for a moment regarding the complaint they were feeling and then a follow-up action was determined.
Meanwhile, 23 respondents said reliability was lacking, there were 6 respondents (26.1%) who were satisfied and 17 respondents (73.9%) who were less satisfied, this was because the hospital provided a rather long service due to a large number of patients and According to patients, it is complicated because there is a flow that they have to go through until the end of the service.This means that patients have to wait at several points such as the registration room, examination room, laboratory, and pharmacy.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.013.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a relationship between reliability and outpatient satisfaction at Kolonodale Hospital, North Morowali Regency.This research is in line with research conducted (Supartiningsih, 2017) Research entitled Service Quality and Hospital Patient Satisfaction in Outpatient Cases.The results of the analysis show that the reliability variable has a positive and significant influence on patient satisfaction at Sarila Husada Hospital, Sragen in outpatient.
This research is in line with the theory put forward by Parasuraman (2014) what is meant by reliability is the ability to provide promised services accurately and the ability to be trusted, especially in providing services promptly., in the same way, according to the promised schedule and without making mistakes each time.
In hospitals, there should be a source of information for patients about health services to the community, such as the path that must be followed so that patients do not feel that the service is quite complicated.Patients have the perception that if a doctor can examine the patient promptly and in sufficient detail then for them that is quality service.Apart from that, when they were first admitted to outpatient care, the nurses received them without complicated procedures, this is in line with their view that quality is the speed of service.
Research conducted in 21 European countries shows that fulfillment of expectations, provider type, and insurance are the main factors that influence patient satisfaction (Bleich, 2009), and also the availability of the information needed by patients (Jackson et al., 2001;Westaway, 2003).

3) The relationship between responsiveness and patient satisfaction
The table above shows that of the 39 respondents who said responsiveness, there were 25 respondents (64.1%) were satisfied, and 14 respondents (35.9%) were less satisfied, this was because even though they thought the officers were responsive to patient complaints.However, they are still dissatisfied because even though the nurse notifies them if there is a delay in examining the patient, for the patient this does not need to happen if the treating doctor arrives according to service hours.
Meanwhile, 11 respondents said responsiveness/responsiveness was lacking, there were 2 respondents (18.2%) who were satisfied and 9 respondents (81.8%) who were less satisfied, this was because even though doctors/officers listened to complaints from patients, they were late.officers receive negative assessments from patients, and sometimes pharmacy officers also tell them how long the process of administering medication is, which according to the patient is quite a long wait for medication.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.018.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a relationship between responsiveness and satisfaction of outpatients at Kolonodale Hospital, North Morowali Regency.
This research is in line with research conducted by Alim et al. (2019), the quality of health services on outpatient satisfaction at Makassar District Hospital with the results that there is a relationship between responsiveness and outpatient satisfaction (p=0.001).
This research is in line with the theory put forward by (Parasuraman A, 2014), timely service is an important factor that needs to be considered in improving service quality.Very long service and long queues not only have a dissatisfying effect on patients but also hurt patient safety, where which greatly affects patient clinical outcomes, especially in patients who are in critical condition.
The condition of service at the hospital is that every person who comes for treatment registers at the registration locker and is then directed to the seventh polyclinic, then the patient will be directed to the laboratory or radiology if supporting examinations are needed, but if not then the patient will be directed to the pharmacy counter to pick up medicine and then to the department administration if the patient has a general status.
Clients or patients expect seriousness and readiness from officers in responding to every complaint and client need.The speed of staff in serving patients is a positive thing in that they increase client satisfaction with the services they provide.Availability of accommodation, ability to communicate with patients, empathy, skills, and ability to answer patient questions are dimensions and drivers of patient satisfaction (Kitapci et al., 2014).

4) The relationship between assurance and patient satisfaction
The table above shows that of the 27 respondents who said the guarantee was guaranteed, there were 21 respondents (77.8%) were satisfied, and 6 respondents (22.2%) were less satisfied, this was because even though the patient felt assured with the services provided What makes patients dissatisfied is when there are already a lot of patients in the queue, the officers start to get overwhelmed and have difficulty dealing with patient complaints so that they sometimes have a high pitched tone towards the patient or family and sometimes they are less friendly towards every patient who comes to their room.
Meanwhile, 23 respondents said Assurance/guarantee was lacking, there were 6 respondents (26.1%) were satisfied, and 17 respondents (73.9%) were less satisfied, this was because respondents felt that sometimes the information given about their condition was only conveyed to only his family, sometimes the information conveyed is insufficient so that the client does not understand what is being asked better because it uses language that is difficult for the patient to understand.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.005.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is a guaranteed relationship with outpatient satisfaction at Kolonodale Hospital, North Morowali Regency.
This research is in line with research conducted (Supartiningsih, 2017) with research entitled Service Quality and Hospital Patient Satisfaction in Outpatient Cases.The results of the analysis show that there is a relationship between insurance variables and outpatient satisfaction (p=0.000),there is an evidential relationship between physical condition on outpatient satisfaction (p=0.000) This research is in line with the theory put forward that the service guarantee dimension is a dimension of service quality in the form of a guarantee that includes the knowledge and skills of officers, politeness and friendliness of officers, officers' ability to communicate, trustworthiness and security guarantees (Supranto, 2014).

5) The relationship of empathy to patient satisfaction
The table above shows that of the 31 respondents who said they were empathetic, there were 23 respondents (74.2%) were satisfied and 8 respondents (25.8%) were dissatisfied, this was because even though the staff, after acting, no longer reassessed the patient's condition, after the patient has been examined and given a prescription the patient no longer observes.
Meanwhile, 19 respondents said empathy was lacking, there were 4 respondents (21.1%) who were satisfied, and 15 respondents (78.9%) who were dissatisfied.This was because even though the patient was a patient with repeated visits, the staff rarely asked for news from the patient.Patients after previous treatment do not always remember the patient's previous problems/complaints.
The results of statistical analysis using the Chisquare test obtained a Continuity Correction value of p=0.001.Because the p-value < α=0.05, the alternative hypothesis is accepted.This means that there is an empathetic relationship with the satisfaction of outpatients at Kolonodale District Hospital, North Morowali District.Patria et al. (2017) with the title Research on dimensions of service quality on outpatient satisfaction.The results of bivariate analysis show a significant relationship between empathy and outpatient satisfaction.
This research is in line with the theory put forward by (Supranto, 2014).The empathy dimension is a dimension of service quality in the form of giving serious attention from service providers to individual consumers.
The empathetic attitude develops by the staff in caring for their clients has a very positive impact on client satisfaction because, with the feeling of care and attention given by the nurse, the client will provide satisfied suggestions.Customer (patient) satisfaction is influenced by the perception of service quality which can be seen from the empathy dimension which includes ease of relationships, good communication, personal attention, and understanding of the needs of patients.Research conducted by Jackson et al. (2001), found that apart from fulfilling patient expectations regarding the services provided, patient autonomy was the factor that had the most influence on patient satisfaction.Comfort, emotional assistance, and respect for patient choices also influence patient satisfaction (Jackson et al., 2001;Nguyen Thi et al., 2002).

6) Variables with the greatest level of relationship to patient satisfaction
The table above shows that related to the results of the general linear model multivariate test, which was assessed through the significance level (p) and F calculation, it shows that of the 5 independent variables entered into the test simultaneously, all of them consistently showed significance, by the bivariate test.The variables direct evidence/tangible and empathy are the most important in increasing patient satisfaction in the outpatient room of Kolonodale District Hospital North Morowali.

Conclusion
From the results of the research that has been carried out, it is concluded that: a) There is a tangible relationship to the satisfaction of outpatients at Kolonodale Regional Hospital, North Morowali Regency.b) There is a relationship between reliability and outpatient satisfaction at Kolonodale Regional Hospital, North Morowali Regency.c) There is a relationship between responsiveness and outpatient satisfaction at Kolonodale Regional Hospital, North Morowali Regency.d) There is a relationship between assurance and outpatient satisfaction at Kolonodale Hospital, North Morowali Regency.e) There is a relationship between empathy and satisfaction of outpatients at Kolonodale Hospital, North Morowali Regency.f) Tangible and empathy variables have the strongest relationship with patient satisfaction.

Table 1 .
Frequency Distribution of Respondents based on Length of Treatment for Outpatients at Kolonodale Regional Hospital, North Morowali Regency

Table 2 .
Frequency Distribution of Respondents Based on the Number of Outpatient Visits by Respondents at Kolonodale Hospital, North Morowali Regency

Table 3 .
Frequency Distribution of Respondents Based on Quality with Tangible Categories of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 4 .
Frequency Distribution of Respondents Based on Quality with the Category of Reliability of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 5 .
Frequency Distribution of Respondents Based on Quality with the Responsiveness Category of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 6 .
Frequency Distribution of Respondents Based on Quality with Assurance Category of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 7 .
Frequency Distribution of Respondents Based on Quality with Empathy Category of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 8 .
Frequency Distribution of Respondents Based on Outpatient Respondent Satisfaction at Kolonodale Hospital, North Morowali Regency

Table 9 .
Tangible Relationship with Outpatient Respondent Satisfaction at Kolonodale Regional Hospital, North Morowali Regency

Table 10 .
The relationship between reliability and satisfaction of outpatient respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 11 .
The Relationship between Responsiveness and Satisfaction of Outpatient Respondents at Kolonodale Hospital, North Morowali Regency

Table 12 .
The relationship Between Assurance and Satisfaction of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 13 .
The Relationship between Emphaty and the Satisfaction of Outpatient Respondents at Kolonodale Regional Hospital, North Morowali Regency

Table 14 .
Variables That Have a Greater Degree of Relationship to Patient Satisfaction