THE EFFECT OF OUTPATIENT PHARMACEUTICAL SERVICE QUALITY ON PATIENT LOYALTY THROUGH PATIENT SATISFACTION OF KARSA HUSADA GENERAL HOSPITAL BATU

Pharmacy Department an important role in the hospital service because almost 80% of patients will have medical prescription. However, the pharmacy department in this hospital has a different between the standard which have been set by the Government and the implementation of pharmacy service. Furthermore, after the intervention applied, it showed the decreased number of waiting time for medicine and also this decline has influence the patient satisfaction. In Karsa Husada general hospital the percentage of patient satisfaction is about 68.50% and the patients who satisfy with the service said that they will visit the hospital again. The purpose of this research is to find out whether the quality improvement of outpatients pharmacy service influence the patient loyalty through patient satisfaction. The method of this research was quantitative research with observational analytical study and used the cross sectional as the approach. The population of this research is about 1.143 patients who have been received outpatient pharmacy service, meanwhile the sample is about 89 patients who are not using insurance. The data analyzed using PLS which using SMART PLS program. Based on the result, it showed that the quality improvement of pharmacy service has positive effect and also significant towards patient satisfaction. However, the result showed that the quality improvement of pharmacy service and patient satisfaction has positive effect but not significant towards patient loyalty, then it also showed that the quality improvement of pharmacy service has positive effects but not significant towards patient loyalty through patient satisfaction in Pharmacy Department on Karsa Husada general hospital. Suggestions that can be given to the hospital that is to keep facilities and do strategy to prevent medicine void. Keyword : Quality of Pharmacy Service, Patient Satisfaction, Patient Loyalty Hospital has a very strategic role as a health service provider in accelerating the improvement of community level, provides quality services in accordance with established standards, and can reach all levels of society. 616 Outpatient service in hospitals is one of the main hospital services, which has larger number of outpatients than inpatient department. From data of Karsa Husada General Hospital Batu in 2016, the number of outpatient visits is increasing every month, reaching 25,277 outpatients from January to June, both new and old patients. JAM


The Effect of Outpatient Pharmaceutical Service Quality on Patient Loyalty through Patient Satisfaction
Pharmacy department plays an important role in the final process of health service in hospital; 80% of patients visit health facilities for prescription (Siregar & Amalia, 2004).In pharmacy department of Karsa Husada General Hospital Batu, there is a gap between the waiting time for finished drugs and compounded drugs in this hospital and the waiting time regulated in Minimum Service Standard.Waiting time affects patient satisfaction (David, Hariyanti & Lestari, 2014).Satisfaction of Outpatient service at outpatient pharmacy department of Karsa Husada General Hospital Batu is 68.50%.It is still below Minimum Service Standard, which is 90%.
Quality of service is a concept consisting of five dimensions which are very instrumental in building patient satisfaction and loyalty.Those five dimensions are tangibles, reliability, responsiveness, assurance and empathy (Parasuraman, Zeithaml & Berry, 1994).Some studies have found that patients who are satisfied with health services are interested in visiting the hospital again.
According to Kotler and Keller, 2007, patient loyalty is measured by using three indicators: repurchase intention, intention recommendation and immunity attractiveness competitors (Kotler & Keller, 2007).Patient loyalty can be seen by the number of revisit patients.The number of outpatients in the first six months in 2016 in Karsa Husada General Hospital Batu is 13,815 patients.There is an increase in the number of patients in the last six months in 2015.
The quality of hospital pharmaceutical refers to the level of perfection in providing service and leads to patient satisfaction, in accordance with the average level of satisfaction of the society and its implementation in accordance with the standard of professional service, which is determined and in accordance with the code of ethics of professional pharmacist.The quality of pharmaceutical services can be measured based on seven dimensions of pharmaceutical service quality, i.e. attitude of pharmacy staff, drug information, drug availability, facilities, location, waiting time for drug service and drug prices (Megawati, Hariyanto & Rachmi, 2016).
In the preliminary study that has been done in the Outpatient Pharmacy Department of Karsa Husada General Hospital Batu, the result shows that there is a gap between waiting time of finished drug and compounded drug and Minimum Service Standard.Researchers wanted to conduct a study in general patients because although there was a gap between waiting time for drugs, 25% of the prescription were from general patients.It also made the researchers to be interested in conducting a research about the loyalty of general patients through pharmaceutical service quality based on patient satisfaction in outpatient pharmacy department of Karsa Husada General Hospital Batu.Researchers conducted research on outpatient pharmacy department because in Karsa Husada General Hospital Batu, the number of outpatients is larger than inpatients.
This study aims to determine whether pharmaceutical service quality affects patient loyalty through patient satisfaction or not.This research is expected to give benefit for Karsa Husada General Hospital Batu in the form of input to increase patient loyalty and patient satisfaction.The findings of this research also can be used to know dimension which influences patient satisfaction and patient loyalty, so that the hospital can arrange strategy of pharmacy department management in order to increase patient satisfaction and patient loyalty.In addition, it can be used for the future researchers to develop scientific research.

METHOD
This research is a quantitative research with observational analytical study.This research used cross sectional approach method.This research was conducted in outpatient pharmacy department of Karsa Husada General Hospital Batu in May 2017.The population of this study is all general outpatients who have had medical examination and treatment in outpatient pharmacy department previously (1143 patients).In this study, researchers took sample of 114 general patients.Sampling technique used is simple random sampling method.
The data was collected by distributing questionnaires to respondents to determine the effect of pharmaceutical service quality on patient loyalty through patient satisfaction.The independent variables measured is pharmaceutical service quality, including the attitude of pharmacy staff, the provision of drug information, the availability of drugs, facilities, location, waiting time for drug service and drug prices.Dependent variables in this research are patient satisfaction and patient loyalty.Data measurement scale used is Likert scale, with five alternative answers.Data was analyzed by using Partial Least Square (PLS) with SMART PLS program.

Descriptive Analysis
The results show that on variable of pharmaceutical service quality, all respondents, who are general outpatients who have had medical examination and treatment in outpatient pharmacy department of Karsa Husada General Hospital Batu previously, agreed that the pharmacy staff treat them well.Average of this item is 4.00.This means the respondents tend to agree that pharmacy staff treat them well.
Not only that, the type of medicine received by patients is in appropriate to the prescription made by the doctor.This is evidenced by the response of respondents who agree that the type of medicine received by patients is in appropriate to the prescription made by the doctor.Average of this item is 4.00.This means that respondents tend to agree that the type of medicine received by patients is in appropriate to the prescription made by the doctor.
Nevertheless, respondents disagree with a statement that the waiting time of drug service is fast.The average of this item is 2.26%.This means that respondents tend to disagree on a statement that the waiting time of drug service is fast.
In the variable of patient satisfaction, calculation result shows that all respondents agree that respondents are satisfied with the willingness of pharmacy staff in assisting the respondent.The average of this item is 4.00.This means that respondents tend to agree that respondents are satisfied with the willingness of pharmacy staff in assisting the respondent.
However, on the variable of patient satisfaction, the lowest item average is the timeliness of service.The respondents agree that they are satis-fied with the timeliness of service, with the average of item amounted to 3.42.This means that respondents tend to doubt that they are satisfied with the timeliness of service provided.
In the variable of patient loyalty, calculation result indicates that most of general patients agree that they will entrust their health service of respondent to Karsa Husada General Hospital Batu and buy medicine in outpatient pharmacy department of Karsa Husada General Hospital Batu.Average of this item is 3.96.This means that respondents tend to agree that they will entrust their health service of respondent to Karsa Husada General Hospital Batu and buy medicine in outpatient pharmacy department of Karsa Husada General Hospital Batu.
In variable of patient loyalty, the lowest item average is recommendation of outpatient pharmaceutical service of Karsa Husada General Hospital Batu to others, with the average value of 3.72.This means that respondents tend to agree that respondents will recommend outpatient pharmaceutical service of Karsa Husada General Hospital Batu to others.

Results of Data Analysis
The result of data analysis shows that facility (MT4) has weight amounted to 0.746.This means that facility is the dominant indicator in measuring variable of pharmaceutical service quality.Then, in variable of patient satisfaction, assurance (KP4) has weight amounted to 0.764.This means that assurance is a dominant indicator in measuring variable of patient satisfaction.Furthermore, the measurement model of patient loyalty also informs that the repurchase intention (Y1) has the biggest weight value of 0.896; thus, it becomes the dominant indicator in measuring patient loyalty.Path diagram in this research model is presented in Figure 1 below.
Q-square of patient loyalty is 60.2%.This shows that the contribution of pharmaceutical service quality and patient satisfaction to loyalty overall amounted to 60.2%, while the rest amounted to 39.8%, which is contribution of other variables not discussed in this research.
The effect of pharmaceutical service quality on patient satisfaction resulted in t-statistics of 19.240.Therefore, it can be interpreted that there is a significant effect of the quality of pharmaceutical service on patient satisfaction.The influence of pharmaceutical service quality on patient loyalty resulted in t-statistics of 0.745.This can be inter-preted that there is effect of pharmaceutical service quality on patient loyalty, but it is not significant.The effect of patient satisfaction on patient loyalty resulted t-statistics of 1.135, it can be interpreted that there is effect of patient satisfaction on patient loyalty, but it not significant.The effect of pharmaceutical service quality on patient loyalty through patient satisfaction resulted in t-statistics of 1.133.This shows that t-statistics <t-table (1.96).Therefore, it can be interpreted that there is effect of service quality on patient loyalty through patient satisfaction, but it is not significant.

Dominant Effect
Exogenous variable that has a dominant effect on endogenous variables can be known through the largest total effect.The analysis results inform variable that has the greatest total effect on patient loyalty, namely pharmaceutical service quality, with a total effect of 0.323.Thus, pharmaceutical service quality is the most influential variable or has the most dominant effect on patient loyalty.

DISCUSSIONS The Effect of Pharmaceutical Service Quality on Patient Satisfaction
The results of this study indicate that there is a significant effect of pharmaceutical service quality on patient satisfaction.This means that the increase in pharmaceutical service quality will also increase patient satisfaction.Service quality plays an important role in patient satisfaction as stated by Malewski that patient satisfaction has been a quality driver and expands competition in the health care market (Malewski, Ream & Gaither, 2015).
The results of research which was conducted by Subekti also state that there is a significant relationship between pharmaceutical service quality and patient satisfaction (Subekti, 2009).This research is similar to research which was conducted by Ihsan that consumer satisfaction is highly dependent on the quality of service provided, in which service quality has several dimensions that influence it (Ihsan, Rezkya & Akib, 2014).

The Effect of Patient Satisfaction on Patient Loyalty
The results of this study indicate that there is no significant effect of patient satisfaction on patient loyalty.This means that the increase in patient satisfaction does not affect the increase in patient loyalty.According to Tjiptono, satisfaction does not necessarily lead to loyalty but usually loyalty begins with satisfaction first (Tjiptono, 2000).Nevertheless, respondents of Karsa Husada General Hospital Batu assume that there are other factors that are not studied making them loyal in using the medical service in this hospital, such as the hospital service quality or medical service quality such as good relationship between physician and patients.
This study is inversely related to a research which was conducted by Megawati that patient satisfaction will be the main determinant that makes the patient choose a hospital (Megawati, Hariyanto & Rachmi, 2016).Another study conducted by Wahdi reveals that patient satisfaction has a significant influence on loyalty of inpatients in Panti Wilas Hospital "Citarum".This means that the higher the level of patient satisfaction, the higher the loyalty of patients to the service provider (hospital) (Wahdi, 2006).Josepth Cronin, Jr. and Steven A. Tailor, also proved in their research that consumer satisfaction will greatly affect loyalty and encourage sales growth (Cronin Jr & Taylor, 1992).

The Effect of Pharmaceutical Service Quality on Patient Loyalty
The results of this study indicate that pharmaceutical service quality has no significant effect on patient loyalty.This means that pharmaceutical service quality does not affect the improvement of patient loyalty.According to Welch, service quality is the best guarantee to create and maintain patient loyalty and defend the hospital in facing global competition (Jack Welch, 2001).
This research is inversely related to the research which was conducted by Wahdi, stating that besides having indirect positive effect on patient loyalty through patient satisfaction, service quality can also have a direct significant effect on inpatient loyalty.This means that the better the quality of services provided by Panti Wilasa Hospital "Citarum", the more loyal patients will be.This can be demonstrated by providing positive information on hospital that the patient will return to this hospital again if they get sick and will recommend to others to use the services provided by the hospital (Wahdi, 2006).

The Effect of Pharmaceutical Service Quality on Patient Loyalty Patient Satisfaction
The results of this study indicate that pharmaceutical service quality has no significant effect on patient loyalty through patient satisfaction.This means that good pharmaceutical service quality and patient satisfaction does not affect the improvement of patient loyalty.According to Cheng, Lai and Yeung, several factors affecting patient loyalty are service quality and patient satisfaction (Cheng, Lai & Yeung, 2008).
This research is inversely related to the research which was conducted by Wahdi, stating that service quality has indirect positive effect on patient loyalty through patient satisfaction (Wahdi, 2006).Respondents who are loyal do not only pay attention to service quality and satisfaction in pharmacy department alone, but most respondents are loyal due to other factors in the hospital in general.Although respondents have to wait for drug service in pharmacy department for too long, they still come back to the hospital if they need health services again because they have good relationship and feel that they will be recovered faster with the help of a particular doctor in Karsa Husada General Hospital Batu

Research Implication
The implication of this research is to know the measurement result of pharmaceutical service quality.It is found that drug availability and waiting time for drug service have negative and significant effect, and form seven dimension of pharmaceutical service quality.This means that the drugs available in pharmaceutical department are not complete.This is evidenced by pharmacy staffs who ask respondents to buy the medicine needed outside the pharmaceutical department as writing prescription for the respondents because the medicines are not available.Incomplete drugs available can be a positive thing for respondents because respondents do not have to wait for drugs for too long in pharmacy department of Karsa Husada General Hospital Batu.However, it influences hospital income.Therefore, it requires a strategy to prevent a condition when drugs needed by patients are not available in pharmacy department.
Waiting time for Drug service in outpatient pharmacy department of Karsa Husada General Hospital Batu is longer than the standard.With the age of general patients (mostly aged 36-45 years), respondents understand that they will wait a little longer because when a respondent meets other respondents in around similar age, he will chat other respondent while waiting for the drug.If the waiting time of drug service is not possible to shorten, the hospital should be able to add facilities or media that can distract respondents in waiting for drugs such as providing newspapers or health magazines.
According to Resmisari, older respondents are more satisfied than young respondents.This is because older patients take time to ask about their health condition; it fulfills their need for knowledge and information of their health condition, while respondents in productive age tend to demand and expect basic service skill more, and criticize the service provided (Resmisari, 2008).
Not only that, this study shows that high patient satisfaction will lead to high patient loyalty with a positive influence, but it is not significant.Patients are loyal because they are satisfied to other services provided in other department.It is expected that hospital can further increase patient satisfaction of pharmaceutical department, so that patients are not loyal because of service provided by other department, but they are loyal to pharmaceutical department by improving indicator of tangibles, reliability and responsiveness.

Research Limitation
This research is a quantitative research.In variable of patient satisfaction, the researchers cannot explore deeper how satisfied the patient to the service provided.Further research is expected to use semi-quantitative research; with qualitative research, patient satisfaction will be known more deeply.
This research is more focused on pharmaceutical service in pharmacy department, in which contribution of pharmaceutical service quality and pa-tient satisfaction is 60.2%.The rest is variables which are not investigated, i.e. hospital image, displacement cost, and price perception (Cheng, Lai & Yeung, 2008).Further research is also expected to measure service quality of hospital from patients start entering hospital until patients go home.
This research only studies general patients; in fact all patients have the same right in receiving services in pharmaceutical department.Furthermore, it is expected that further research can examine the effect of pharmaceutical service on patient loyalty through patient satisfaction based on general patients and BPJS patients.

CONCLUSION
Based on the results of this research, it can be concluded that the improvement of pharmaceutical service quality has positive and significant effect on patient satisfaction in outpatient pharmacy department of Karsa Husada General Hospital Batu, while improvement of pharmaceutical service quality has positive effect on patient loyalty, patient satisfaction has positive effect on patient loyalty, and improvement of pharmaceutical service quality has positive effect on patient loyalty in outpatient pharmacy department of Karsa Husada General Hospital Batu through patient satisfaction, but they are not significant.

SUGGESTIONS
Based on the research results, analysis and discussion that have been done, several things can be considered in order to improve patient loyalty by improving pharmaceutical service quality through patient satisfaction, they are: hospital can continue to serve patients, listen carefully to what patients ask without answering it hurriedly, keep the facility in pharmacy department in a good condition by evaluating and repairing it if there is damage, do some strategies to avoid problems in drug stock such as ABC method, add facilities or media to distract patients from waiting for drugs, increase the knowledge and ability of pharmacy staff to make patient more confident in receiving pharmaceutical service in pharmacy department by conducting training to improve their competence in giving service in pharmacy department, behave kindly to respondents so that patients feel comfortable with the service provided, one of them is by conducting service excellent training, improve indicator of tangibles, reliability and responsiveness.
Future research can examine the quality of hospital services in general to patient loyalty through patient satisfaction in order to know what factors play a role in patient loyalty of Karsa Husada General Hospital Batu.Future research also can use questionnaires that can measure the quality of pharmacy better, and use qualitative research to explore patient satisfaction deeper and study BPJS patients.
Figure 1 PLS Analysis