The influence of service quality and trust on satisfaction of BPJS health outcoming patients in Islamic Hospital Karawang

This study aims to obtain empirical evidence and found the clarity of the phenomenon and concluded on Influence of Service Quality and trust on patient satisfaction of outpatient health BPJS at the Islamic Hospital Karawang. This thesis is expected to contribute to the development of science, especially the management, marketing management, service quality, trust and patient satisfaction. The study was conducted by using descriptive and verification methods, namely: collecting, presenting, analyzing, and testing hypotheses, and make their conclusions and suggestions. Samples were collected using Proportionate Stratified random sampling method with a sample size of 393 respondents from the population of 21.627 people. Data analysis technique used is the technique Scale Range Analysis and Path Analysis with the help Method of Successive Interval (MSI), the computer program Microsoft Excel 2013, and SPSS version 20. From the analysis of research data, obtained some conclusions as follows: Service Quality amounted to 1397,4 is at Agree criteria, Means service quality rated Good. Trust at 1427,6 is at Agree criteria, meaning the trust rated Good. Patient satisfaction of 1432,3,5 is at Agree criteria, meaning patient satisfaction in rated Good. There Correlation Between service quality by trust at 0,811. This shows that a very strong and direct Correlation because it has a positive value. There Effect of Partial Between service quality on patient satisfaction by 42,8% and there Between Partial Influence Trust toward patient satisfaction of 37,9%. There Simultaneous Effect Between Service Quality and Trust toward patient satisfaction of outpatient health BPJS at the Islamic Hospital Karawang amounted to 80,7%, while the rest are other factors not examined by 19,3%. From the description above, the suggestions given include improving the quality of service and providing trust to increase patient satisfaction.


Introduction
The development of technology and information causes public knowledge to increase, so that people are more selective in choosing the service facilities they use. The selection of these service facilities is usually taken by the community by utilizing assistance from various media which is then taken into consideration in making decisions about the service to be used. One of the important services for the community is health services. Because basically everyone needs a healthy body in carrying out their activities so that they can carry out their activities well. Therefore, optimal health services and guarantees of trust are needed so that the community gets satisfactory results.
In addition, the service sector has experienced very rapid development, as has occurred in the hospitality, insurance, banking, aviation, tourism and telecommunications service industries. Likewise in the health service industry, whether it is a hospital or a health center, so that the business can survive and thrive requires knowledge of good service and trust from patients. There are various sectors engaged in service companies, one of which is a company engaged in the health sector. Everyone has various ways to obtain excellent health. A person who is sick will usually try to treat the disease he suffers until he is healed. Health services are efforts to organize individually or together in organizations to prevent and improve health, maintain and cure disease and also restore the health of individuals, groups, families and or the public (Ministry of Health of the Republic of Indonesia).
The influence of advances in science and technology has increased public awareness and demand for good services, including in this case the hospital as a health institution engaged in services, which include surgery and care for the sick, resulting in the fact that patients have better opportunities. In choosing the hospital he wants in, carrying out treatment will lead to increasingly high competition between hospitals, where the main product of the hospital is medical services which include surgery and services for the sick. In the 1945 Constitution Article 28H paragraph 1 it is stated that everyone has the right to live in physical and spiritual prosperity, to live and to have a good and healthy living environment, and to have the right to health services. From this article we know that the state has responsibility for the health of its citizens. The government has made a policy on health insurance which is a component of the health funding sub-system, as a step to carry out the mandate of the basic law in ensuring the health of every citizen.
Health insurance is formulated in Law Number 40 of 2004 concerning the National Social Security System (SJSN), that health insurance is administered nationally based on the principle of social insurance and the principle of equity as regulated in Article 19 paragraph 1 of the SJSN Law. In 2011 concerning the Social Security Administering Body. Article 60 paragraph 1 of the BPJS Law mandates the implementation of the National Health Insurance (JKN) on January 1, 2014. BPJS Health itself is a transformation from PT. Askes. The existence of BPJS Health is expected to be able to achieve the target in 2019. No later than January 1, 2019, all Indonesians have a National Health Insurance to obtain health care benefits and protection in meeting their basic health needs organized by BPJS Health. To support the realization of health insurance for the entire population as well as the realization of a healthy environment and behavior, the implementation is carried out by appointing health service providers. One year into the National Health Insurance program, the sustainability of BPJS Kesehatan has experienced pros and cons in the community. This relates to the satisfaction that is felt directly by people who use the BPJS Health card for the services they receive, both at the BPJS Health office, first-level health facilities, or advanced health facilities. There are many benefits, but there are also complaints.
Islamic Hospital Karawang is one of the public hospital health services which has the main task and function based on the regulations of the Singaperbangsa Foundation in Karawang Regency in the deed of Notary Khodijah Syahbudi Saleh SH. Number 14 of 1999 concerning the establishment of the Organization. This is in accordance with its vision, "To become the hospital of choice for the people of Karawang and its surroundings through Islamic Health Services and prioritizing Quality and Patient Safety". The main task of the Karawang Islamic Hospital is to carry out health efforts in an efficient and effective manner, by prioritizing healing and recovery efforts that are carried out in a harmonious, integrated manner through health and prevention and referral efforts. The following is a polyclinic located at the Karawang Islamic Hospital. Based on table 1, there are 9 polyclinics in the Karawang Islamic Hospital, namely radiology polyclinic, obstetrics and gynecology polyclinic, otolaryngologist polyclinic, psychiatric or psychiatric polyclinic, internist polyclinic, pediatric polyclinic, dental polyclinic, neurosurgery polyclinic, and surgery polyclinic. In implementing the main tasks of the Karawang Islamic Hospital through improving the quality of health services, of course, it is closely related to the level of patient satisfaction, especially outpatients at the Karawang Islamic Hospital. The satisfaction experienced by patients is closely related to the quality of services provided by the hospital, such as nurses, doctors, and the quality of human resources themselves. The following is the number of BPJS Health outpatients at the Karawang Islamic Hospital 2019: There are several possibilities that cause the number of patients to fluctuate and become unstable, the number of players in the hospital industry demands that the Karawang Islamic Hospital must be more creative in developing the quality of its services and increasing the ability of trust in an effort to create unsatisfactory patient satisfaction. Patient trust will arise because of the belief that a good quality image is not based on the point of view or perception of the service provider. According to Kotler and Keller (2016) service quality is a performance that can be offered by one person to another. This performance can be in the form of an intangible action and does not result in the ownership of any goods and against anyone. Good service quality will also have a good impact on the company because it will become a royal customer and provide benefits for the company.
Service quality is a central point for a service company in meeting the level of customer satisfaction and loyalty. The quality of this service is important because it will have a direct impact on the company's image so that it becomes an advantage for the company. How not, if a company has got a positive value in the eyes of consumers, then the consumer will give good feedback, and it is not impossible to become a regular customer or repeat buyer. The Effect of Service Quality on Consumer Satisfaction has an important role in creating customer satisfaction. Consumers' perceptions of whether or not the company's services are good or not depend on the suitability and desire of the services they receive. Service provider companies, the services provided are a measure of customer satisfaction. If the perceived service quality is smaller than expected, consumers will feel disappointed and dissatisfied and even have other negative impacts on the company.
In addition, trust in the context of health services can be defined as the patient's belief that doctors and staff will do things that aim to ensure the well-being of patients. Patients who have a more open attitude or trust health care providers will tend to use the services provided more often. According to Siagian and Cahyono (2014) trust is a belief from one party regarding the intentions and behavior of the other party, thus consumer trust is defined as a consumer's expectation that the service provider can be trusted or relied on in fulfilling its promises. The level of trust given by the patient is very dependent on the performance and services provided from a hospital so that the patient feels comfortable and provides a stimulus to recover quickly. Consumer trust is the consumer's response to the evaluation of the perceived discrepancy between expectations and the actual performance of a product in its use, with the development of trust an important factor that has a major contribution to overall consumer satisfaction due to the marketing relationship. Patient satisfaction is defined as a person's feelings, which can be in the form of pleasure or disappointment, which comes from the comparison between the person's perception of a product or service received with previously held expectations. According to Herlambang (2014: 79), actually customers do not buy products or services, but buy benefits, so that if customers are satisfied with the benefits they receive, it will have a good impact on the company. A customer who is satisfied with the benefits they receive, they will talk to other people, and it is a free promotion for the company. For this reason, the researcher made observations about the various complaints felt by patients in the suggestion box during the 2020 period at the Karawang Islamic Hospital. to 30 outpatient BPJS patients so as to obtain the following conclusions. There is a facility damage 25 5 2 The staff is not friendly 23 7 3 Complex administrative service process and referral system 23 7 4 Slow service 19 11 5 Cleanliness is not maintained 15 15 6 Medical personnel are not communicative 15 15 7 Lack of responsiveness of officers to patient complaints 12 18 8 There are gap in patient care 11 19 9 Provision of drugs that are still burdened with purchases at a cost to the pharmacy 10 20 10 Docter rarely available 10 20 Source: data processed by researchers, 2020 Based on the table above regarding the results of observations and interviews that researchers conducted on BPJS Outpatients at the Karawang Islamic Hospital, it shows that the services provided by the hospital are still unsatisfactory to the patients; this is also a factor constraint in realizing a trust in the hospital. Damage to facilities is the dominant complaint at this hospital. In fact, the facility is an important means of supporting health that cannot be ignored. A sense of comfort and a positive environment greatly affects the level of quality of the patient's recovery. Based on the description of the background of the problem above, the authors are interested and have the desire to research "The Effect of Service Quality and Trust on BPJS Health Outpatient Satisfaction at the Karawang Islamic Hospital".

Research Method
The study method is basically a scientific way to obtain data with certain purposes and uses. The scientific method of research activities is based on scientific characteristics, namely rational, empirical, and systematic (Sugiyono, 2011:2). This research uses descriptive and verification research methods.

Research Instrument
In principle, research is to take measurements, so there must be a good measuring instrument. The measuring instrument in research is called a research instrument. So the research instrument is a tool used to measure the observed natural and social phenomena. Specifically called research variables (Sugiono, 2011:102). The variables that will be examined in this research are Service Quality, Trust, and Patient Satisfaction. The instruments in this study are described as follows:

Sample
Sugiyono (2013:81) explains that the sample is part of the number and characteristics possessed by the population. If the population is large, and it is impossible for the researcher to study everything in the population, for example due to limited funds, manpower, and time, the researcher can use a sample taken from that population. Based on the results of calculations using the Slovin formula with an error rate of 5%, the number of samples studied was 393 respondents.

Sampling Method
According to Sugiyono (2011: 81), the sampling technique is a sampling technique. To determine the sample to be used in the study. This technique is used when the population has members/elements that are not homogeneous and proportionally stratified by using the incenditial technique. Sugiyono, (2011:82).

Data Collection Method
In this study using data collection methods with direct field observations to obtain direct data and information at the Karawang Islamic Hospital, namely: 1. Interview 2. Quisioner 3. Observation

Data Validity Test
This study uses validity test, reliability test and normality test. This is to show that the research instrument in the form of a questionnaire given to respondents is valid, reliable and normal research data.

Data Analyisis
This research uses path analysis. According to Riduan and Kuncoro (2014: 2). Path analysis is used for Path analysis (path analysis) is used to analyze the pattern of relationships between variables with the aim of knowing the direct or indirect effect of a set of independent variables (exogenous) on the dependent variable (endogenous). The analysis design for this research can be seen in Figure  1 below: Hypothesis testing to describe the three research variables statistically is as follows: 1.
Correlation between Service Quality and Trust (t test) Ho : rx1x2 = 0 There is no correlation between Service Quality and Trust. H1 : rx1x2 ≠ 0 There is a correlation between Service Quality and Trust.

Partial Effect of Service Quality and Trust on Patient Satisfaction (t test).
Ho : ρyx1, ρyx2 = 0 There is no partial effect between Service Quality and Trust on Patient Satisfaction.
H1 : ρyx1, ρyx2 ≠ 0 There is a partial effect between Service Quality and Trust on Patient Satisfaction.

Simultaneous Effect of Service Quality and Trust on Patient Satisfaction (F test)
Ho :ρyx1, ρyx2, ρyx2x1 = 0 There is no simultaneous effect between Service Quality and Trust on Patient Satisfaction. H1 :ρyx1, ρyx2, ρyx2x1 ≠ 0 There is a simultaneous influence between Service Quality and Trust on Patient Satisfaction.

Results and Discussion
Based on the results of respondents' responses to each questionnaire, the following will be made a recapitulation of the answers. This aims to determine the criteria or profile and the scale range of the variables studied. The relationship between the two exogenous variables can be seen in table 8 below:  (2-tailed) .000 N 393 393 **. Correlation is significant at the 0.01 level (2-tailed).

Source : SPSS Data Processing Results 2021
The correlation can be seen in Figure 2. below: From the results of the analysis above, it is obtained that the correlation coefficient between the exogenous variables is Service Quality (X1) and Trust (X2) can be assessed at 0.811. If 0.80 -1,000 then the level of Service Quality relationship (X1) and Trust (X2) which is very strong and unidirectional because of the positive value.

Path Analysis
Based on the results of data processing using SPSS 20 software, obtained path coefficients for each variable Quality of Service (X1) and Trust (X2) on Patient Satisfaction (Y). The results of the analysis can be seen in table below: Based on table 8. shows the path coefficient between the variables of Service Quality (X1) and Trust (X2) on Patient Satisfaction (Y).

A. Means of Path Coefficient, Coefficient of Determination, and Partial Effect of Service Quality Variable (X1) on Patient Satisfaction (Y). 1) Service Quality Line Coefficient (X1) Towards Patient Satisfaction (Y)
Based on table 9 the path coefficient of the Service Quality variable on Patient Satisfaction is 0.497. The path coefficient of the Service Quality variable on Patient Satisfaction can be described in the figure below: Based on the results of the analysis above, it is known the magnitude of the direct influence of Service Quality (X1) Against Patient Satisfaction (Y) BPJS Health outpatients at the Karawang Islamic Hospital are 24.7%, meaning that the quality of service can explain its role in increasing patient satisfaction. BPJS Health outpatients at the Karawang Islamic Hospital are 24.7%. Service quality is a factor that affects patient satisfaction. It is hoped that BPJS Health will be able to attract the attention of consumers and improve its quality through the quality of services it has. If the quality of service is considered positive, it will create positive patient satisfaction. Therefore, the author wants BPJS to continue to improve the quality of service to patients. Service quality is an understanding obtained by service providers as a result of the service perceived by the customer with the quality of service expected by the customer. In general, respondents stated that Service Quality is influenced by the indicators revealed in the questionnaire, while the suggestions from the author on the indicators that are considered the lowest are indicators of understanding customer desires, weaknesses in understanding customer desires on these indicators are true because there are still long queues in the queue. For registration, BPJS Health outpatients can wait up to 5 hours, the hospital should suggest using registration using the JKN mobile application so that they no longer have to wait long, making it easier for outpatients and so that patients do not feel different from regular patients. And nurses are advised to be more sensitive to what patients want and need indiscriminately.

3) Partial Effect of Service Quality (X1) on Patient Satisfaction (Y)
The Partial Effect of Service Quality (X1) on Patient Satisfaction (Y) can be seen in table below: Based on table 10, it shows that the partial effect of the Service Quality variable (X1) on Patient Satisfaction (Y) is 0.428 or 42.8%.

B. Means of Path Coefficient, Coefficient of Determination, and Partial Effect of Trust Variable (X2) on Patient Satisfaction (Y). 1) Trust Path Coefficient (X2) on Patient Satisfaction (Y)
Based on table 8 the path coefficient of the Service Quality variable on Patient Satisfaction is 0.446. The path coefficient of the Service Quality variable on Patient Satisfaction can be described in the figure below: Based on the results of the analysis above, it is known that the direct influence of Trust (X2) on Patient Satisfaction (Y) BPJS Health outpatients at the Karawang Islamic Hospital is 19.9%, meaning that Trust can explain its role in increasing patient satisfaction BPJS Health outpatients at Islamic Hospital Karawang by 19.9%.

3) Partial Effect of Trust (X2) on Patient Satisfaction (Y)
The partial effect of Trust (X2) on Patient Satisfaction (Y) can be seen in According Table 11 shows that the partial effect of the Trust variable (X2) on Patient Satisfaction (Y) is 0.379 or 37.9%. Trust is another factor that affects patient satisfaction for BPJS Health outpatients. It is hoped that BPJS Health will be able to understand and provide good trust. If trust is considered positive, positive patient satisfaction will be created. Lack of trust makes patients a little hesitant to use BPJS services, therefore BPJS must be able to convince patients to use BPJS services. Trust in the context of health services is the belief of users of health services (patients) that health service providers care about their welfare. In general, respondents considered agreeing to the indicators on Trust that were revealed in the questionnaire, as for suggestions from the author on the indicators that were rated the lowest, namely the indicators of alertness and fast action, the slow handling of outpatient health bpjs compared to those who did not use, the party should Hospitals can be fair in serving all patients. So far, patients who use BPJS feel that they are stepchildren by the hospital from the start of service, alertness and handling time. The equation of the path is as follows:: = Other variables that are not measured, but affect Y ρyx1 = The path coefficient that describes the magnitude of the direct influence of Service Quality (X1) on Patient Satisfaction (Y) ρyx2 = Path coefficient that describes the magnitude of the influence of Trust (X2) on Patient Satisfaction (Y) rx1x2 = Service Quality Correlation (X1) and Trust (X2) Based on Figure 5 shows that the magnitude of the associative positive degree or path coefficient of the Service Quality variable is 0.497, greater than the Trust variable 0.446, meaning that Service Quality (X1) has a greater contribution to Patient Satisfaction (Y) than Trust (X2). The influence of Service Quality (X1) and Trust (X2) on Patient Satisfaction (Y) can be seen in table below: The overall path analysis test results can be described as shown in the table below: Based on table 13 shows that the coefficient of determination (R2) of 0.807 means that 80.7% of the Patient Satisfaction variable (Y) can be explained by the variables of Service Quality (X1) and Trust (X2), or it can be interpreted that Service Quality (X1) and Trust (X2) has a contribution to Patient Satisfaction (Y) of 80.7% while the remaining 19.3% is the contribution of other variables (ε) which were not studied. Service Quality and Trust jointly have an influence on BPJS Health outpatient satisfaction, therefore to maintain consumer trust, BPJS Health hopes to pay attention to Service Quality and understand BPJS Health outpatient user trust. The better the quality of service and the higher the trust will affect the satisfaction of patients who use BPJS services. Patient satisfaction, how far is a consumer's satisfaction with the goods or services received, because of the expectations he had before the goods or services were received. In general, respondents considered agreeing to the indicators on patient satisfaction revealed in the questionnaire, as for suggestions from the author on the indicators that were rated the lowest by users, namely the indicators of the registration process being not complicated. through which stage first and given an understanding using a language that is better understood by the patient or the patient's family. And the hospital must be willing to give more priority to patients who need more information.

Conclusions
Based on the formulation of the problem and objectives compared with the results of research and discussion, it can give a conclusion as follows.

1.
There is a partial effect between Service Quality and Trust on Patient Satisfaction. a. The partial effect of service quality on patient satisfaction is 42,8%. b. The partial effect of trust on patient satisfaction is 37.9%. Because 37.9% is smaller than 42.8%, it can be stated that service quality contributes more to satisfaction than trust.

2.
Simultaneous effect of service quality and trust on patient satisfaction is 80.7% sig. (0.000) < (0.05). Thus Ho is rejected so that it can be concluded that Service Quality and Trust have an influence on patient satisfaction of 80.7%, while the remaining 19.3% is the contribution of other variables (ε) which were not examined.