Patient Satisfaction Level at the Outpatient in University of Muhammadiyah Malang Hospital

Introduction: The hospital is one of the health care facilities expected to provide appropriate health services and information for patients and the broader community. Patient satisfaction is one of the essential things for health care providers as a measuring tool to evaluate service quality. Satisfaction can increase the number of visits that impact increasing sources of income for hospitals and, at the same time, realize a healthy and prosperous society. Objectives: The purpose of this study was to identify patient satisfaction in the outpatient installation of the Muhammadiyah Malang University Hospital in indicators of conformity with expectations, ease of obtaining services, and willingness to recommend. Methods: The design of this research is descriptive observational. The sample in this study were patients who visited the outpatient installation of the University of Muhammadiyah Malang Hospital in November 2020; as many as 136 respondents were selected by accidental sampling. Data collection with a patient satisfaction questionnaire. Data analysis with descriptive analysis and presented in the frequency distribution. Results: The results showed that as many as 68.4% of respondents stated that the service was as expected, 52.2% were easy to access services, 50.7% were willing to recommend to other parties, and 54.4% said they were satisfied. Conclusions: Patient satisfaction with the University of Muhammadiyah Malang Hospital in several indicators is relatively high, but it needs improvement in several respects. Nurses, doctors, and other human resources need to maintain good service delivery by providing appropriate, fast, always smiling, and friendly service to patients.


Introduction
All health issues in the Sustainable Development Goals (SDGs) are integrated into one goal: to ensure a healthy life and promote well-being for all people of all ages. The development of the health sector for the SDGs is highly dependent on the active role of all stakeholders, including the government, the business world, social institutions, professional organizations, and academia. As one of the health service centers, the hospital, managed by the government and social institutions, has a significant role in making it happen. Owned resources can ensure sustainability by improving the service system from low-performing to high-performing (Squires, 2019). patient satisfaction could be increasing the number of community visits in utilizing health facilities to realize good health degrees. Therefore, hospitals are required to continue to improve the quality of their services to provide visitor satisfaction.
Patient satisfaction is the level of one's feelings after comparing the performance or perceived results to expectations. Good service in a hospital can provide satisfaction to the patient.
If the results felt by the patient are the same or exceed expectations, a feeling of satisfaction and dissatisfaction will arise. If the patient is satisfied with the services provided, of course, the patient will feel comfortable, happy, and the patient will feel more confident in the services provided (Yuliani et al., 2015). The level of patient satisfaction with services is an essential factor that can do a service that is responsive in dealing with patient complaints, can minimize time and costs, and maximize the effect of service on patients (Awalinda et al., 2019).
Patient satisfaction who seeks treatment at the hospital will increase visits to increase the source of income for the hospital. Patient dissatisfaction is most often expressed concerning the attitude and behavior of officers, among others: delays in the services of doctors and nurses, doctors are difficult to find, doctors who are less communicative and informative, length of the admission process, aspects of service, and environmental order and cleanliness (Ismail, 2018). Satisfaction or dissatisfaction of patients or hospital visitors can contribute to evaluation tools to improve their performance.
Many studies on patient satisfaction have been carried out, such as the study in Banda Aceh by Kamil (2012). Research in Baturetno by Handayani (2016) measures the level of satisfaction with the dimensions of tangibility, reliability, responsibility, and empathy. Some of these research results found that the average value of patient satisfaction ranges from 50% -80% of respondents. Still, there is also a score of an index of patient satisfaction that is only 40.8%. In this study, researchers measured satisfaction by looking at the satisfaction indicators: conformity with expectations, ease of obtaining services, willingness to recommend, and patient satisfaction. Conformity with expectations is a job perception and assessment of expectations (Sitio & Ali, 2019). acceptability is a significant aspect of patient satisfaction, and it can easily obtain services (Dyer et al., 2016). Willingness to recommend is increasingly being used to measure and manage patient loyalty. However, there is little data in the literature linking the willingness to recommend questions with service quality items commonly used in surveys to identify critical drivers of the optimal patient experience (Lis et al., 2011).
This study aimed to identify the level of satisfaction of outpatients in the Outpatient Installation of the General Hospital of the University of Muhammadiyah Malang.

Methods
The design of this research is descriptive observational. The population in this study were patients who visited the outpatient installation of UMM RSU in November 2020 as many as 212 people. The sample selection used an accidental sampling technique with the following criteria: 1) communicate verbally well and could read and write, 2) registered as a patient at UMM RSU, and 3) willing to be a respondent obtained 136 people. The instrument of data collection using a questionnaire was then analyzed by descriptive analysis.
Data collection was obtained from direct sources by using a questionnaire. The questionnaire that measures patient satisfaction includes three indicators, namely: conformity with expectations consisting of 3 questions, ease of obtaining consisting of 2 questions, and willingness to recommend there are three questions. Answers using a 5 Likert scale, namely strongly disagree, disagree, neutral, agree and strongly agree. In comparison, the questionnaire for patient satisfaction consists of 15 questions with answers using 4 Likert scales, namely always, often, sometimes, and never. Cronbach's Alpha validity test > 0.05 indicates an Instrument is valid and reliable.

Characteristics of respondents
The characteristics of the respondents are shown in table 1 and table 2; it is found that the majority are female as many as 77 people (56.6%), the last education level is SMA/SMK as many as 81 people (59.6%), working as many as 94 respondents (69.1%), marital status of 125 respondents (91.9%), and the average age is 40.5 years with a minimum age of 25 years and a maximum age of 63 years.

Patient Satisfaction
This study measures patient satisfaction based on indicators: conformity of expectations, ease of obtaining services, willingness to recommend, and level of satisfaction. The results showed that as many as 68.4% of respondents stated that the service was in line with expectations, 52.2% said it was easy to access services, 50.7% were willing to recommend to other parties, and 54.4% said they were satisfied with the service.

Conformance to Expectations
Patient satisfaction results from the gap between an expected thing and the characteristics perceived by the patient from the service received. Patient satisfaction is seen as an attitude that results from the confirmation or disconfirmation of expectations compared to the reality received in the service (Kamil, 2011). The first indicator of patient satisfaction is the conformity of expectations. Conformity of expectations matches the wishes that become expectations compared to the reality they receive. The product or service received, the service received, and the facilities obtained are by the expectations of the patient or visitor. This assessment indicator assesses the perceptions of patients or hospital visitors to the work of health facilities (Sitio & Ali, 2019).
Based on Figure 1, it was found that of the 136 respondents, the majority, 93 (68.4%), stated as expected, and 43 (31.6%) did not meet expectations. Respondents felt that 1) the services provided in the outpatient department of UMM RSU were following the wishes of the patient; 2) during treatment, professional employees always serve the patient; and 3) existing facilities are in line with expectations, for example, a comfortable treatment room. While in another study conducted by Tuami et al. (2018) that patient satisfaction can be obtained if the patient gets something that is in line with expectations, which can be in the form of expertise and skills of medical and nursing staff, attitudes and behaviour of medical and nursing staff, quality of the physical environment such as lighting, space arrangement, ventilation, waiting time and queues (Tuami et al., 2018).

Ease of Obtaining Services (accessibility)
The ease in obtaining services or accessibility offered by the outpatient installation of the University of Muhammadiyah Malang Hospital with a strategic location located on the Batu-Malang axis road makes it very easy for patients to come and complete health services are available that patients get treatment according to their needs. Patients also feel that the administrative process is easy and fast at the outpatient installation of UMM RSU. In this study, 52.2% of patients visiting the polyclinic of UMM Hospital were satisfied in obtaining access to services.
Access is usually defined as access to services, providers, and institutions in health care. According to some experts, access complements health services because services can be reached with good access to services (Fitri et al., 2016). This result certainly gives input to the management of RSU UMM to further improve the accessibility of facilities with a method that adapts to advances in information technology.
Accessibility is an important aspect of good general practice in improving performance. Patients tend to prioritize the ease of getting services so that service accessibility simultaneously affects hospital patient satisfaction (Raivio et al., 2014). The affordability of health services is closely related to patient satisfaction. Patient satisfaction is related to service quality, so service is called quality if users of health services can reach the service.

Willingness to Recommend
Willingness to recommend is the willingness of patients or service recipients to provide recommendations for services or health check services to friends, family, and or other parties in utilizing the service products offered because of satisfactory service, having complete medical equipment, and adequate facilities. The Willingness to Recommend Question is increasingly used to measure and manage patient loyalty. However, there is little data in the literature linking the willingness to recommend questions with service quality items commonly used in surveys to identify critical drivers of the optimal patient experience (Lis et al., 2011).
Based on Figure 1, it is known that out of 136 respondents, 69 respondents (50.7%) were willing to recommend and 67 respondents (49.3%) were not willing to recommend. Willingness to recommend this includes statements: 1) suggesting other people seek treatment at UMM Hospital because the service is good, 2) UMM Hospital has complete medical equipment, and 3) service facilities are attractive, comfortable, and clean. As research conducted by Cancer Treatment Centers of America (CTCA), the willingness to recommend this is related to service quality. Patient-reported service quality assesses the extent to which an individual's health care experience matches their expectations, which can influence a patient's willingness to recommend a healthcare provider to friends and colleagues. On the other hand, Previous treatment history was found to be predictive of a patient's willingness to recommend, so that newly diagnosed patients were more likely to recommend compared to those who had been previously treated. Age and gender are not significant; patients in the intervention room are more likely to recommend the room to others who need services (Lis et al., 2011;Quan et al., 2012).

Satisfaction Level
Satisfaction is a patient's response to the suitability of patients' level of interest or expectations before receiving services with after they receive. According to Kotler (2004) in Nursalam (2014), satisfaction is a person's feeling of pleasure that comes from comparing the pleasure of activity and a product with his expectations. Satisfaction is a person's feelings of pleasure or disappointment that arise after comparing his perceptions or impressions of a product's performance or results and expectations. Patient satisfaction is related to the quality of hospital services. By knowing the level of patient satisfaction, hospital management can improve service quality (Alawiyah, 2018;Nursalam, 2014) The study results are described in Figure 1 states that from 136 respondents, 74 respondents (54.4%) were satisfied with the patient's satisfaction, and 62 respondents (45.6 %). The level of satisfaction in this study assessed the satisfaction of patients visiting the polyclinic of the University of Muhammadiyah Malang with the services received, which included: nurses always maintain their appearance, be friendly with a smile and greet, offer help without being asked, provide easy-to-understand explanations, be thorough and skilled in nursing actions., provide support and motivation to visitors. The level of community satisfaction, especially patients who visited the polyclinic of RSU UMM, was felt because they felt the quality of service at the level of good nurse performance. This is following research conducted by Jaya & Syarufuddin (2015) that the service quality of Dr. Cipto Mangunkusomo has a significant influence on customer satisfaction (Jaya & Syarufuddin, 2015). This is also consistent with a satisfaction survey at the UK's National Health Service (NHS) hospice that patients' assessment of their care is strongly related to their trust in nurses and doctors and their perception of whether there are sufficient nurses to provide the care needed. Nurses are significant figures related to patient perceptions of service quality (Aiken et al., 2018).

Conclusion
The majority of patients who visited and carried out examinations at the outpatient installation of the University of Muhammadiyah Malang Hospital expressed satisfaction that most of what was obtained was in line with their expectations. Most of the patients felt that it was easy to obtain services. Most of the patients were also willing to recommend others to take advantage of the outpatient unit-Jalan RSU Muhammadiyah University Malang as a choice of health facilities. Indeed, the satisfaction felt in various dimensions has not been maximized, which is only in the <70% satisfaction range, so hospital management and leaders need to improve performance, completeness of facilities, and the ability of all hospital staff in terms of quality and quantity.