The Effect of Service Quality on Satisfaction and its Implications on Trust (A Survey on Patients at RSGM Maranatha)

Hospital services are currently an absolute thing in marketing its services, various problems that occur in terms of service can be identified, even though the service products provided are not the focus of the problem, it needs to be considered because service is a parameter in selling services at hospitals. This study attempts to discuss the effect of service quality and trust on patient satisfaction at RSGM Maranatha Bandung City. The research method used in this research is descriptive and verification method. The population in this study were patients who used health services at RSGM Maranatha Bandung City. The number of samples used was 100 people based on slovin calculations. The data collection method used in this study was a questionnaire. Analysis of research data using Path Analysis with the help of the SPSS for Windows data analysis tool. The results of the study show that service quality variables affect patient trust and satisfaction. Patient satisfaction affects trust and patient satisfaction is able to mediate the effect of service quality on patient trust.


INTRODUCTION
The quality of health services is the level of perfection of health services carried out in accordance with the established code of ethics and service standards, resulting in satisfaction for each patient. Quality service is needed because it is the right of every customer, and can provide an opportunity to win the competition with other health service providers. The quality of service and value has a direct impact on customers. Quality service is needed because it is the right of every customer, and can provide an opportunity to win the competition with other health service providers.
World Health Organization(WHO) put forward the dimensions of quality (quality) of Hospitals in SPM (Minimum Service Standards) referring to a view in determining the assessment of the type and quality of services seen from access, effectiveness, efficiency, safety and security, comfort, continuity of service, technical competence, and human relations(Fortunately Kuzairi, 2021).
As a manifestation of the realization of health development in Indonesia, the government is obliged to provide and improve both health services and services for the community. Meeting the need for health services is not impossible for people who are less fortunate. The underlying reason is that health is a human right and one of the elements of welfare that must be realized in accordance with the ideals of the Indonesian people as meant in Pancasila and the preamble to the 1945 Constitution of the Republic of Indonesia, so that every activity and effort to improve health status society that is maximally carried out based on non-discriminatory, participatory, protective and sustainable principles which are very important for the formation of Indonesian human resources, One of the health service facilities in question is a hospital. The development of medical science and technology is quite rapid at this time, there are many things that hospitals can do to help patients seek treatment. In addition to the main goal of helping patients, hospitals also have other goals as follows(Dedy Alamsyah, 2011): 1) As an organization that brings together organized medical personnel with permanent medical facilities that aim to provide medical services, continuous nursing care, diagnosis and treatment of patient diseases. 2) As a place for sick people to receive medical services as well as a place to organize clinical education for medical students, nurses and various other health professional staff. In Indonesia, dental and oral health efforts have not been carried out in a comprehensive, integrated and sustainable manner and implementation that is maintenance, improvement and protection of dental and oral health is still lacking.(Ministry of Health, 2018). Dental and oral health services are all efforts to prevent and treat disease, as well as restore and improve dental and oral health which are carried out on the basis of the relationship between dentists and other dental health workers with individuals or communities who need them. (RI Ministry of Health, 2007). Dental health services are no longer the main service but are development services, so they need to be reorganized. Based on this, the government issued Law No. 36 of 2009 concerning Health, article 93 paragraph 1 states that dental and oral health services are aimed at maintaining and improving the degree of public health in the form of improving dental health, preventing dental disease, treating dental disease, and restoring dental health. by the government, regional government, and/or the community which is carried out in an integrated, integrated and sustainable manner.
Nationally, according to 2018 Riskesdas data, as many as 57.6% of Indonesia's population had dental and mouth problems over the last 12 months, but only 10.2% received treatment by dental medical personnel. Based on age group, the largest proportion with dental and oral problems was in the 5-9 years age group (67.3%) with 14.6% having received treatment by dental medical personnel. Meanwhile, the lowest proportion with dental and oral problems was aged 3-4 years (41.1%) with 4.3% having received treatment by dental medical personnel at the Hospital.(Ministry of Health, 2018).
The hospital is one of the basic health services which is a reference for the community, one of which is RSGM Maranatha which is a dental and oral hospital in the city of Bandung. Oral Dental Hospital (RSGM) Maranatha is one of the oral dental hospitals that provides dental and oral health services for all levels of society, which is also used as a means of learning and educational process for students of the dental profession program. Maranatha Oral Dental Hospital also provides comprehensive dental health services and is supported by general and specialist dentists as well as supported by adequate facilities and modern technology. RSGM operations based on government Regulation Minister of Health number 1173 of 2004, according to its function can be divided into two, namely RSGM education and non-educational RSGM. RSGM education is an RSGM that provides dental and oral health services, which is also used as a means of learning, education and research for dental health professionals and other health workers and is bound through collaboration with the faculty of dentistry. In order to obtain more detailed information regarding hospital operations, researchers conducted an initial survey to obtain patient information regarding perceived service quality, service satisfaction and patient trust. Data collection was carried out for 20 patients at RSGM Maranatha on 14 July 2021 using a closed questionnaire with three scales, namely good, sufficient and not good regarding the quality of service at RSGM Maranatha which can be seen as follows: RSGM Maranatha has made various innovations to improve the quality of services such as by implementing online registration, conducting training for medical, non-medical and paramedical staff which aims to provide satisfaction to patients who use health services at RSGM Maranatha Bandung City. Hospitals are required to provide quality services based on existing operational standards and affordable by the community. Patients demand services that are efficient, ready, comfortable, and responsive to sick patients (Mulyadi, D. Fadli, M. Fitriyani Cipta, nd) The preliminary study conducted also found that patient satisfaction with the services of RSGM Maranatha Bandung City was still not optimal. The patient's answer to the statement of satisfaction with the service that was felt gave the highest answer with the satisfaction category of only 55% at the point of the assessment carried out. More details can be seen in table 1.2 below: Subsequent assessments were carried out on consumer trust regarding the services of RSGM Maranatha Bandung City which were also found to be still not optimal. It was known that respondents in the good category had the highest score on the integrity aspect of 65%, followed by the ability aspect of 55% and the confidence aspect of 45%. A more detailed explanation can be seen in  (Supartiningsih, 2017)showed different results, where the tangible variable had a negative and insignificant effect on patient satisfaction, reliability had a positive and significant effect on patient satisfaction, responsiveness had a positive and insignificant effect on patient satisfaction, assurance (assurance) has a positive and significant effect on satisfaction and the variable empathy (empathy) has a negative and not significant effect on patient satisfaction at Sarila Husada Sragen Hospital in Outpatient Patients.
Technological advances and the era of globalization are growing rapidly, people can easily get information about the quality of service as desired, if the hospital is not able to compete and improve according to consumer needs then it is certain that there will be a decrease in patient visits and service quality. One of the Hospital's strategies to increase patient visits is by improving the quality of health services. If consumers are satisfied with the services provided, it is likely that consumers will be loyal to the hospital (Rosalia & Purnawati, 2018).
Patient loyalty as a form of patient satisfaction is an integral part of health service quality assurance activities, meaning that measuring the level of patient satisfaction must be an activity that cannot be separated from measuring the quality of health services. The dimension of patient satisfaction is one of the most important dimensions of the quality of health services. Good service quality will lead to customer satisfaction or service users (patients). (Andriani, 2017).
Based on this description, it can be concluded that RSGM Maranatha must be able to improve its performance in providing health services supported by an information system that is up to date, accurate, transparent and accountable so that it can be used as an evaluation of hospital performance. This can have an impact on people's perceptions negatively or positively if not managed properly.
Therefore researchers are interested in conducting a study of the effect of service quality on satisfaction and its implications for patient trust at RSGM Maranatha Bandung City.

METHOD
The research method used in this study is a quantitative method with a verification approach. According to (Sugiyono, 2019)Quantitative Research method, namely quantitative data measurement and objective statistics through scientific calculations derived from a sample of people or residents who were asked to answer a number of questions about the survey to determine the frequency and percentage of their responses. Meanwhile, according to verification research (Sugiyono, 2019)is aimed at knowing the relationship between two or more variables, or the method used to test the truth of a hypothesis in a study intended to test a theory and will try to produce a scientific method, namely the status of a hypothesis in the form of a conclusion, whether a hypothesis is accepted or rejected.
The quantitative method used in this research is to conclude whether there is an influence of the independent variables on the dependent variable. This study was to determine the magnitude of the influence of service quality, trust on patient satisfaction at RSGM Maranatha.
Population according (Sugiyono, 2019)states that the population is the area of generalization of objects that have certain qualities and characteristics determined by the researcher to be studied and then drawn conclusions. The population in this study were patients who used health services at the Maranatha Hospital in Bandung City, totaling 24,190 people based on data on the number of outpatient and inpatient visits at health care facilities in the publication "Bandung City Health Profile 2019" by the Bandung City Health Office. The number of respondents in this study was 99.58 which was rounded up to 100 respondents

RESULT Outer Model Analysis
The analysis of this stage aims to define and specify the relationship between latent variables and the construct of a variable. Based on the tests that have been carried out, the following is a picture of the research model:

Figure 3. Full SEM-PLS model using SMARTPLS Software Validity and Reliability Test
The validity test can be seen through the Everage Variance Distracted (AVE) value. AVE describes the average variance or discriminant extracted for each indicator, so that the ability of each item to divide measurements with the others can be known. AVE value equal to or above 0.5 indicates a good convergent. While the reliability test can be seen from the Cronbach Alpha value. Cronbach's Alpha aims to calculate a construct that can be evaluated. A good indicator group is if it has a Cronbach's alpha value > 0.70. Based on the tests that have been carried out, the following are the results of the validity and reliability tests:

Evaluation of the Coefficient of Determination (R2)
Evaluation of the suitability of the inner model is seen through the coefficient of determination or R2. Test Based on the results of data analysis, the following is the value of the coefficient of determination: The results of table 4.6 explain that the first model is known that the Rsquare value of the service quality variable on trust has a value of 0.450. The acquisition of this value explains that the percentage of trust can be explained by service quality of 45.0% and the remaining 55% can be explained by variables that are outside the focus of discussion in this study. In addition, the Rsquare value of the service quality variable on trust and patient satisfaction has a value of 0.171. The acquisition of this value explains that the percentage of trust can be explained by service quality of 17.1% and the remaining 82.9% can be explained by variables that are outside the focus of discussion in this study.

Path Analysis Test
The path coefficients test is used to see whether the path coefficient value is positive, if it is positive then the effect of a variable on is unidirectional, but if the value of an exogenous variable increases then the endogenous variable also increases. Conversely, if the path coefficient value is negative, then the effect of a variable on is in the opposite direction, if an exogenous variable increases, the value of the endogenous variable decreases. If the pvalues are < 0.05 then the effect of exogenous variables on endogenous variables is significant, and if the probability value is > 0.05 it means that the effect of exogenous variables on endogenous variables is not significant. Based on the tests that have been carried out, the following are the results of the path coefficients test: The results from table 4.7 explain that the service quality variable on trust has a coefficient value of 0.203 with a P-value of 0.022 <0.05, so it can be said that the effect of service quality on trust is significantly positive, then H1 is declared accepted. The variable service quality on satisfaction has a coefficient value of 0.413 with a P-value of 0.000 <0.05, so it can be said that the effect of service quality on satisfaction is significantly positive, then H2 is declared accepted. Then for the variable satisfaction on trust has a coefficient value of 0.561 with a P-value of 0.000 <0.05, so it can be said that the effect of satisfaction on trust has a significant positive effect, then H3 is accepted. Besides that, The results of the first hypothesis showed that there was a significant positive effect on the quality of services provided by RSGM Maranatha Bandung City on patient trust, so the first hypothesis in this study was accepted. The results of this research indicate that the high quality of services provided by RSGM Maranatha Hospital in Bandung City will have an effect, conversely if the quality of services provided is low it will affect the decrease in patient confidence.

DISCUSSION The Effect of Service Quality on Patient Trust
The results of this study are in line with the results of research by Suhermin and Hermawati (2021); Kartikasari et al (2014) and Wididana (2016). Trust is a person's willingness to depend on another party with a certain risk. Customers are the main focus in business, because without customers the company cannot earn profits to run its business. Therefore, the main thing that must be done is to provide quality service so as to create trust to get loyal customers to the company (Anindya, 2017 in Suhermin and Hermawati, 2021).
Integrity is matters related to company behavior in providing services and running its business (Mayer, et al., 1995);Kim, et al., 2003); Kartikasari et al., 2014)). The company's efforts to create good service quality aim to form relationships between customers and companies and foster customer trust in the company. The process of creating patient trust in service quality is based on their experience with the company. Experience is the basis for creating customer confidence in the company's ability to meet expectations. This experience will affect consumer evaluations in consumption, use directly and indirectly with companies (Costabile, 2002in Kartikasari et al., 2014.

Effect of Service Quality on Patient Satisfaction
The results of the second hypothesis showed that there was a significant positive effect on the quality of services provided by RSGM Maranatha Bandung City on patient satisfaction, so the second hypothesis in this study was accepted. The results of this research indicate that the high quality of services provided by RSGM Maranatha Hospital, Bandung City, will affect the increase in patient satisfaction, conversely if the quality of services provided is low it will affect the decrease in patient satisfaction.
The results of this study are in line with the results of research by Suhermin and Hermawati (2021), Sutrisno (2016), and Wididana (2017). Good service quality will create emotional judgments and increase satisfaction. Companies must provide satisfying service to their customers because if consumers are satisfied with the services provided by the company, they will be able to create strong and profitable relationships for the company (Bakti andSumaedi, 2015 in Suhermin andHermawati, 2021). In addition, the services provided are able to meet or exceed the expectations or expectations of the customer, so the customer feels satisfied. Hospitals must improve the quality of their services to patients, where the higher the quality of services provided will create a tendency for patient behavior that benefits the company.
The quality of health services refers to the level of perfection of health services in creating a feeling of satisfaction for each patient. The more perfect the satisfaction, the better the quality of health services. However, relatively good service quality may not necessarily satisfy patients. In general, patients cannot assess technical competence, so they assess service quality from non-technical characteristics or interpersonal relationships and service convenience (Blank 1982in Supartiningsih, 2017. As a service provider that provides various kinds of services for consumers, customer satisfaction is the main goal that must be met by the company. Consumer satisfaction is the level of one's feelings after comparing the performance/results he feels with his expectations (Kotler andKeller, 2007 in Supartiningsih, 2007).

The Effect of Patient Satisfaction on Patient Trust
The results of the third hypothesis showed that there was a significant positive effect on patient satisfaction given RSGM Maranatha Bandung City on patient trust, so the third hypothesis in this study was accepted. The results of this research indicate that if patient satisfaction is higher it will affect the increase in patient trust, conversely if patient satisfaction with the services provided is low, it will affect the decrease in patient trust.
The results of this study are in line with the results of research by Suhermin and Hermawati (2021) and Wididana (2016). Overall patient satisfaction is the result of the situation before, during and after treatment. The quality of health care, the quality of doctor and patient communication, the length of time waiting for health services, the quality and quantity of medical equipment, the quality of the clinical environment and the cost of care affect patient satisfaction (Tang, 2013in Tanudjaya, 2014. Patient trust in the hospital is not formed in a short time or just one time. Patient trust in a dental clinic can be formed through positive experiences and satisfaction with the services provided so far (Suki, 2011in Tanudjaya, 2014. In creating trust in patients, the hospital must minimize or avoid work errors that can occur. Thus, the patient will feel satisfied with the care services provided and later the patient's trust will be formed in the hospital (Tanudjaya, 2014).
Patient satisfaction is an important thing to consider in building patient trust. Satisfaction with the services obtained will influence the level of decision on the next visit. Patients and families will visit again if they are satisfied, and believe in the quality of services provided. Thus, patient satisfaction must be increased by providing the best service, so that patient trust can be built (Wididana, 2017).

The Role of Satisfaction as Mediation in the Relationship between Service Quality and Patient Trust
The results of the fourth hypothesis showed that patient satisfaction was able to mediate significantly the effect on the quality of services provided by RSGM Maranatha Bandung City on patient trust, so the fourth hypothesis in this study was accepted. The results of this research indicate that patient satisfaction will improve the quality of services provided by RSGM Maranatha Bandung City so that it will increase patient confidence.
The results of this study are in line with research by Suhermin and Hermawati (2021), Wididana (2017) and Kartikasari et al (2014). Satisfaction is an important factor to influence the relationship between service quality and trust. When patients have high satisfaction, the hospital will provide and develop positive behavior towards the quality of services it provides to patients. When a hospital provides good quality service to patients, patients will indirectly trust the hospital as their place of treatment. Increased patient trust in the hospital will create a successful relationship between the hospital and its patients.
Increased competition requires every hospital to be able to provide maximum health service satisfaction for patients, so they are reluctant to turn to other hospitals, even patients are considered to be passive marketers for hospitals by conveying positive recommendations by word of mouth. ) which is beneficial to the hospital. If the relationship between satisfaction and patient trust is positive, then high satisfaction will increase patient trust (Wididana, 2017).
Satisfaction is an attitude towards the results of the transaction which is expected to influence further behavior. Meanwhile, trust is the customer's perception of the company's ability based on experience or leads to transaction stages which are characterized by the fulfillment of product performance expectations and the achievement of satisfaction (Costabile,  Kartikasari et al, 2014). That is, patient satisfaction is a mediator variable that links service quality to patient trust.

CONCLUSION
Based on the test results of the research data and the elaboration in the discussion, the following conclusions can be formulated: 1. Hypothesis 1 which states that service quality influences patient trust in this study is stated to be supported and the hypothesis is accepted. That is, the high quality of services provided by RSGM Maranatha Hospital in Bandung City will have an effect, conversely if the quality of services provided is low it will affect the decrease in patient confidence. 2. Hypothesis 2 which states that service quality influences patient satisfaction in this study is stated to be supported and the hypothesis is accepted. That is, the high quality of services provided by RSGM Maranatha Hospital, Bandung City, will affect the increase in patient satisfaction, conversely if the quality of services provided is low it will affect the decrease in patient satisfaction. 3. Hypothesis 3 which states that patient satisfaction influences patient trust in this study is declared supported and the hypothesis is accepted. That is, the higher patient satisfaction will affect the increase in patient trust, conversely if patient satisfaction with the services provided is low, it will affect the decrease in patient trust. 4. Hypothesis 4 which states that patient satisfaction can mediate the effect of service quality on trust in this study is declared supported and the hypothesis is accepted. That is, the satisfaction felt by patients will improve the quality of services provided by RSGM Maranatha Bandung City so that it will increase patient confidence.