The Influence of Hospital Brand Image and Service Quality on the Patients

Loyalty Which IsMediated by the Patients Satisfaction at

Qadr Hospital in Tangerang

Eni Trismiati
Graduate Program in Management Masters Degree at Esa Unggul University Jakarta
enitrismiatisularso@yahoo.co.id

Abstract
Brand image and service qualityare crucial for hospitals to make patients feel
satisfied with the services provided, which will eventually improve the patients
loyalty. The formulation of the problem in this study is to find out whether
hospital's brand image, service quality and patients satisfactioninfluence patients
loyalty. This research aims to determine the effects of hospital brand image
andservice qualityon patients loyalty mediated by the patients satisfaction in
outpatient hospital units of Qadr Hospital Tangerang. The design of this research
is explanatory research. The population in this study are outpatients treated at the
Qadr Hospital with a sample of 150 respondents. Sampling technique used is
accidental sampling method. The data quality testing used Factor Analysis for
validity test and Cronbach's Alpha for reliability test. The collected data is
processed by using SEM (stuctural Equation Model) which is operated by lisrel
8.3 software as a tool of analysis. The results show that hospitalbrand image has a
significant and positive effect on patients satisfaction, brand image has a
significant influence and positive impact on patients loyalty, service quality has a
significant and positive effect on Patients Satisfaction, Service quality has a
significant and positive influence on patients loyalty, and Patients Satisfaction
has a significant and positive impact on patients loyalty. In conclusion, it is
proven in this study that hospital brand image and good quality service can
improve patients satisfaction and loyalty. It is recommended that the
management of Qadr Hospital improve the hospital brand image and service
quality so that both can have an impact on patients satisfaction and
increasepatients loyalty.

Keywords: Hospital Brand Image, Service quality, and Patients Satisfaction

Patients Loyalty

Universitas Esa Unggul

INTRODUCTION
Loyalty is one important
thing that every company has to
build to win the
competition. According to Reicheld
and Sasser in Suhartanto, 5%
increase in customer retention can
increase profits by 25% to 85%, and
60% increase in sales to new
customers is on the recommendation
of customers who are loyal to the
company.
Although it is not too much
different from the product, a brand
gives a significant impact because
itserves as a marker of a service,
which distinguishes it from the
services provided by other service
providers(Rahma, in Thomas
S. Kaihatu). Therefore, the customer
will always take into account
a brand, especially in the hospital
industry, in theiroverall
considerations to identify whether
the service quality provided by a
hospital can give them higher
satisfaction.
Hospital brand image attracts
the attention of conceptual model
researchers intending to identify the
important role ofbrand Image on
patients satisfaction and patients
loyalty. This research refers to a
research conducted by Wu whotested
hospital brand image, Service
quality, Patients satisfaction and
loyalty.
Wu (2009) tested hospital
brand image, Service quality,
patients satisfaction and
loyalty. Four of the six research
hypotheses tested were successfully
proven. The results show that there is
a positive correlation between
hospital brand image with patients
loyalty through improved service
quality and patients
satisfaction. Thomas, S (2011), tested
the Influence ofservice quality onthe
Customers Satisfaction using Brand
Image as the intermediary
variable. From his research, it is
proven that service quality does give
a significant and positive effect on
patients satisfaction and brand
image.
This study is a replication of
a previous study by researcher Chan
Chao Wu, titled The Impact Of
Hospital Brand Image on service
quality, patients satisfaction and
loyalty.The writer modified the
previous study to find out how the
influence of brand image and service
quality are to the patients
loyalty,through the patients
satisfaction in Qadr Hospital.
THE ORETICAL
BACKGROUND
Brand image
Brand image is a set of
customers confidence in a particular
brand (Kotler and
Armstrong). According to Supranto
and Limakrisna, brand image is what
customers think and feel when they
hear or see a brand and what
customers learn about the
brand. Brand image is also called a
schematicmemory brand, containing
the interpretations of the target
market on the product characteristics,
product benefits, usage situation and
marketing characteristics. Another
definition of Brand Image is a set of
customers confidence in various
brands (Kotler & Armstrong). While
Aaker said that the brand association
is something that relates to the brand
in the minds of customers (Aaker)
Service quality
Universitas Esa Unggul

According to
Parasuraman, et.al in MN nasution:
Service quality is a global
judgements or attitude concerning
the superiority of the services
performed by comparing customers
perceptions and
expectations. According to Lovelock
and Lauren: Service qualitys is a
long-term customers cognitive
evaluation of the delivery of services
of a company. Tjiptono and Gregory,
Berry, Parasuraman in MN Nasution
has identified five groups of
characteristics used in evaluating
customers service, as follows: (1)
Tangible, in the form of appearance
of physical facilities, equipment,
personnel and means of
communication; (2) Reliability, the
ability of health services to provide
the promised services immediately
and satisfactorily; (3)
Responsiveness, namely the
willingness of staff to assist
customers and provide responsive
services; (4) Insurance, included in it
the ability, courtesy, and
trustworthiness performed by the
staff who are free from danger, risk
or doubt; (5) Empathy, which
includes the ease of relationships,
good communication, and
understanding of customer needs
Health Care Quality
Service quality is the best
service that is performed by a person,
group or institution that gives
satisfaction to customers or the
public and in turn the satisfaction
will create customers loyalty to a
person or community / group /
institution that provides the services.
3
Good health services must
meet the following basic
requirements (Anwar, 1996): (a)
Available and sustainable, meaning
that the kinds of health services
needed by the public are not hard to
find, and is always available in the
community at all times; (B)
acceptable and reasonable, meaning
that it is not contrary to the
confidence and trust of the
public; (C) Easily accessible, to
achieve good services, the
distribution of health facilities is very
important, so there is no
concentration of health facilities only
in certain areas; (D) affordable,
meaning that health care costs must
be set in accordance with the
peoples economic ability; (E)
Quality, which refers to the degree of
perfection of the health services
provided, which on one hand
satisfies the service users, and on the
other hands its arrangement is in
accordance with the stipulated code
of ethics and standards.
Patients satisfaction
According to oliver in MN
Nasution Customers satisfaction is
an after-sale evaluation, on which
the perception of the performance of
selected products meets or
exceedspre-sale expectations. If the
performance does not meet the
expected perception, dissatisfaction
occurs, according to Kotler and
Keller (2009). Meanwhile, according
to Tse and Wilton in Tjiptono and
Gregory, customers satisfaction is
the customers responses to the
perception evaluation on the
difference between the initial
expectations and the perceived
service after the consumption of the
 4

product. Aditama identifies that purchase. Meanwhile, according to

patients are those treated in
hospital. To create patients
satisfaction, Hospitals must create
and manage a system to obtain more
patients and to retain
patients. However, the efforts to
improvethe perfection of satisfaction
to grab customerscan be done in a
variety of strategies.
Loyalty
Customer loyalty is a repeat
purchase made by a customer for a
commitment to a brand or
company. (Kotler). Mowen and
Minor in Suningsih defines loyalty as
a condition where the customers
have a positive attitude toward a
brand, have a commitment to the
brand, and intend to continue to
purchase in the future. Another
definition of loyalty from
Dhammesta says that customers
loyalty shows a tendency to use a
particular brand with a high level of
consistency. This means that loyalty
is always associated with customers
preferences and actual
Sheth and Mittal in Tjiptono,
customers loyalty is customers
commitment to a brand, stores or
suppliers, based on a very positive
attitude and is reflected in a
consistent repeat purchases.
Hospital
Hospital is a public
facility that serves as a center for
health care, which includes the
prevention and cure for diseases, as
well as the maintenance,
improvement and complete health
recovery. Based on Law No. 44 of
2009 on hospitals, a hospital is a
health care institution that organizes
complete personal health services
that provides inpatient, outpatient
and emergency health
care. WHO (World Health
Organization) explains that hospital
is an integrated social and medical
organization that serves as a center
for health care providers, both
preventive healing and training
center and social-biological research.

Citra
Merek RS
X1
Kepuasan Loyalitas
Pasien Pasien
Y1 Y2

Kualitas
Layanan
X2
HYPOTHESES AND
RESEARCH MODEL
Da Silva et al. States that image
is correlated with customers
satisfaction. On the basis of the the
customers (patient) experience, they
will providejudgements and an
evaluation of the overall service
performance of the hospital. Based
on the comparison of the expected
service qualityand the performed
service quality, customers will leave
a positive or negative or even neutral
emotions, depending on whether the
customer's expectations are met or
not.Based on this, the proposed
hypothesis is as follows:
H 1: Hospital brand image has an
effect on the increase of Patients
satisfaction.
Marilees and Fry discovered that
image has a direct effect on
loyalty. Image is an obvious
predictor of customers
loyalty. Good image will form a
public mindset on where to go to get
health services, that when people
have health problems, they
accordingly will think of a hospital
based on their experiences or based
on the information they have
received. The 2nd hypothesis can be
formulated as follows:
H 2: Hospital brand image has an
affect on the increase of patients
loyalty
Wu, said that high service
qualityis correlated with high
customers satisfaction. Patients
satisfaction serves as a medium for
service quality and behavioral
intentions. The quality of health care
is not just concerned with how
medical personnel provides services
to patients, but also how the patient
feels comfortable with the conditions
and situations that hospitals
create. Thusthe 3rd hypothesis is put
forward, as follows:
H 3: Service qualityhas an affect
on the increase ofPatients
satisfaction
Customer loyalty depicts
customers commitment to reuse
services needed in the future. High
loyalty from the community will
save some costs for the
hospital. When the service
productsrendered by a hospital
exceed expectations, it will lead to
the patients satisfaction so that the
customers intention to re-use the
services will increase. Based on this
hypothesis, the 4th hypothesis is
proposed as follows:
H 4: Service qualityhas an affect
on the increase inpatients loyalty.
Patients satisfaction will
produce a positive impact on the
hospital. If patients are satisfied with
the services provided by the hospital,
they will hold a perception that the
hospital has given good services to
the community. Patients who are
satisfied with the serviceswill have
an increased trust and confidence in
the hospitals optimum service
provision, so that the patients will
remain faithful to use the services of
the hospital in the future. Based on
this, the 5th hypothesis is proposed
as follows: ,
H 5: Patients satisfactionhas an
effect on Patients loyalty
METHOD
Sampling and Data Collection
Universitas Esa Unggul

The data collection is
conducted to obtain data, namely the
primary data,to solve the problem. In
this study, primary data is obtained
by distributing questionnaires to 150
respondents. The sampling technique
used in this study is Accidental
Sampling.
Measures
The research statement has
six responses which use linkert scale
type, ranging from score 1 for
strongly disagree response to score 6
for strongly agree
response. Statements for the variable
of the brand image consists of
facilities, comfortable environment,
confidence in the hospital and the
proper attitudes of the
doctors. Research statements for the
variable ofservice qualityrefer to the
instrument created by
Parasuraman et.al which consist
of tangible, Reliability,
Responsiveness, Assurance and
Empathy. The research statements on
patients satisfaction consist of
satisfaction with hospital services,
and research statements forthe
variableof Loyalty statement consist
of preferences and intention to return
despite relatively high prices.
From all the questionnaires
distributed, the data obtained
showsthat the gender characteristic
of the most respondents was 56.7%
female, the age characteristic was
45.4% between 35-49 years, and the
educational characteristic was 34.7%
educated in high school, the work
characteristic was 50.7% working in
private sectors, the financing
characteristic was 55.3% using
private financing. Of all respondents,
6
as many as 77.3% respondents
visited Qadr Tangerang Hospital
more than 3 times.
Validity Test
In this study, the validity is
tested out using analysisfactor. In the
factor analysis, if the KMO value is
below 0.5, the factor analysis can not
be used or accepted. The acceptable
KMO value is above 0.5, precisely
when it is 0.6 to 0.9. KMO value of
0.9 indicates a very satisfactory
value, while when KMO value is
below0.5, the factor analysis can not
be accepted. From the result of data
validity test conducted, all statements
are considered valid and qualified
for further test.
Test Reliability
Reliability Test is conducted by
using Cronbach Alpha test. Of all the
data that was tested, all Items in the
questionsare considered very reliable
RESULT
Evaluation Model
Measurements (Outer Model)
In this research, validity and
reliability test on each latent variable
will be conducted,namely; variable
image of Brand, Service Quality,
Satisfaction and Loyalty with the
help of lisrel 8.3. Reflexive
individual measurement is
considered valid if it has a loading
value() with a measured latent
variable 0.5, if one ofthe indicators
has a loadingvalue ()<0.5, the
indicator should be dropped because
it would indicate that the indicator is
not good enough to accurately
measure latent variables. To measure
the reliability,the value of Construct
Reliability should be (CR> 0.70)
and Variance Extractshould
 7

be (VE>0.50). If they meet the In this study, a variable is

requirements, indicators are able to
consideredreliable when it has
represent the latent variables.
The results of structural a composite reliability value greater
equation path diagram output than 0.7 and has AVE value greater
using software lisrel 8.3 are as than 0.5. Reliability test result of each
follow, latent variable can be seen in the
Figure 2: T Values table above. Based on the result of
Table 2: The Measurement of Validity and
Reliability Model SEM the above table, it can be concluded
Standardized
Latent T
Indicator Loading Error CRthatVElatent variable of exogenous
Variabels Values
Factor
Hospital brand image and service
CM1 0.6 0.6 12.3 0.6
Hospital CM2 0.8 0.4 16.5 quality have AVEvalues of > 0.5
Brand CM3 0.8 0.4 12.1 0.9and 0.7. As such, latent variables
Image CM4 0.8 0.4 15.7
CM5 1.0 0.0 26.0 of endogenous Loyalty and Patients
Tangible 0.8 0.3 17.2 0.6
satisfactionhave AVE values of > 0.5
Reliability 0.8 0.4 15.7
Service
Responsiveness 0.8 0.3 17.8 0.9and 0.7. Thus, it can be concluded
quality
Assurance 0.7 0.5 14.9 that the indicators used inthe
Emphaty 0.8 0.4 18.1
L1 0.6 0.6 12.2 variablesis
0.5 sufficiently reliable or
Loyalty L2 0.8 0.4 9.3 0.7capable to measure the contructs.
L3 0.7 0.5 9.0
Patients The results of Goodnesfit Of
0.8 0.7
satisfaction K1 0.8 0.4 9.0 Fit test is as follow: the result of Chi-
Square test on exogenous construct
obtain a value of 1.860, which is below
Based on table above, it can
the value of Chi-Square-ValueCutt-
be concluded that all indicators have
off 3, RMR 0073, RMSEA = 0.074,
loading values greater than 0.5 and t
GFI = 0.980, AGFI = 0960 , CFI
value is greater than t table
0970, NFI = 0990, NNFI = 0990, IFI
(1.96). This means that none of the
= 0990, RFI = 0950. These results
indicators were dropped and all
indicate that CONSTRUCTS meet
indicators are valid to measure latent
the criteria offit model (Goodness of
variables.
Fit Indices).
 8

Evaluation of Structural coefficients of path parameter (path

Model (Inner Model) coeficient parameter). The following
Structural model can be is the hypothesis discussed in this
evaluated by looking at the value of study:
R 2 on endogenous variables and
Table 3: Conclusion on Structural Model
Path T
Hypothesis Description
Coefficient Values
Hospital brand image has an
Hypothesis
influence on the increase in 0.35 9.15
Accepted
H1 patients satisfaction.
Hospital brand image has an Hypothesis
influence on the increase of 0.21 2.75 Accepted
H2 patients loyalty
Service quality has an influence on Hypothesis
0.65 14.74
H3 the increase in Patients satisfaction Accepted
Service quality has an influence on Hypothesis
0.32 2,22
H4 the increase of patients loyalty. Accepted
Patients satisfaction has an Hypothesis
0.51 2.08
H5 influence on patients loyalty Accepted

DISCUSSION path coefficient of 0.65 and t value of

Hypothesis 1, brand image
has a significant influence and
positive impact on patients
satisfaction, with a path coefficient
of 0.35 and t value of 9.15, and t
value greater than t table
(1.96). Hypothesis 2, brand image
has a significant influence and
positive impact on patients loyalty,
with a path coefficient of 0.21 and t
value of 9.15. Hypothesis 3, Service
quality has a significant and positive
effect on patients satisfaction, with a
14.74. Hypothesis 4, Service quality
has a significant influence and
positive impact on patients loyalty,
with a path coefficient of 0.32 and t
value of 2.22. Hypothesis 5, Patients
satisfaction has a significant and
positive impact on patients loyalty,
with a path coefficient of 0.51 and t
value of 2.08.
The Influence of Hospital Brand
Image onPatients satisfaction
 9

Based on the results, it is better the brand image hospital is, the
understood that the variable of more loyal the patients will be.
Hospital brand image significantly This study result is inaccordance
influences and has positive impact on with the study conducted byWu
patients satisfaction in the (2010) which discovered that the
Outpatient Unit of Qadr Hospital, brand image of the hospital has direct
Tangerang. This means that the and indirect effects on patients
better the brand image of a hospital loyalty.This means that the brand
is, the more patients will come as image of the hospital, with an
they feel satistfied. addition of service quality, not only
The result above is directly increasespatients loyalty but
similar to the research conducted by also increase patients satisfaction,
Neneng Syamsiah (2009) which and later on increases patients re-
states that there is a positive effect of visit intention.
the brand image on customers
perceived value toward the The Effect of Service quality
hospital. The result of this study also onPatients satisfaction
has a similar result with the studies Based on the results of the study,
conducted by Wu (2010) and the data obtained shows that the
Thomas (2008). variable of sevice quality
significantly influences and has a
The Influence of Hospital Brand positive impact on patients
Image onPatients loyalty satisfaction in the Outpatient Unit of
Based on the results obtained, it Qadr Hospital, Tangerang. This
can be depicted that a variable means that the higher the service
ofhospital brand image significantly quality is, the greater the patients
influences and has a positive impact satisfaction will be.
on Patients loyalty in Outpatient The result supportsthe previous
Unit of Qadr Hospital, research conducted by Thomas. K
Tangerang. This means that the (2011) which discovered that service
quality proved to give a positive and
 10

significant impact on patients

satisfaction.This study also supports The Influence of Patients
the concept proposed by Zeithtml satisfaction on Patients loyalty
and Bitner (1996) which says that Based on the results of the study,
customers satisfaction is influenced the data obtained shows that the
by service quality so that the better variable of patients satisfaction
the service qualityis, the greater the significantly influencespatients
costumer satisfaction will be. Wu satisfaction and has a positive
(2010) also stated that the service impact on patients loyalty in the
quality is highly correlated with high Outpatient Unit of Qadr Hospital,
customers satisfaction. Tangerang. This means that the
higher the patients satisfaction, the
The Effect of Service Quality on more loyal the patients.
Patient Loyality Patients satisfaction will
Based on the result of the study, result in a positive impact on the
the data obtained shows that the hospital. If patients are satisfied with
variable of service quality the services provided by the hospital,
significantly and positively an appreciation that the hospital has
affectspatients loyalty in the given good services to the
Outpatient Unit of Qadr Hospital, communitywill be created. Patients
Tangerang. This means that the who are satisfied with the services
better theservice quality is, the higher will experience an increase in their
the patients satisfaction will be. trust and confidence beleiving that
This study is in line with the the hospital will provide optimum
research conducted by Wu (2010), services for them so that the patients
the result of which implies that the will remain faithful or loyal to the
service quality improves patients hospital in the future.
satisfaction, which in the endof the
day affectspatients loyalty.

CONCLUSION
 11

Based on data obtained and the hospital should pay very much
analysis conducted, it can be attention to the service quality given
concludedas follows: to its patients. Service quality has a
Brand image has a significant significant influence and positive
influence and positive impact on impact on patients loyalty.This
patients satisfaction. The first fourth hypothesis that the service
hypothesis that brand image has an quality has an influence on patients
influence on patients satisfactionis loyaltyis also statistically
statistically proven. Therefore, to proven. Good quality services will
improve patients satisfaction, Qadr have an impact on patients
Hospital is expected to continue to satisfaction and will contribute to
maintain the good brand image of the patients retention and loyalty. The
hospital. Then, the second hypothesis hospital profitability will increase
that brand image has a significant along with the increase in patients
influence and positive impact on loyalty.
patients loyaltyis alsostatistically Patients satisfaction has a
proven. This suggests that a good significant influence and positive
brand image can increase loyalty, impact on patients loyalty. This fifth
which, in the end of the day, will hypothesis that the service quality
affect the profitability of Qadr has an influence on patients
Hospital. loyaltyis statistically proven. Patients
Service quality has a who are satisfied with the services
significant influence and positive will remain faithful to Qadr hospital
impact on patients satisfaction, this in the future.
third hypothesis that the quality of
the service has an influence on Managerial Implications
patients satisfactionis statistically For the managerial
proven. This shows the importance implication of the study, the
of service quality in writerdicovered that this study could
improvingpatients become an input for the management
satisfaction. Therefore, the Qadr of the Qadr Hospital, Islamic Village
 12

Tangerang, which will implicate on expectations. Health facilities as

the managerial policy in accordance supporting means of service quality
with the hospitals priority. can also be improved by ways of,
The results could be used as a i.e., re-painting the building to make
point for consideration and it look brighter and cleaner. In
evaluation on the hospital brand addition, health tools that support
image, service quality, patients service qualityshould always be
satisfaction and patients loyalty. In checked regularly so that the
addition to that, the results of this products of medical examinationare
study can be used to determine accountable. Medical devices that are
factors that can increase a hospital already out of date are supposed to
brand image, service quality, be replaced or updated immediately.
patients satisfaction and patients It is advisable that Qadr
loyalty. It is recommended that the Hospital Management actively
management of Qadr Hospital be evaluate patients satisfaction,
able toimprove the brand image of particularly outpatients,by paying
this Islamic-nuanced attention to questionnaires obtained
hospital. Maintaining a good brand as an evaluation tool to find out the
image can be carried out by levels of patients satisfaction. It is
minimizing errors in running the recommendedthat the management
operations of the hospital. In doing immediately respond for
so, i.e, immediately following up improvement if there is a complaint
complaints of patients such as dirty from patients regarding the service
environment, doctorstardinessand qualityprovided and that the
others are some of the occurring management implementcompetency-
errors. and-capability-based customer
Qadr Hospital Management is relationship strategies in serving the
expected to be able evaluate the customers or patients.
service qualitygiven to its patients, It is also recommended that
particularly outpatients , so that it management pay attention to doctors,
can meet or even exceed the patients nurses and other personnels in Qadr
 13

Hospital in order that they are able to satisfaction. Patients will feel
provide a quality service in satisfied when the service received is
accordance with the existing in accordance with the expectations
standards. Doctors and nurses are the and therefore, strategies to improve
frontline service providers and service quality should be a routine
therefore require necessary education performed program and
and training on a regular basis to isregularlyevaluated. Then, In order
improve the service quality provided to increase patients loyalty, it is
to patients. recommended to enhance service
It is also suggested that the excellence and rid factors that pose
hospital management increase obstacles in increasing patients
patients loyalty in Qadr Hospitalby loyalty.
increasingpatients

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