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

Loyalty Which Is Mediated by the Patient Satisfaction

Eni Trismiati
Program Studi Magister Manajemen, Universitas Esa Unggul, Jakarta. Indonesia
Tel : +622185718001885/ E-mail: enitrismiatisularso@yahoo.co.id

Dr.Rokiah Kusumapradja, MHA

Universitas Esa Unggul, Jakarta. Indonesia
Telp : +62181319645666 / E-mail : rokiah.kusumapradja@esaunggul.ac.id

Abstract
Brand image and service quality are 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 satisfaction influence
patients loyalty. This research aims to determine the effects of hospital brand
image and service quality on 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).
The results show that hospital brand 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 increase patients loyalty.

Keywords: Hospital Brand Image, Service Quality, and Patient Satisfaction

Patient 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 their overall 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 who tested 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 of service quality on
the 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.

THEORETICAL 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 schematic memory 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)

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Service Quality
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 trust worthiness 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.
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 product. Aditama identifies that 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
improve the perfection of satisfaction to grab customers can be done in a variety
of strategies.
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Loyalty
Customer loyalty is a repeat purchase made by a customer for a
commitment to a brand or company. Kotler (2009) 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 purchase. Meanwhile, according to 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.

Research Framework
A hospital must try to follow a strategy of how to improve the quality of service
so that patients were satisfied with the services provided. Therefore, hospitals
must have a brand image positive hospital by providing complete services to
patients. Satisfactory service is expected to affect the loyalty of patients resulted
in increased patient visits.

Brand Image Hospital (X1) has a reputation that is a good indicator of a hospital,
a comfortable environment, Trust Hospital, Right Attitudes of Physicians. While
Quality of Service (X2) can be seen from the five dimensions namely Tangible,
Reliability, Responsiveness, Assurance and Empathy. Patient satisfaction (Y1)
into mediation to the loyalty of patients who have an indicator that patients are
satisfied with the services provided by the hospital. Further more, the influence of
patient satisfaction with the hospital's brand image and quality of service are
positive, it will affect the Patient Loyalty (Y2) having an impact on repeated visits
to hospital patients. Picture of the general framework of this study can be
explained in the figure below:
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H2

Hospital
Brand H1
Image Patient H5 Patient
X1 Satisfaction Loyalty
Y1 Y2
Figure
H3 1 : Research Framework
Service
Quality H4
X2

Figure 1. Research Framework

HYPOTHESIS 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 provide judgements
and an evaluation of the overall service performance of the hospital. Based on the
comparison of the expected service quality and 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. Thus the 3rd
hypothesis is put forward, as follows:
H 3: Service quality has an affect on the increase of patients 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 products rendered by a hospital exceed expectations, it
will lead to the patients satisfaction so that the customers intention to re-use the
 6

services will increase. Based on this hypothesis, the 4th hypothesis is proposed as
follows:
H 4: Service quality has an affect on the increase in patients 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 satisfaction has an effect on Patients loyalty

METHOD
Measures
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.
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 shows that 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, as many as 77.3% respondents visited Qadr 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.
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Reliability Test
Reliability Test is conducted by using Cronbach Alpha test. Of all the data that
was tested, all Items in the questionsare considered very reliable

RESULTS
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 loading value () <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 Extract should
be (VE>0.50). If they meet the requirements, indicators are able to represent the
latent variables.

Based on table above, it can be concluded that all indicators have loading
values greater than 0.5 and t value is greater than t table (1.96). This means that
none of the indicators were dropped and all indicators are valid to measure latent
variables.

Table 1: The Measurement of Validity and Reliability Model SEM

Standardized
Latent T
Indicator Loading Error CR VE
Variabels Values
Factor
CM1 0.6 0.6 12.3 0.6
Hospital CM2 0.8 0.4 16.5
Brand CM3 0.8 0.4 12.1 0.9
Image CM4 0.8 0.4 15.7
CM5 1.0 0.0 26.0
Tangible 0.8 0.3 17.2 0.6
Reliability 0.8 0.4 15.7
Service
Responsiveness 0.8 0.3 17.8 0.9
quality
Assurance 0.7 0.5 14.9
Emphaty 0.8 0.4 18.1
L1 0.6 0.6 12.2 0.5
Loyalty L2 0.8 0.4 9.3 0.7
L3 0.7 0.5 9.0
Patients
0.8 0.7
satisfaction K1 0.8 0.4 9.0
 8

In this study, a variable is considered reliable when it has a composite

reliability value greater than 0.7 and has AVE value greater than 0.5. Reliability
test result of each latent variable can be seen in the table above. Based on the
result of the above table, it can be concluded that latent variable of exogenous
Hospital brand image and service quality have AVE values of > 0.5 and 0.7.
As such, latent variables of endogenous Loyalty and Patients satisfaction have
AVE values of > 0.5 and 0.7. Thus, it can be concluded that the indicators used
in the variables is sufficiently reliable or capable to measure the contructs.
The results of Goodness fit test is as follow: the result of Chi-Square test
on exogenous construct obtain a value of 1.860, which is below the value of Chi-
Square-Value Cutt-off 3, RMR 0073, RMSEA = 0.074, GFI = 0.980, AGFI =
0960 , CFI 0970, NFI = 0990, NNFI = 0990, IFI = 0990, RFI = 0950. These
results indicate that construct meet the criteria of fit model (Goodness of Fit
Indices).

Evaluation of Structural Model (Inner Model)

Structural model can be evaluated by looking at the value of R2 on
endogenous variables and coefficients of path parameter (path coeficient
parameter). The following is the hypothesis discussed in this study:

Table 2: 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
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 path coefficient of 0.65 and t value of
14.74. Hypothesis 4, Service quality has a significant influence and positive
 9

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

Based on the results, it is understood that the variable of Hospital brand
image significantly influences and has positive impact on patients satisfaction in
the Outpatient Unit of Qadr Hospital, Tangerang. This means that the better the
brand image of a hospital is, the more patients will come as they feel satistfied.
The result above is similar to the research conducted by Neneng
Syamsiah (2009) which states that there is a positive effect of the brand image on
customers perceived value toward the hospital. The result of this study also has a
similar result with the studies conducted by Wu (2010) and Thomas (2008).

The Influence of Hospital Brand Image onPatients loyalty

Based on the results obtained, it can be depicted that a variable ofhospital
brand image significantly influences and has a positive impact on Patients loyalty
in Outpatient Unit of Qadr Hospital, Tangerang. This means that the better the
brand image hospital is, the more loyal the patients will be.
This study result is inaccordance with the study conducted byWu (2010)
which discovered that the brand image of the hospital has direct and indirect
effects on patients loyalty.This means that the brand image of the hospital, with
an addition of service quality, not only directly increasespatients loyalty but also
increase patients satisfaction, and later on increases patients re-visit intention.

The Influence of Service Quality on Patients Satisfaction

Based on the results of the study, the data obtained shows that the variable of
sevice quality significantly influences and has a positive impact on patients
satisfaction in the Outpatient Unit of Qadr Hospital, Tangerang. This means that
the higher the service quality is, the greater the patients satisfaction will be.
The result supportsthe previous research conducted by Thomas. K (2011)
which discovered that service quality proved to give a positive and significant
impact on patients satisfaction.This study also supports the concept proposed by
Zeithtml and Bitner (1996) which says that customers satisfaction is influenced
by service quality so that the better the service qualityis, the greater the costumer
satisfaction will be. Wu (2010) also stated that the service quality is highly
correlated with high customers satisfaction.

The Influence of Service Quality on Patient Loyality

Based on the result of the study, the data obtained shows that the variable of
service quality significantly and positively affectspatients loyalty in the
Outpatient Unit of Qadr Hospital, Tangerang. This means that the better
theservice quality is, the higher the patients satisfaction will be.
This study is in line with the research conducted by Wu (2010), the result of
which implies that the service quality improves patients satisfaction, which in the
endof the day affectspatients loyalty.
 10

The Influence of Patients Satisfaction on Patients Loyalty

Based on the results of the study, the data obtained shows that the variable of
patients satisfaction significantly influencespatients satisfaction and has a
positive impact on patients loyalty in the Outpatient Unit of Qadr Hospital,
Tangerang. This means that the higher the patients satisfaction, the more loyal
the patients.
Patients satisfaction will result in a positive impact on the hospital. If
patients are satisfied with the services provided by the hospital, an appreciation
that the hospital has given good services to the communitywill be created. Patients
who are satisfied with the services will experience an increase in their trust and
confidence beleiving that the hospital will provide optimum services for them so
that the patients will remain faithful or loyal to the hospital in the future.

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

Managerial Implications
For the managerial implication of the study, the writer dicovered that this
study could become an input for the management of the Qadr Hospital, Islamic
Village Tangerang, which will implicate on the managerial policy in accordance
with the hospitals priority. The results could be used as a point for consideration
and evaluation on the hospital brand image, service quality, patients satisfaction
and patients loyalty. In addition to that, the results of this study can be used to
determine factors that can increase a hospital brand image, service quality,
patients satisfaction and patients loyalty. It is recommended that the
 11

management of Qadr Hospital be able to improve the brand image of this Islamic-
nuanced hospital. Maintaining a good brand image can be carried out by
minimizing errors in running the operations of the hospital. In doing so, i.e,
immediately following up complaints of patients such as dirty environment,
doctorstardiness and others are some of the occurring errors.

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