DETERMINANT OF LOYALTY OF EXECUTIVE CLASS PATIENTS AT AMBULATORY SERVICES AT SILOAM HOSPITALS TB SIMATUPANG DURING COVID-19 PANDEMICS

. Business competition in the health industry is getting tighter, especially since the COVID-19 pandemic has significantly decreased patient visits. This study aims to determine the determinants of executive patient loyalty at the Siloam Hospitals TB Simatupang outpatient installation during the COVID-19 pandemic era. This research is quantitative research with an observational research design. The study population consisted of 520 patients with a sample of 84 patients with research instruments using a questionnaire. The results of the study stated that most respondents were loyal to services at the executive clinic, with an NPS of 50%. Customer satisfaction, service quality, perceived value, trust, hospital brand image, and commitment significantly and positively affect executive patient loyalty. Specifically, the commitment variable has a direct influence on loyalty. Customer satisfaction, service quality, trust, hospital brand image, and OCB indirectly affect loyalty. Commitment (0.865) is the most influential variable on patient loyalty. Furthermore, the variables customer satisfaction (0.541), trust (0.484), service quality (0.425), OCB (0.249), hospital brand image (0.107) respectively also have a degree of influence on patient loyalty


INTRODUCTION
Business competition in the health industry is getting more challenging, especially between hospitals.This can be seen from the growth in the number of hospitals in Indonesia which has been increasing from year to year, where DKI Jakarta Province is ranked fourth in terms of private hospital growth in Regional 1 after East Java, West Java and Central Java.(1) People are reluctant to go to the hospital for treatment during the COVID-19 pandemic and of course this affects the income costs to meet the operational needs of the hospital, especially with the increasingly tight competition in the hospital world today.
Siloam Hospitals TB Simatupang is one of the Siloam Hospitals Group hospitals in the elite area of South Jakarta that does not cooperate with BPJS Kesehatan.At the beginning of 2020, this hospital decided to have the newest superior service in the outpatient unit, namely the executive clinic.
Patient loyalty is the key to healthcare providers' business success and provides the best health impact for patients.(2)Many dimensions affect patient loyalty in the hospital.The results of an integrated review conducted by Zhou et al. (2017) from various sources (PubMed, CINAHL, OVID, ProQuest and Elsevier Science Direct) regarding the determinants of patient loyalty in healthcare providers, found that there were eight determinants of patient loyalty, namely: satisfaction, quality, value, brand image, trust, commitment, OCB (Organizational Citizenship Behavior), and customer complaints.Loyal patients are more likely to return to the same health service, spread positive word-of-mouth and recommend it to others.(2)On the other hand, patients who are disloyal will very easily switch to other health services and spread negative news to others.(3)However, since the COVID-19 (Coronavirus Disease 2019) pandemic, there has been a significant decrease in the number of outpatient visits at Siloam Hospitals TB Simatupang.In addition, the researchers also conducted a brief telephone survey of outpatients at Siloam Hospitals TB Simatupang in June 2020.Based on information from the patients, they did not feel the need to go to the hospital because they were not in a sick condition, and others said they still felt afraid and worried about visiting the hospital because of the COVID-19 pandemic.Therefore, this research is expected to provide an overview of the determinants of executive patient loyalty to face increasingly fierce business competition in the era of the COVID-19 pandemic.

METHODS
This type of study is quantitative with a survey method and is descriptive-analytic with a crosssectional approach.The study population was all Siloam Hospitals TB Simatupang executive clinic patients (520 patients), and the study sample was carried out by accidental purposive sampling.These patients came for treatment at the Siloam Hospitals TB Simatupang executive clinic (82 patients) with exclusion criteria, namely patients who were not willing to be research respondents.
Before data collection, the researcher administered an ethical review to the Research Ethics and Community Service Commission FKM UI with the certificate number for approval for this research ethics: Ket-721/UN2.F10.D11/PPM.00.02/2020.This study began with collecting and processing data obtained from questionnaires using a Likert scale, then tested for validity, reliability, and normality.The data processing results will be analyzed further to answer the research objectives by conducting a path analysis to see the relationship between the independent and dependent variables.

Distribution of Respondent Characteristics
This study examines the characteristics of respondents based on age, gender, education, occupation, and sources of medical expenses.
Moreover, statistical analysis shows that the adult age group (20-60 years), female gender, residence distance of ≤5km from Siloam, personal payment method, obtaining information from relatives and family regarding the executive clinic are the most respondents in this study.4) Besides, this study found that some passive respondents (45.2%) were almost in balance with the number of promoters.This finding is a signal that needs to be responded to because customers in the passives category have the potential to switch to becoming customers of other hospitals.(4)

Variable Trust to Loyalty
This study reveals a significant and positive influence between trust and loyalty.Trust is a desire to depend on a trusted partner, so trust is the main predictor of loyalty in relationships in the service industry.(5,6) This is also in line with various studies which state that the higher the level of patient trust, the more loyal the patient is to a hospital.Even patients who trust a particular hospital tend not to consider moving or changing their destination hospital.(6)(7)(8)(9)(10)(11)

Variable Commitment to Loyalty
This study reveals a significant and positive influence between commitment and loyalty.Commitment is essential in building mutually beneficial long-term relationships that will eventually form loyalty to a brand, store, or supplier based on a positive attitude and is reflected in consistent repeat purchases.(12) It is in accordance with research on outpatients at RSI Gondanglegi which shows that most patients have high loyalty and are committed to staying in treatment when they switch membership to become BPJS participants.(13) Other studies have also found that patient commitment significantly affects patient loyalty.(10,14)

Variable Customer Satisfaction to Loyalty
This study reveals a significant and positive influence between customer satisfaction and loyalty.Customer satisfaction is the most important factor in linking customer loyalty.If the customer is satisfied, then the customer will buy the product or service again and again.(14,15) This is in accordance with various studies on patients in hospitals that customer satisfaction is positively related to customer loyalty.(16)(17)(18)

Variable Service Quality to Loyalty
This study reveals that there is a significant and positive influence between service quality on loyalty.The perceived quality of service at the hospital is a subjective evaluation of service from the patient's perspective.(19) The measuring model/instrument developed to assess service quality based on consumer perceptions is the SERVQUAL (Service Quality) scale with five dimensions, namely: tangibles, reliability, responsiveness, assurance, individual attention (empathy).(20) Based on research Fatima, Malik and Shabbir (2018), aspects of healthcare quality (physical/environmental, staff friendliness, responsiveness, communication, privacy and security) have a significant relationship with patient loyalty which is intervened by patient satisfaction.(17)

Hospital Brand Image Variable on Loyalty
This study reveals that there is a significant and positive influence between hospital brand image and loyalty.Through a good brand image, customers are expected to get satisfactory service quality so as to increase the degree of customer satisfaction which in the end the customer becomes loyal.(21) This is consistent with research which states that brand image increases patient satisfaction through improving perceived service quality, which in turn increases intention to return.(22) The results of other studies state that the brand image of hospital is capable of being a significant intervening variable on marketing mix variables and patient loyalty.(16) Other studies also state that high hospital image is significantly related to patient loyalty.(23)(24)(25)(26)

Variable Perceived Value to Loyalty
This study reveals that there is a significant and positive influence between perceived value on loyalty.Perceived value is the comparison between the benefits received by the customer and the sacrifices that must be made when using the service.(8,27) This result is also in line with another study stating that patients' perceived value is related to patient loyalty, both directly and indirectly, through customer satisfaction.(28) Another study was conducted on 165 patients in educational hospitals in Indonesia and concluded that perceived value is related to patient loyalty.(29)

Executive Patient Loyalty Determinant Path Analysis
Based on statistical results, found several exogenous variables that are not related to endogenous variables, it is necessary to repeat the regression analysis for models that are not significant.With reference to the results of the path analysis above, the implications found to answer the problem formulation of this study are as follows:

Only the commitment variable can explain patient loyalty.
Only the commitment variable has a direct influence on loyalty.Of the various statements contained in the commitment variable, the patient's emotional relationship with nurses and staff at the executive clinic is the main reason patients continue to use their services, which is the item with the lowest mean value.Based on this, management can help improve the patient's emotional relationship with nurses and staff at the executive clinic, especially during the COVID-19 pandemic which requires care, interpersonal communication skills, and proactivity from officers.

Customer satisfaction, service quality, trust, hospital brand image,and OCB has an indirect effect on patient loyalty.
Based on the results of statistical tests, patient satisfaction with the speed of service at the executive clinic is the lowest satisfaction in customer satisfaction.Jdoctor's appointment on timeis an item that is considered to have the lowest service quality in service quality.The average respondent said that their visit was not the first visit to the trust variable.Siloam TB Simatupang has a good image and reputationis the item with the lowest mean value in the hospital brand image.And patients also feel that all officers at the executive clinic are not on time in the OCB variable.
Based on the results above, it can be seen that the average patient who visits the executive clinic is an old patient and complains about the speed of service, the doctor's schedule, and the punctuality at the executive clinic.In addition, Siloam TB Simatupang also needs to improve its image and reputation, especially for executive clinic services.Moreover, the hope is that the executive clinic can become a one-stop service for patients who want excellent and comfortable treatment services, especially during the COVID-19 pandemic.Due to this pandemic, many people are reluctant to go to the hospital and prefer to use telematic-based health applications.Therefore, Siloam Hospitals TB Simatupang needs to implement a new normal policy in treating patients, namely through the image of a clean and safe hospital.

The results also show that commitment (0.865) is the variable with the largest total effect of all variables.
This means that commitment is the most influential variable on patient loyalty.Furthermore, the variables customer satisfaction (0.541), trust (0.484), service quality (0.425), OCB (0.249), hospital brand image (0.107) respectively also have a degree of influence on patient loyalty.

CONCLUSION
Based on the research results, there are several conclusions, namely: Customer satisfaction, service quality, perceived value, trust, hospital brand image, and commitment have a significant and positive influence on patient loyalty executives at Siloam Hospitals TB Simatupang.Besides that, variable commitment has a direct influence on loyalty.Customer satisfaction, service quality, trust, hospital brand image, and OCB indirectly affect loyalty.And commitment (0.865) is the most influential variable on patient loyalty.Furthermore, the variables customer satisfaction (0.541), trust (0.484), service quality (0.425), OCB (0.249), hospital brand image (0.107) respectively also has a degree of influence on patient loyalty.

RECOMMENDATIONS
Hospital management in the future must always prioritize increasing patient commitment, as well as customer satisfaction, trust, service quality, OCB, hospital brand image to achieve patient loyalty.Several things that can be done are to improve the patient's emotional relationship with nurses and staff at the executive clinic, especially during the COVID-19 pandemic which requires caring, interpersonal communication skills, and proactivity from officers.It is hoped that the executive clinic can also become a one-stop service for patients who want excellent and comfortable treatment services, especially during the COVID-19 pandemic.In addition, it is necessary to routinely evaluate the customer feedback forms in outpatient installations, especially executive clinics so that the services received by patients meet their expectations.
Besides that, dealing with this pandemic, many people are reluctant to go to the hospital and prefer to use telematic-based health applications.Therefore, a new normal policy is needed in handling patients, namely through a clean and safe hospital image, as well as policies related to guidelines for using telematic-based health applications.

Table 1 .
Distribution of Respondent Characteristics Respondent in Siloam Hospitals TB Simatupang 2022