Evaluation of service quality and complaint handling on outpatient satisfaction at the pharmaceutical installation of mokoyurli

ABSTRACT


Introduction
The quality of pharmaceutical services provided by health staff in hospitals greatly affects satisfaction levels.Moreover, friendly health staff in hospitals who quickly provide services can affect the improvement of the quality of services (Rikomah, 2017).Outpatient satisfaction from pharmaceutical installation services can be measured using the servqual method.This method consists of five dimensions: tangible evidence, responsiveness, assurance, reliability, and empathy (Parasuraman et al., 1988).Tangible evidence is related to physical facilities, completeness, and the appearance of staff.Responsiveness is associated with the staff's speed to respond and help patients.Assurance is associated with the knowledge and politeness of the staff and can increase patient confidence.Meanwhile, reliability is associated with reliable and precise service providers.Finally, empathy is associated with staff who have a sense of concern for patients (Parasuraman et al., 1988).
Patients assess that service is considered quality if they are satisfied with the provided services.Providing services to patients is inseparable from their complaints which occur if they begin to get a service that does not meet their expectations.Patients submit their complaints because they want the hospital to reconsider its services.Patients' complaints that are immediately solved will make them more satisfied.According to (Pohan, 2007), patient satisfaction is the expected result of health services.
This research employed the servqual concept to describe satisfaction levels by investigating the difference between expectations and services.The differences would cause gaps, consisting of gaps 1, 2, 3, 4, and 5.The combination of gaps 1 to 4 is gap 5 (Windasuri & Susanti, 2016).Thus, this study only investigated the results of analyzing gap 5.Meanwhile, the outpatients' satisfaction levels were investigated using the customer satisfaction index (CSI) method.This method can determine overall patient satisfaction scores (Sumarwan, 2019).The servqual concept was then developed in the IPA model (importance-performance analysis) to measure consumers' desires and investigate a company's strategies to achieve a quality product.The IPA model consists of four parts and is bounded by two perpendicular and intersecting lines, X and Y lines; the lines are then described in a Cartesian diagram (Supranto, 2011).Research on the quality of services is necessarily conducted because the measurement of patient satisfaction is crucial.Therefore, satisfaction should be measured periodically and meticulously (Pohan, 2007).
This study aims to determine the quality of services from five dimensions, such as tangible evidence, reliability, responsiveness, assurance, and empathy, using the servqual method.The level of patient satisfaction was measured using the customer satisfaction index (CSI).Meanwhile, the quality of services and handling of outpatients' complaints were identified using the importanceperformance analysis (IPA) method.Research on the quality of services for outpatients in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital was necessarily conducted.Based on outpatients' explanations and a brief interview with the pharmaceutical installation staff of the hospital, the most frequent complaints of outpatients deal with the inconvenient waiting rooms and long waiting-time for medicine.The satisfaction measurement is crucial and should be done along with the measurement of quality dimensions of health services.

Materials and Methods
This is a descriptive study that employed qualitative and quantitative approaches.This research was conducted by distributing questionnaires to outpatients who received services in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital and interviewing the complaint management staff and pharmaceutical installation staff of the hospital.The subjects of this study were outpatients who received services in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital.The patients were selected using the purposive sampling method.Meanwhile, the number of samples was selected using the Slovin formula, as follows (Ismail, 2018).The data were collected by distributing questionnaires to the outpatients and interviewing the complaint management staff and the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital.The questionnaires distributed to the patients contained performance and expectation statements to gain the servqual results, customer satisfaction index, and importance-performance analysis.Meanwhile, the complaint management staff and the pharmaceutical installation staff were interviewed to determine responses to the associated attributes in the main priority.
This study began with examining related journals and then observing the pharmaceutical installation of Mokoyurli Buol Hospital.The next step was distributing the questionnaires to outpatients to test the questionnaires' validity and reliability.These questionnaires contained performance and expectation statements.These Questionnaires were adapted from (Parasuraman et al., 1988) and (Satibi et al., 2021).The valid and reliable questionnaires were then redistributed to the patients.The questionnaires completely answered by the patients were then analyzed.The last step was interviewing the complaint management staff and pharmaceutical installation staff about attributes in the main priority quadrants to determine responses to attributes that were necessarily improved and frequently complained by the patients.

Data Analysis
The data analysis began with the servqual analysis to investigate the differences between perceptions and expectations, known as the "gap" of services, by using the following formula (A.Parasuraman et al., 1985).
The gap is considered as positive when the K > H. Thus, the service is considered surprising and very satisfying.
Meanwhile, the gap is considered zero when K = H.Thus, the service is considered quality and satisfying In contrast, the gap is considered negative when the K < H. Thus, the service is considered less quality and not satisfying.
The next analysis was the customer satisfaction index (CSI) to determine overall customer satisfaction scores by showing the service indicators.The steps to determine the CSI are as follows (Aritonang Lerbin R, 2005) in (Zulhazizah et al., 2018).Determining the score weight (WS) obtained from the results of multiplication between the WF and the MSS with the formula of WSj = WFj X MSSj Determining the customer satisfaction index (CSI) with the formula of The final analysis employed the importance-performance analysis (IPA).The steps of this analysis are as follows (Supranto, 2011).
Calculating the adherence (Tki) levels between performance level and expectation levels with the formula of Tki = The description of each item is divided into four quadrants, as follows (Martilla & James, 1977).Quadrant A refers to factors/attributes considered affecting patient satisfaction and pivotal service elements.The management could not execute the quadrant based on the patients' expectations.As a result, the services are disappointing or unsatisfying.

Importance
Quadrant B refers to basic service elements successfully implemented by the hospital.Thus, this success must be maintained because it is crucial and satisfying.
Quadrant C refers to factors with less important influence on the patients while its implementation is mediocre.Thus, the services are considered less important and less satisfying for the patients.
Quadrant D refers to factors with less important influence on patients, but its implementation is very excessive.As a result, the service is considered less important but highly satisfying the patients.

Results and Discussion
This research was conducted in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital to examine 100 outpatients of the 1,046 total population.The results of the validity test showed that the questionnaires about reality and expectations were valid.Each item is considered valid if the r-table < r-count (Herlina, 2019).The result of the reliability test is above 0.6 indicating that the questionnaires are good.

Servqual Analysis
The servqual analysis or gap of outpatients was conducted by investigating five dimensions: tangible evidence, reliability, responsiveness, assurance, and empathy.The results of the analysis are summarized in the following Table 1.Table 1 shows that the average score between reality and expectations on the tangible evidence dimension is negative (-0.6).The results of this study are in line with the research by (Fan et al., 2017), which has discovered that patients' perception of the quality of service could not meet their expectations.The attribute with the smallest gap is the easily accessible location of the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital.Meanwhile, the attribute with the largest gap is the physical facilities.The location of the pharmaceutical installation of Mokoyurli Buoul Regional Public Hospital has a negative value with the smallest value because some patients have argued that another hospital has a pharmaceutical installation nearer to the examination room.Therefore, the patients have considered that the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital is more distant than that of another hospital.This research agrees with (Yuliati et al., 2016), who discovered that the smallest gap refers to the easily accessible and strategic location of outpatient pharmaceutical installations.
The attribute with the largest gap is related to physical facilities.The patients stated that physical facilities, such as a waiting room in the pharmaceutical installation of the hospital, were inadequate and hot.They also sometimes had to stand when taking the medicines due to an insufficient number of seats.These findings are in line with the research by (Yuliati et al., 2016), which has revealed that the largest gap in the tangibility dimension is an attribute of physical facilities, such as buildings, waiting rooms, and uncomfortable environments for outpatient patients.The overall score of the tangibility dimension shows a negative gap.This finding agrees with (Nangaro et al., 2019), who have discovered several negative gaps in the tangible evidence dimension.
Table I shows that the average score of the gap analysis on the reliability dimension is -0.1.This score indicates a difference between reality and expectations.The attribute with the smallest gap refers to clear service procedures in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital.Meanwhile, the attribute with the largest gap refers to the explanation about medicine prices.The attribute with the smallest gap (-0.05) refers to clear service procedures in the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital.Some patients argued that a pharmaceutical installation located inside the hospital building has made them confused to find it when submitting the prescription.It probably occurs because the information of the pharmaceutical installation is covered by other patients who are standing in front of the windows of the installation.
The attribute with the largest gap (-0.2) is to the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital who explain the prices of the received medicine.The pharmaceutical installation staff only explains medicine prices to general patients (non-health insurance).In contrast, the staff does not explain medicine prices to patients with health insurance (BPJS) although some of them want to know the prices.As a result, some patients showed disagreement in the reality part.Meanwhile, some patients showed disagreement, agreement, and strong agreement in the expectation part.The reliability dimension is the dimension with the smallest gap.This finding disagrees with research by (Pareraway et al., 2016), which has discovered that the reliability dimensions give the lowest satisfaction to outpatients with the biggest gap.
Table I shows that the average score of the gap analysis on the responsiveness dimension is -0.84.The attribute with the smallest gap (-0.21) is the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital who always help patients gladly.The difference between reality and expectations leads to the emergence of a negative gap in this attribute.The attribute with the largest gap (-1.81) is the patients' short waiting time to manage prescriptions.This finding shows that general patients do not perceive the expected reality in this attribute.Outpatients consider that they have to wait a long to manage their prescription.The connection of outpatient prescription, inpatient, and emergency rooms is one of the causes of long waiting times.This finding agrees with research by (Nangaro et al., 2019), which has deployed that the reliability dimension has a negative value.Furthermore, Table I shows that the average score of the gap analysis on the assurance dimension is -0.16.The attribute with the smallest gap (-0.08) is the patients' assurance to receive the correct medicine.This attribute is associated with the largest gap referring to the patients' safety feeling when delivering the prescription to the pharmacist.Some of the patients showed disagreement answers.They explained that they did not know if they had delivered the prescriptions to a pharmacist or not.According to some patients, they will still feel safe even though the medicine is given by a pharmacist's assistant.Meanwhile, in the part of expectations, some patients have suggested that the pharmacists should introduce themselves and tell the patients if the one who is handling the medicine is a pharmacist or not.However, the limited number of pharmacists disables them to serve many patients; thus, they are sometimes assisted by a pharmacist assistant to provide services.This finding agrees with research by (Sulo et al., 2019), which has revealed that the assurance dimension has a negative gap, which signifies that outpatients' satisfaction in the pharmaceutical installation has not been fulfilled.The pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital willingly help and give solutions to the problems of my treatment.
3.47 3.75 -0.28 The pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital gladly find an alternative medicine following my financial conditions.
3.17 3.45 -0.28 The pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital observe patients' faces when handing medicine.Table I shows that the average score of the gap analysis on the empathy dimension is -0.25.The attribute with the smallest gap (-0.2) is the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital who try to understand patients' complaints.This attribute still has a negative gap because some respondents' answers in the reality part showed disagreement with such a statement.However, the respondents' answers in the expectation part showed agreement with such a statement.This finding indicates that the pharmaceutical installation staff should more comprehensively understand the patient's complaints.The attribute with the largest gap (-0.3) is the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital who deliver medicines by observing patients' faces.During the pandemic, medicine delivery is hindered by the window; thus, the staff could not maximally observe patients' faces when handing over medicines.Such a condition has triggered some patients to argue that the staff does not observe their faces when handing over the medicines.Patient satisfaction based on the empathy dimension is inseparable from the staff's sense of care to the patients who need help (Sari et al., 2019).

Customer Satisfaction Index (CSI)
The results of the CSI analysis show that patient satisfaction from the service quality and complaint handling is categorized as fairly satisfying with a value of 56.53%.The outpatient satisfaction from the pharmaceutical installation of Mokoyurli Buol Regional Public Hospital can increase along with the improvement of quadrant A in the importance-performance analysis method.

Importance Performance Analysis (IPA)
The IPA method is used to describe performance and expectations (Sari, 2018).The description of each item is divided into four quadrants, as follows: The attribute in the tangible evidence dimension included in quadrant A is the physical facilities.The patients have complained about the waiting room and insufficient numbers of seats that made them stand up when waiting for the medicines.This finding agrees with research by (Nangaro et al., 2019), which has discovered that seats in a pharmaceutical installation should be added to accommodate many patients because some of them must stand up while waiting for the medicines.
The interview was conducted after the respondents' answers to the statement of performance and expectations had been analyzed.The interview with the pharmaceutical installation staff was aimed to determine responses of attributes in quadrant A. In the interview, the coordinator of the outpatients pharmaceutical installation explained that the waiting room was inadequate, and the pharmaceutical installation was still under construction.These complaints had been confirmed to the management.The result of the interview with the head of the pharmaceutical installation shows that the outside waiting room makes the patients less comfortable.In fact, the outside waiting room is only used during the pandemic.The lack of seats sometimes makes the patients stand up when waiting for medicines.Cleanliness and comfort are important to create patients' high loyalty to the hospital (Chairunnisa & Puspita, 2017).(Megawati et al., 2016) have revealed that one of the patients' complaints is about waiting room facilities; in fact, the waiting room is a service that affects patient satisfaction.
The attribute in the responsiveness dimension included in quadrant A is the patients' long waiting time when managing their prescriptions.The patients stated that they had to wait a long time for medicines, especially when the queue was a lot.This finding agrees with the research by (Astuti & Kundarto, 2018), which has discovered that one of the priorities necessarily fixed is the prescription service that should be provided precisely and quickly by the pharmacists.Respondents' complaints related to the long waiting time cause long queues of patients, especially at certain hours.The coordinator of the outpatient pharmaceutical installation explained that the process of medical services was relatively long because the pharmacists served the inpatients, outpatients, and emergency rooms.The medicine administration is prioritized for patients who are newly hospitalized and administered as cito patients.There were initially two pharmaceutical counters inside the hospital building.However, during the Covid-19, the counters were moved outside the building.
Based on the results of the interview, the long waiting time for medicines is caused by the availability of one counter.All prescriptions for outpatients, inpatients, and emergency rooms are connected in one place to submit the prescription.This finding is in line with the research by (Purwanto et al., 2015), which has discovered that the long waiting time occurred because the pharmaceutical installation of Blambangan Regional Public Hospital only uses one counter for the queue system.
The attribute of the responsiveness dimension categorized in quadrant A is the pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital who clearly explain when the medicine will be given.The patients said that they were not informed about how long they should wait.The outpatient coordinator and the head of the pharmaceutical installation stated the pharmaceutical installation staff always informed the patients about how long they should wait for medicines.However, since the waiting room is hot and less comfortable, the patients become impatient.The head of the pharmaceutical installation also argued such information should be provided to patients.Informing the exact duration of waiting time depends on each individual or service provider.
The next attribute of the responsiveness dimension is the adequate number of pharmaceutical installation staff at Mokoyurli Buol Regional Public Hospital during rush hours.The average answers of the respondents showed disagreement and strong disagreement with the statement.The patients argued that one of the causes of the long waiting time for medicines was an inadequate number of pharmaceutical installation staff, who serve patients.This finding is in line with the research by (Sulo et al., 2019), which has discovered that the cause of patients' long queues is the lack of pharmaceutical installation staff during the rush hours.The results of the interview with the outpatient coordinator and the head of pharmaceutical installation show that the hospital has many pharmaceutical installation staff.However, the connection of outpatient, inpatient, and emergency rooms makes the pharmacy management interrupted.The emergence of Covid-19 has made the pharmaceutical installation staff work in shifts.The reduction of pharmaceutical installation staff causes the patients to think that the number of staff is insufficient to serve the patients during rush hours.
The next attribute categorized in quadrant A is the handling of complaints.The patients argued that they had frequently complained about the less convenient waiting room.However, their complaints were not solved quickly.As a result, they have not seen any fair and reasonable solutions for their complaints.The complaint handling flow in Mokoyurli Buol Regional Public Hospital describes that complaints from patients can be directly delivered to the head of the pharmaceutical installation.During the interview, the pharmaceutical installation staff, who firstly handle patients' complaints, stated that the complaint about the improvement of the pharmaceutical installation had been done by forwarding the complaint to the hospital management.If the complaints are unresolved at that time, they will be discussed with the management of public and employment affairs.
The next attribute is the patients' ignorance about the hospital's phone number, social media, or email address.The lack of information from public relations leads to the patients' ignorance to contact the hospital at any time when they have complaints about services.The management staff who handles complaints necessarily regards the issue of patients' lack of information about the hospital's social media to deliver their complaints.This finding is in line with the research by (Muhadi, 2016), which has revealed that since technological information, such as social media, has increasingly advanced, the hospital should adjust and develop social media-based services.

b) Quadrant B
The attribute in the tangibility dimension categorized in quadrant B is the pharmaceutical installation staff who always wear uniforms as scheduled.The medicine needed by the patients is always available.However, some of them sometimes should buy the medicine outside the hospital because their medicine is out of stock.Fortunately, such an incident rarely occurs.The location of the pharmaceutical installation of the Hospital is very close to the hospital lobby.After the patients complete the medical examination, they can easily reach the pharmaceutical installation.
The attribute in the reliability dimension categorized in quadrant B is the pharmaceutical installation that always provides punctual services.Outpatients who come in the morning mostly complete their medical examination at 9 or 10 AM.At these hours, the pharmaceutical installation staff have been ready to service the patients.The pharmaceutical installation of Mokoyurli Buol Hospital has clear service procedures because the process of prescription submission is simple and Calculating the mean importance score (MIS) obtained from the MIS of each indicator with the formula satisfaction score (MSC) obtained from the MSC of each indicator with the formula factors (WF) obtained from the presentation of the values of MIS of each indicator in the total of MIS of all indicators with the formula of WFj = interest scores Calculating the average scores of performance and customer expectations with the formula of The average score of the implementation levels Y ̅ = The average score of the consumer interests n = Number of respondents Furthermore, the values of X and Y were plotted on a Cartesian diagram.The formula to gain the boundar lines (X, Y) is as follows.attributes/facts that can affect patient satisfaction Fig. 1.Importance-performance analysis in Cartesian

Table 1 .
The servqual analysis or gap of outpatients was conducted by investigating five dimensions Tangible evidence, reliability, responsiveness, assurance, and empathy

Table 1 (
Continue).The servqual analysis or gap of outpatients was conducted by investigating five dimensions Tangible evidence, reliability, responsiveness, assurance, and empathy