2

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 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 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 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 Patients Satisfaction

Patients Loyalty

1

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
2
2
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.
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
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,
2009). While Aaker said that the
brand association is something that
relates to the brand in the minds of
customers (Aaker, 2010)

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
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.
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
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
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.

Citra
Merek RS
X1 Kepuasan Loyalitas
Pasien Pasien
Y1 Y2
Kualitas
Layanan
X2

HYPOTHESES AND satisfaction. On the basis of the the

RESEARCH MODEL customers (patient) experience, they
Da Silva et al. States that image will providejudgements and an
is correlated with customers 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
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,
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
be (VE>0.50). If they meet the
requirements, indicators are able to
represent the latent variables.
The results of structural
equation path diagram output
using software lisrel 8.3 are as
follow,
 2

Figure 2: T Values
Table 2: 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

Based on table above, it can each latent variable can be seen in

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.
In this study, a variable is
consideredreliable when it has
a composite reliability value greater
than 0.7 and has AVE value greater
than 0.5. Reliability test result of
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 AVEvalues of >
0.5 and 0.7. As such, latent
variables of endogenous Loyalty and
Patients satisfactionhave AVE
values of > 0.5 and 0.7. Thus, it
can be concluded that the indicators
used inthe variablesis sufficiently

7
reliable or capable to measure the offit model (Goodness of Fit
contructs. Indices).
The results of Goodnesfit Of
Fit test is as follow: the result of Chi-
Square test on exogenous construct Evaluation of Structural
obtain a value of 1.860, which is Model (Inner Model)
below the value of Chi-Square- Structural model can be
ValueCutt-off 3, RMR 0073, evaluated by looking at the value of
RMSEA = 0.074, GFI = 0.980, AGFI R 2 on endogenous variables and
= 0960 , CFI 0970, NFI = 0990, coefficients of path parameter (path
NNFI = 0990, IFI = 0990, RFI = coeficient parameter). The following
0950. These results indicate that is the hypothesis discussed in this
CONSTRUCTS meet the criteria study:

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
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.
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.
CONCLUSION
Based on data obtained and the
analysis conducted, it can be
concludedas 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 loyaltyis statistically proven. Patients
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
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.
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
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
writerdicovered 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
management of Qadr Hospital be
able toimprove 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, doctorstardinessand
others are some of the occurring
errors.
Qadr Hospital Management is
expected to be able evaluate the
service qualitygiven to its patients,
particularly outpatients , so that it
can meet or even exceed the patients
expectations. Health facilities as
supporting means of service quality
can also be improved by ways of,
i.e., re-painting the building to make
it look brighter and cleaner. In
addition, health tools that support
service qualityshould always be
checked regularly so that the
products of medical examinationare
accountable. Medical devices that are
already out of date are supposed to
be replaced or updated immediately.
It is advisable that Qadr
Hospital Management actively
evaluate patients satisfaction,
particularly outpatients,by paying
attention to questionnaires obtained
as an evaluation tool to find out the
levels of patients satisfaction. It is
recommendedthat the management
immediately respond for
improvement if there is a complaint
from patients regarding the service
qualityprovided and that the
management implementcompetency-
and-capability-based customer
relationship strategies in serving the
customers or patients.
It is also recommended that
management pay attention to doctors,
nurses and other personnels in Qadr
Hospital in order that they are able to
provide a quality service in
accordance with the existing
standards. Doctors and nurses are the
frontline service providers and
therefore require necessary education
and training on a regular basis to
improve the service quality provided
to patients.
It is also suggested that the
hospital management increase
patients loyalty in Qadr Hospitalby
increasingpatients
satisfaction. Patients will feel
satisfied when the service received is
in accordance with the expectations
and therefore, strategies to improve
service quality should be a routine
performed program and
isregularlyevaluated. Then, In order
to increase patients loyalty, it is
recommended to enhance service
excellence and rid factors that pose
obstacles in increasing patients
loyalty.
 2

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