Outpatient’s Satisfaction Analysis of Pharmaceutical Service in Pharmacy Installation in Reksodiwiryo Hospital Padang

Background : Currently, Indonesia's health development began to emphasize improving the quality of health care, where service quality should be oriented to customer satisfaction to continue to exist during global competition. This study aims to determine the level of satisfaction of outpatients at the depot pharmacy installation at Reksodiwiryo Padang Hospital. Method : This research is a cross-sectional study design. Sampling was carried out from February to March 2022 with a sample of 425 people using the accidental sampling technique. Data were analyzed using univariate and Cartesian diagrams. The sample is outpatient in pharmacy installation Reksodiwiryo Padang. Result : Patients are dissatisfied with all dimensions, there is the tangibles dimension (70.6%), the reliability dimension (66.1%), the responsiveness dimension (57.4%), the assurance dimension (49.6%), and dimensions of empathy (38.8%). In the Cartesian diagram analysis, the most questions were category B, then C, A and finally D. There are two attributes involved in quadrant A, there is the punctuality of the officers in serving and the drug items are always available. Conclusion : Most of the respondents expressed dissatisfaction with the services received at the pharmacy installation of the Reksodiwiryo Hospital. The hospital management can refer to the cartesian diagram analysis to prioritize better improvement. This is an open-access article under the CC–BY-SA license.


Introduction
Patient satisfaction is a feeling of pleasure that arises after receiving services received or experienced directly [1]. One component that makes patients less satisfied is that the officers provide services that are not fast, precise, and responsive to the services desired by patients [2].
Hospital is a health service institution that provides complete individual health services [3]. Health services in hospitals can be in the form of outpatient services, inpatient services, and emergency services which include medical services, medical support, nursing and midwifery services, and non-medical services [4]. Distribution, compounding, monitoring drug use, monitoring of adverse drug reactions, and drug information services are the main services provided through the Hospital unit [5].
In health services, measuring patient satisfaction with the Servqual method has often been used and is considered one of the most valid methods [6]. SERVQUAL is built on the comparison of two main factors, namely the customer's perception of the real service they receive (Perceived Service) with the actual service that is expected/wanted (Expected Service). The five dimensions of Servqual are RATER (Reliability, Assurance, Tangibles, Empathy, and Responsiveness) [7]. The sample of the study was some outpatients who redeemed drugs at outpatient depots in February-March 2022 and met the inclusion criteria. Inclusion Criteria are Outpatients who redeem drugs at the outpatient pharmacy depot at Reksodiwiryo Hospital who are 18 years old or older. Able to communicate well and also willing to be a respondent. The author exclude a sample that had been a respondent in this study.
In this study, the sample calculation uses the Cochran formula for an unknown population, (1) The number of samples from the calculation is 425 people. This quantity already includes 10% of the reserve sample. Sampling was done by accidental sampling method. Data collection was carried out by researchers and assisted by two enumerators who were carried out by equalizing perceptions before collecting data. Enumerator with a bachelor's degree in public health. Data collection was carried out at the end of the service stage, named after the patient who took the drug at the pharmacy depot.
The SERVQUAL measuring instrument was adopted which was then modified according to the nature of the services in the pharmaceutical installation of Reksodiwiryo Hospital, Padang, which consisted of five dimensions, namely tangibles, reliability, responsiveness, assurance, and empathy. From the existing literature, the research instrument with the SERVQUAL method has been widely used in measuring consumer satisfaction, including measuring consumer satisfaction in the health care sector. Respondents' answers were measured using a Likert Scale (Table 1). Data analysis was done by descriptive and IPA analysis. In the descriptive analysis, the SERVQUAL questionnaire consists of two groups of statements. The first part is a questionnaire containing a group of statements to assess customer performance on service quality. The second part is the same statement as the first part which is aimed at assessing customer expectations. All of these statements cover the five dimensions of service quality previously mentioned, namely tangibles, reliability, responsiveness, and empathy. To assess the results, the total expected score will be compared to the total performance score. In the form of an equation it can be stated as follows: SERVQUAL Score= Performance Score -Expectation score 1) If the Performance Score -Expectation Score < 1, it means that the quality of service is poor 2) If the Performance score -Expectation Score = 1, it means that the service quality is good 3) If the Performance Score -Expectation score > 1, it means that the quality of service is very good Furthermore, the IPA analysis is carried out. The comparison score between expectations and reality will be applied to the Cartesian quadrant diagram to determine IPA or quadrant analysis. IPA is a technical analysis used to identify what important performance factors an organization must demonstrate in meeting the expectations of their service users.
Based on Figure 1, Quadrant A describes the condition of high expectations while performance is low or not yet maximal. Quadrant B describes items that have high expectations with high performance. Quadrant C describes the condition of low expectations but high performance. Also, quadrant D describes conditions of low expectations and low performance [18].

Results
The results of this study were obtained from data processing after data collection was carried out with a questionnaire at the hospital. Reksodiwiryo as many as 425 respondents. Most of the respondents were women 62.8%) with age 56-65 years (34.4%) from Lubuk Begalung (25.2%). Most have a job less (57.4%) and finished Senior High School (SHS) (46.6%). Respondents have <2 million acceleration and use BPJS insurance (99.8%). Most have visited policlinic Penyakit Paru (22.3%) more than twice (87.5%). They didn't have experience in another hospital (53.2%). More details can be seen in Table 2.
The frequency distribution of the level of patient satisfaction overall was not satisfied as many as 362 patients (85.2%). Based on service quality dimensions, most patients are not satisfied with a dimension of tangibles (70.6%), reliability (66.1%), responsiveness (57.4%), assurance (49.6%), and empathy (38.8%). More details can be seen in Table 3.
The following is the total data for the average performance score, expectation score, and average SERVQUAL score on each dimension. The level of performance and overall patient expectations can be seen in the following table. The difference between performance and expectations is the Servqual Score. While the comparison between performance and expectations is a measure of the level of satisfaction. Table 4 shows that the quality of service is poor (<1) based on tangibles (-0.41), reliability (-0.47), responsiveness (-0.37), assurance (-0.23), and empathy (-0.16). There was a good quality of reasonable drug price in assurance (0.06).
The diagram aims to see the distribution of attributes in the four quadrants based on Table 5, each attribute is entered into a quadrant according to its respective position. Most statements in Quadrant B which are comfortable pharmacy waiting room, the appearance of the pharmacist is neat and clean, the cleanliness of the waiting room is maintained, pharmacists can solve problems well, pharmacists never make mistakes when giving medicine, pharmacists can answer questions well, the procedure at the pharmacy is fast and uncomplicated, pharmacists provide clear information about the drugs given, namely: how to use, dosage, side effects, storage methods, etc., pharmacists administer drugs correctly and thoroughly, pharmacy staff is polite and friendly, pharmacists understand the patient's needs, pharmacists put the patient's interests first, pharmacists do not discriminate against patients. It means that services have high expectations with high performance. More clearly can be seen in Figure 2.    The comfortable pharmacy waiting room Tangibles  3 The appearance of the pharmacist is neat and clean Tangibles  4 The cleanliness of the waiting room is maintained Tangibles  8 Pharmacists can solve problems well Reliability 10 Pharmacists never make mistakes when giving medicine Reliability 12 Pharmacists can answer questions well Responsiveness 16 The procedure at the pharmacy is fast and uncomplicated Responsiveness 17 Pharmacists provide clear information about the drugs given, namely: how to use them, dosage, side effects, storage methods, etc. Assurance

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Pharmacists administer drugs correctly and thoroughly Assurance 19 Pharmacy staff are polite and friendly Assurance 22 Pharmacists understand the patient's needs Empathy 24 Pharmacists put the patient's interests first Empathy 25 Pharmacists do not discriminate against patients Empathy C 2 The design of the pharmacy room/building is attractive. Tangibles   5 Adequate entertainment facilities (TV/newspapers etc.) in the waiting room Tangibles   6 Availability of brochures and information about drugs in the waiting room Tangibles  9 Pharmacists immediately serve when the patient submits a prescription Reliability 11 Not long waiting time Reliability

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The clerk tells the patient how long the patient has to wait until the prescription can be given to the patient Responsiveness

Discussion
In this study, most of the respondents were dissatisfied with the service quality of the Pharmacy installation at Reksodiwiryo Hospital, Padang. The results of this study indicate that performance is still below the patient's expectations where dissatisfaction is found on all dimensions. The dimension with the lowest average satisfaction is the tangibles dimension where most of the respondents stated that they were not satisfied with the quality of service received [19]. These results are in line with research that shows high levels of patient satisfaction with medical and nursing services. On the other hand, lower satisfaction rates are recorded concerning the facilities and the administrative services which are connected with the funding and the efficiency of a healthcare system [20].
The results of this study are not in line with the other researchers who analyzed satisfaction at the pharmacy installation of X hospital. Where in the results of the study it was stated that most patients were satisfied with the services received (80%) while there were 20% of patients stated they were not satisfied [21]. Regarding the level of patient satisfaction in pharmaceutical services at the Wae Laku Ruteng pharmacy, Manggarai Regency stated that the five service dimensions were satisfied [22].
Looking at the data on the characteristics of the respondents, most of the respondents are patients with more than two visits. This shows that although most of the patient satisfaction is in poor condition, most of the patients also choose to stay and seek treatment at the Pharmacy Installation of the Reksodiwiryo Hospital. Based on the researcher's observations, this was because the patient did not have other experiences with other hospitals, as well as access to the Reksodiwiryo Hospital which was close to the patient's domicile. In addition, educational background, income, and the dominance of BPJS patients greatly affect the answers and perceptions of patients answering interview questions. In this study, it is known that based on respondents' perceptions, performance on the empathy dimension is perceived to be better than the other four dimensions. Meanwhile, the lowest average expectation score is on the tangibles dimension and the highest is on the reliability dimension. The reliability dimension relates to the hospital's ability to provide services that are promised to patients correctly from the first time.
This shows that the service attribute on the reliability dimension is considered the most important by the respondents. Meanwhile, the attributes of the tangibles dimension are not very important to the respondents. Based on the results of the research conducted by research that patient satisfaction affects patient trust and patient commitment. Another outcome of this study is that there is a mediating effect of patient trust in the impact of patient satisfaction on patient commitment [23].
Meanwhile, the average Servqual score (difference between performance scores and expectations) has the lowest patient satisfaction on the reliability dimension and the highest on the empathy dimension. This shows that the reliability dimension is considered important by the respondents, but the performance received is still far from the respondent's expectations. While on the empathy dimension, respondents do not show expectations that are too high, but the performance they receive is sufficient or close to the respondent's expectations.
The results of this study are not in line with research that states that the reliability dimension ranks third in the level of patient satisfaction. The first order of the highest level of satisfaction is the responsiveness dimension and the last order of the lowest level of satisfaction is the tangible dimension [24].
From the implementing elements, the attributes that affect patient satisfaction at the Padang City Reksodiwiryo Hospital are divided into 4 four parts. Quadrant A is a quadrant that shows the attributes that affect patient satisfaction at the Padang City Health Center, but in its implementation, it is not in accordance with the patient's wishes so that in its implementation it needs to be prioritized by the Public Health Center in the Padang City area because these attributes are considered very important by patients. but in practice, it is not satisfactory. Attributes that belong to quadrant A are attributes number 7 and number 21 ( Figure 2). Attributes in quadrant A have a lowperformance score below the average. However, it has high expectations or the same as the Vol. 16 average. This shows that in fact these attributes are considered important by the respondents, but the performance received by the respondents is still low.
The results of this study are in line with another research at Sebelas Maret University Hospital which also states that one of the attributes of the assurance dimension is in quadrant A, namely the attribute of officers providing information about drug side effects. Where the attribute category of the author is related to the availability of drugs in pharmacy installations [25].
Factors located in quadrant B are considered Important and Expected as a supporting factor for customer satisfaction so that the management is obliged to ensure that the performance of the institution it manages can continue to maintain the achievements that have been achieved. In this study there are 13 attributes that are in quadrant B, namely 1, 3,4,8,10,12,16,17,18,19,22,24, and 25 ( Figure 2). The attributes in quadrant B already have a high and above-average performance average. This means that the service received has been well felt by the respondents. However, respondents' expectations of attributes in this dimension are also high. This is the reason why many attributes are distributed in quadrant B. Patients consider these attributes to be important, and their perceived performance is sufficient to meet the average score.
This study is not in line with research at a hospital in Mojokerto which stated that most of the attributes were in quadrant C (low priority). Where quadrant C is the second improvement priority after quadrant A [26]. This is one of the factors that cause many loyal patients to seek treatment at the hospital. Reksodiwiryo even though the interview results showed a large number of dissatisfaction. Most of the respondents did not have experience going to other hospitals, as well as the perceived performance at the hospital. Reksodiwiryo is high above average. However, in line with patient expectations which are also high, it is hoped that RS. Reksodiwiryo can maintain and improve services on attributes in quadrant B.
Factors located in quadrant C have a low level of Perception or Actual Performance and are considered not too important and or too expected by consumers. Factors in quadrant C may be a concern by management after improving the factors in quadrant A. Factors in quadrant C are 8, namely 2,5, 6,9,11,13,20, and 26 ( Figure 2). Attributes in quadrant C have low-performance values. However, respondents' expectations of these attributes also mean that respondents assess the existence of services on these attributes as not very important. However, the hospital can still improve and improve performance in quadrant C after improvements in the main priority quadrant A.
Quadrant is D considered Not Too Important and or Not Too Expected so the management needs to allocate resources related to these factors to other factors that have a higher priority for handling which still requires improvement, for example in quadrant B. in quadrant D, namely numbers 14 and 23 ( Figure 2). Attributes in quadrant D have high-performance figures, which are above average. This means that the service received is good according to the respondent. Meanwhile, the expected rate in quadrant D is low, which shows that respondents actually think that the attributes in quadrant D are not very important.
In this study, the reliability dimension occupies a very important factor to be considered by the management of Reksodiwiryo Hospital in order to meet customer satisfaction, this is in line with research 27, 28, 29. In line with that research in Dar Es Salaam, Tanzania found several factors that affect the satisfaction of patients to hospital pharmacy installations are long waiting times, unavailability of drugs in hospital pharmacy installations, and the lack of comfort in waiting room 30.

Conclusion
Most of the respondents stated that they were dissatisfied with the outpatient service at the pharmacy installation at the Reksodiwiryo Padang Hospital. The highest patient satisfaction rate is in the empathy dimension and the lowest patient satisfaction is in the tangible dimension. There is a gap between the average performance value and the average expected value on all service dimensions. Two attributes become priority improvements, namely the punctuality attribute of the officer in serving and the attribute of the drug item being always available. The author's suggestion to the person in charge of drug logistics planning is to do better drug planning so that there is no