Corresponding Author: Usamah

INTRODUCTION

In the global competition for healthcare providers, competition between local hospitals is also rife with issues of increasingly unhealthy competition. Examples of conventional competitive strategy illustrations that exist in local hospitals are as follows (Widajat, 2013) :

1. Hospital A opened a special service unit, "perinatology," with sophisticated equipment and prepared more senior human resources experts. This service unit has long been a core business in RS H. As a result, RS H complained because the number of patients decreased and was interested in moving to RSUP A (meaning that RS H lost competition with RSUP A from the aspect of human resources).

2. Hospital C provides advanced diagnostic units (MRI, MSCT-Scna, etc.) already present in Hospital D. As a result, there is competition in tariffs, advertising, etc., to compete for the same market share in adjacent areas.

Both illustrations show that competitive strategies in local hospitals compete to maximize each other's internal strengths and take advantage of the opponent's weaknesses to defeat competitors as opponents. The new problem amid such competition is that some win, some lose, or even both lose. Customers are more attracted to hospitals outside the competing company's market.

RSUD Wakatobi is one of the health service providers owned by the Regional Government of Wakatobi, Southeast Sulawesi. There is only one hospital in Wakatobi Regency, the Wakatobi Regional General Hospital. This hospital can provide limited specialist medical services. The hospital also accommodates referral services from puskesmas. However, the majority of patients who visit are BPJS patients. In 2023, BPJS patients inpatient at Wakatobi Regional General Hospital were 3028 patients (96.53%), compared to 109 general patients (3.47%). This is a decrease in the percentage of general patients compared to BPJS patients. More details can be seen in Table 1.

Table 1. Data of BPJS inpatients and general patients

	2020	2021	2022	2023
BPJS	150	391	1828	3028
General	48	84	133	109

Table 2. Data on BPJS outpatients and general patients

	2020	2021	2022	2023
BPJS	330	413	1964	4190
General	898	1071	2318	1724

Table 3. Data on BPJS emergency room visits and general patients

	2020	2021	2022	2023
BPJS	402	300	1532	1419
General	203	221	460	217

Outpatient and emergency room visits also found the same phenomenon, namely a decrease in the percentage of general patients. On the one hand, the coverage of BPJS patients has increased, but it continues to decline for general patients. The data on BPJS outpatients and general patients can be seen in Table 2. Likewise, in emergency room visits, the same phenomenon was found. More details can be seen in Table 3. Wakatobi residents who have more financial capacity choose to seek treatment outside the island rather than at RSUD Wakatobi.

Figure 1. Comparison of the percentage of BPJS patients and general inpatients

Figure 2. Comparison of the percentage of BPJS patients and general outpatients.

Figure 3. Comparison of the percentage of BPJS and

general patients visiting the emergency room.

In achieving goals oriented towards patient satisfaction, in addition to aspects of hospital facilities, the role of doctors, paramedics and non-medical personnel is very important because their performance will determine the perception and performance felt by patients towards the services provided (Sriningsih & Marlina, 2020). Service quality is important for health service providers, and a large proportion is also given to marketing practitioners who pay attention to service quality (Barus, 2017).

Strategy is an agreement on determining long-term goals and visions, which then become a common reference in achieving the goals that have been set (Palenewen & Mulyanti, 2023). Strategy does not only talk about processes and results, but it is equally important that strategy also discusses how an agreement has become an important factor in determining strategic policies. Policies that are not accompanied by agreement among all stakeholders will have a significant influence on the strategic management process (Nasrullah & Iswanto, 2021).

Service Quality is something that is obtained by the customer from the service provider, in this case, a company or organization, with reference to the customer satisfaction indicator. Service quality requires a company/business organization to deliver maximum service to customers with the aim that customers get satisfaction and ultimately become loyal or fanatical customers (Ismail & Yunan, 2016). Furthermore, (Ismail & Yunan, 2016) state that tangible service qualities such as empathy, responsiveness, assurance, reliability, and sensitivity positively impact satisfaction and make loyal clients (customer loyalty), especially in health.

This research aims to analyze strategies that can be applied to improve the quality of service at Wakatobi Regional Hospital with a focus on the dimensions of reliability, responsiveness, assurance, empathy, and physical evidence. The benefit of this study is to provide in-depth insight into effective strategies in improving service quality at Wakatobi Regional General Hospital. By focusing on service dimensions such as reliability, responsiveness, assurance, empathy, and physical evidence, this study can assist hospital management in identifying areas that require improvement and developing more effective approaches to meet patient needs.

METHOD

This research is a descriptive qualitative research using the analysis of the results of interviews and observations. The informants in this research are the Directors of Wakatobi Regional Hospital and the staff of Wakatobi Regional Hospital who have relevance to the issues that occur. In this research, there are two main data sources, namely primary data and secondary data. Primary data used in this research is through observation and interviews. Secondary data in this research is obtained from literature studies such as journals, books relevant to this research, and sources from the Internet. The data analysis methods used in this research are data reduction, data display, and conclusion drawing/verification. Data validity uses source triangulation, method triangulation, investigator triangulation, and theory triangulation.

RESULTS AND DISCUSSION

Strategies to Improve Service Quality at Wakatobi Regional General Hospital Using Service Quality

A strategy is a way, scarcity, or method of carrying out an activity by all interested parties to achieve the desired goal. In this case, strategy is very important to be applied in everything as well as in a hospital agency, especially in improving the quality of patient service. The strategy referred to in this study is all the plans and efforts that will be made by all levels in achieving certain goals, to improve the quality of patient service. In connection with this, the strategy, in this case, is very important to improve services at the Wakatobi Regional General Hospital because the strategy is a strategy or a process to determine the direction to go to achieve all the missions that will be addressed.

Service quality is the level of service related to patient expectations and needs (Gultom et al., 2022), which means that the company can be said to be able to provide products, goods, and services, if by the wishes of the patient. If the patient is satisfied with the company's products and services, the quality of service can be said to be good. Service quality can be interpreted as the level of consumer satisfaction. Which, this is obtained by comparing other similar types of services. Thus, consumers can compare hospitals A and B regarding service quality. Service quality is good to what the patient expects. It can be categorized as satisfactory by the patient's expectations. Meanwhile, it is very satisfying if it exceeds the patient's expectations.

Based on this, the author is concerned that patient loyalty results from good health services. Patient loyalty is one of the goals of improving the quality of health services (Vigaretha & Handayani, 2018). In line with this study, to determine the level of service quality of the Wakatobi Regional General Hospital, the researchers grouped the inpatient service quality strategies of the Wakatobi Regional General Hospital, namely the physical appearance of hospital services, hospital service reliability, hospital service responsiveness, hospital service assurance, and hospital service empathy.

Physical Display of the Hospital

The hospital's physical appearance (Tangibles) is a service dimension that usually gets the first attention of other service dimensions. Physical appearance is the first indicator in assessing a service because this dimension is the easiest to assess. After all, it is the most abstract or visible, so it gets the first attention from respondents or people who get services (Mulyanti Syam, 2018). The physical appearance referred to in this study is by the inpatient services at the Wakatobi Regional General Hospital, namely the completeness of service facilities in the inpatient room, the cleanliness and comfort of the treatment room, the comfort of the treatment room, the neatness of the nurses in providing services, and the uniform of the nurses in providing services. Based on the results of interviews with Doctor Achmad, the President Director of the Hospital, said that:

"Not yet; some things are still needed for facilities and infrastructure."

This is in line with the results of interviews with Mr. Rusalim as Hospital Staff, saying that:

"Facilities and Infrastructure are still inadequate".

In line with the results of an interview with Mrs. Neny as Director of Hospital Services, said that:

"Not yet, because there are still some patients who are referred out to other hospitals."

Based on the interview results above, than infrastructure at the Wakatobi Regional General Hospital is insufficient. neededeas Tangible (direct evidence), namely, the community, is impressed by the physical appearance and appearance of services that can be directly felt. By the Decree of the Minister of Administrative Reform Number 63 of 2004, one of the principles of public service that must be fulfilled is the comfort of the environment and the completeness of adequate supporting facilities. The service environment must be orderly and organized, provided with a comfortable, neat, and clean waiting room, a beautiful and healthy environment, and equipped with service support facilities such as parking, toilets, places of worship, and others. This is not one of the principles of public service, namely environmental comfort. These incomplete service facilities make people feel less satisfied with the services the Wakatobi Regional General Hospital provides and demand quality improvement efforts that must be carried out immediately.

Hospital Reliability

Reliability of hospital services in the study is the consistency of the appearance of services and the reliability of services to inpatients by assessing the accuracy of nurses in providing services, completeness of medical service facilities (tension, lab, pharmacy), ease and simplicity in registration, and ease of knowing service requirements (Sary Maya, 2017). In order to improve the quality of service to patients, Wakatobi Regional General Hospital provides services by standard operating procedures (SOP) from the hospital's vision and mission. All those who work in hospitals, both doctors, nurses, midwives, and non-medical officers, must always be alert and careful because this has to do with service to patients; all those who work at the Wakatobi Regional General Hospital must put aside personal interests when providing services to patients, this can have a negative impact if hospital staff are not alert and careful.

Based on the results of interviews with Doctor Achmad Th, the President Director of the Hospital, said that:

"All who work here must have a great spirit of responsibility and must always be ready and careful. Personal problems must be put aside first. If you are working, you must focus on serving patients."

While the results of an interview with Mrs. Neny as Director of Hospital Services said that:

"The implementation of Batang Regency Hospital services is based on the Standard Operating Procedure (SOP) for each type of service. So the SOP is a guide that explains in detail how a process must be carried out".

Based on the interview results above, in measuring service quality, reliability must be briefly summarized as the ability to provide accurate, timely, and trustworthy services. In this case, the quality of service at the Wakatobi Regional General Hospital has paid attention to reliability, which consists of indicators of accuracy, ability to perform tasks, experts on duty, ability to serve customers, and clear service standards.

Hospital Responsiveness

Responsiveness carried out by the hospital to patients is one of the most important things, given that the service is a service that concerns the patient's life. In certain circumstances, for example there are critical patients, the responsiveness of hospital services is the main thing to do compared to other services. The responsiveness of hospital services to inpatients is assessed through the ability of officers to overcome patient complaints, the seriousness of officers in serving, and the immediacy of drug services. Based on the results of interviews with Doctor Achmad Th, the President Director of the Hospital, said that:

"Very good".

While the results of an interview with Mrs. Neny as Director of Hospital Services said that:

"Yes, very good".

This is in line with the results of an interview with Mr. Rusalim as Hospital Staff, saying that:

"Yes, good enough".

Based on the interview results above, the Wakatobi Regional General Hospital provides good, fast, precise response services and the delivery of clear information to patients; when officers provide services to patients who have to wait a long time without clear reasons, this can hurt the agency itself. Wakatobi Regional General Hospital has a 24-hour service number for patients who want to ask about treatment services and others. In this case, the hospital does not differentiate the services provided to general patients or BPJS; all are in accordance with the procedure and will be followed up directly by the responsible party. As stated by Mrs. Neny, Director of Hospital Services, said that:

"We serve all patients equally without differentiating between general and BPJs because our job is to serve wholeheartedly and try to ensure that patients do not wait too long to receive services from doctors."

It can be concluded that in improving the quality of service to patients, the Wakatobi Regional General Hospital has paid attention to the responsiveness dimension, in terms of responsiveness in providing good, fast, and precise service and in conveying information clearly to patients, because the advantages provided by the Wakatobi Regional General Hospital are by the motto that every employee must always pay attention to, in this case, the hospital does not discriminate in providing services between general patients and bpjs, which distinguishes perhaps in terms of the facilities provided from each type of inpatient room.

Hospital Service Guarantee

Service assurance provided by the Wakatobi Regional General Hospital to patients is expected to provide a sense of security and comfort for patients. The basis for assessing service assurance in this study is that the nurse's examination schedule is well taken care of, the doctor conducts routine examinations, certainty and clarity of service procedures, and certainty and clarity of service requirements. Based on the results of interviews with Doctor Achmad, the President Director of the Hospital, said that:

"Yes, with the JKN program, Wakatobi Regency has met Universal Health Coverage (UHC)."

While the results of an interview with Mrs. Neny as Director of Hospital Services said that:

"Yes, because the BPJS Health program has covered all Wakatobi people."

This is in line with the results of an interview with Mr. Rusalim as Hospital Staff, saying that:

"Public services at RSUD Wakatobi have been implemented quite well".

Based on the interview results above, the quality and safety of services so that people are free from risk or doubt. A sense of security for services can be obtained if there is a guarantee of safety for the delivery of services performed. Service processes that follow procedures and structure will give a positive impression to the service user community. The competence of the officers is considered qualified. However, environmental security is still in doubt because the security system regarding patient visiting hours is not running properly.

Wakatobi Regional General Hospital, in its services, always strives to provide timely service because the advantages of the hospital are quality, friendly, safe, visionary, and optimistic, serving patients wholeheartedly. Insurance services provided by the hospital are in the form of BPJS insurance, BPJS employment and Jasa Raharja. Based on the results of an interview with Mrs. Neny as Director of Hospital Services, said that:

"We have visiting hours for patients, and even then, they are limited. In the morning, from 10.00 to 12.00, while in the afternoon, from 15.00 to 17.00, for the sake of security, we also install CCTV, and visitors can enter and exit only from the door that has been determined. The number of visitors who enter is also a maximum of 3 people. For health reasons, we also prohibit children under 12 years old from entering the hospital treatment area."

It can be concluded that the Wakatobi Regional General Hospital pays attention to the assurance dimension. Hospital staff can be trusted to provide knowledge and hospitality and are believed to support the guarantee of costs in services. Wakatobi Regional General Hospital cooperates with several insurance companies, such as BPJS Health, BPJS Employment, and Jasa Raharja.

Empathy of Hospital Service Officers

Empathy is often perceived as less important than the other four dimensions in assessing service quality in an organization (Safrizal & Aldanisa, 2019). However, this dimension is the most important for certain customers, especially those with a fairly high educational background and a wealthy family background. This can be explained from Maslow's theory, where at the highest level, human needs are no longer based on fulfilling primary things but rather on self-actualization. (Muazaroh & Subaidi, 2019). The indicators that researchers use to be able to assess the quality of service to inpatients are the Ethics / Politeness of officers in providing services, the friendliness of registration officers, the friendliness of nursing staff, the friendliness of doctors, whether nurses often ask about the patient's condition and the skills of officers to understand the patient's special needs.

Based on the results of interviews with Doctor Achmad, the President Director of the Hospital, said that:

"Yes, in implementing officer services with a smile, polite, friendly, and provide good service."

While the results of an interview with Mrs. Neny as Director of Hospital Services said that:

"Yes, the staff at RSUD Wakatobi have a sense of empathy towards patients."

This is in line with the results of an interview with Mr. Rusalim as Hospital Staff, saying that:

"Yes, the staff at RSUD Wakatobi have a sense of empathy or care for patients".

Based on the interview results above, the level of politeness and friendliness of the Wakatobi Regional General Hospital service officers upholds values and norms. The values and norms that apply in this community include friendliness and politeness. Patients will be happier when meeting with officers who serve with smiles and friendly greetings. This caring, patient, and friendly attitude can transmit enthusiasm to patients when they want to recover. Good communication and empathy from hospital staff will allow them to respond to patients more comprehensively.

Employees who work at the Wakatobi Regional General Hospital must serve wholeheartedly, have a friendly, friendly, polite, and courteous attitude, patiently must always provide services expected by patients, and always put the interests of patients first without discrimination. As stated by Mrs. Neny Sunarti, Director of Hospital Services, said that:

"We do not differentiate what else is discriminatory, for example, Wakatobi residents or not; we are a hospital that serves all people who need health; the most that makes a difference is in terms of room facilities; this depends on what the family wants to be in."

It can be concluded that the Wakatobi Regional General Hospital also pays attention to the empathy dimension in terms of improving the quality of service to patients; the hospital conducts good communication relationships and always tries to understand what needs are expected by patients, in this case, all hospital staff do not discriminate or discriminate, all try to provide the best service, by providing a polite, courteous, friendly, friendly and responsible attitude. In this case, it is by the theory described by the author that in improving the quality of hospital services, it must pay attention to the empathy dimension in the form of prioritizing work arrangements, serving politely, courteously, and responsibly, and providing services without discrimination.

Strategies to Improve Service Quality at Wakatobi Regional General Hospital Using Service Quality

Strategy is an agreement on determining long-term goals and visions, which then become a common reference in achieving the goals that have been set. Strategy does not only talk about processes and results, but it is equally important that strategy also discusses how an agreement has become an important factor in determining strategic policies. Policies not accompanied by agreement among all stakeholders will significantly influence the strategic management process (Clarke et al., 2018). A hospital is a health care institution that organizes comprehensive individual health services that provide inpatient, outpatient, and emergency services (Decree of the Minister of Health of the Republic of Indonesia No. 340/MENKES/PER/III/2010) (Mayasari et al., 2020). Hospitals also have the main task of organizing plenary individual health services with efforts to cure, recover, improve, prevent, referral services, research and development, and community service.

Service quality will directly impact the image of the hospital. Indirectly, this can also be a means of promoting the hospital. Patients who use the company's products and services will feel satisfied with the service and will most likely visit the Hospital if they have a complaint. In addition, because they are satisfied with the service, these patients will give an impression to the wider community regarding good service and satisfaction with the hospital's health services. The main objective is that health services are actions taken by an agency to consumers to meet the needs and desires of patients (Wijaya W RA, 2016).

In essence, the results of this service's quality will bring satisfaction because satisfaction is closely related to service improvement. The better the service provided to the patient, the higher the level of patient satisfaction. The quality of health services is a guarantee for the community to obtain an optimal degree of health. Quality health services in hospitals will always be related to the structure of the process and the outcome of the service system in the hospital. The quality of health services in hospitals can also be seen from the level of utilization of service facilities by the community, the quality of service, and the level of efficiency of the hospital.

CONCLUSION

Based on the results of the above research, in this case, the services applied at the Wakatobi Regional General Hospital still need to be by the dimensions of service quality where physical evidence. At the same time, those that have been applied include reliability, assurance, empathy, and responsiveness. Service quality needs to be applied by every public service in providing services to patients. One of the good service qualities is the comparison between reality and the expectations of Wakatobi Regional General Hospital patients. If the reality received is more than expected, the service is said to be of quality, and the patient is satisfied. While the services provided are different from those applied, the service is considered less quality and less good. Based on the results of the above conclusions, the suggestions in this study are as follows: For the Wakatobi Regional General Hospital, it is hoped that it can improve the quality of service to patients in the existing physical appearance dimension, especially related to inpatient facilities such as cleaning treatment rooms every day and adding hospital facilities and infrastructure. In addition, it is important to continue to improve the ability of nurses, doctors, and staff so that the services provided are better by including them in training that supports their work. For future researchers, it is hoped that this research will provide new insights into strategies to improve service quality at the Wakatobi Regional General Hospital using service quality. This research can also provide new references for further research and complement strategies to improve service quality.

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