The Effect of Service Quality and Commitment to Quality on Patient Satisfaction and Word of Mouth Intention in the Regional General Hospital of Tamiang Layang Barito Timur Regency

: This study aims to examine the effect of service quality and commitment to quality on patient satisfaction and word of mouth intention as intervening variables in patients at the Tamiang Layang Regional General Hospital, East Barito Regency. The population in this study were 122 inpatients in the rose and jasmine rooms, the data were taken from questionnaires distributed to respondents. Data were analyzed using SmartPLS Version 3. The results of this study are Service Quality has an effect on patient satisfaction, Commitment to quality has an effect on patient satisfaction, Service quality has an effect on Word Of Mouth Intention, Commitment to quality has an effect on Word Of Mouth Intention, Patient satisfaction has an effect on Word Of Mouth Intention Regional General Hospital Tamiang Layang, East Barito Regency.


INTRODUCTION
The field of health sciences in Indonesia has undergone development over time, spanning the pre-independence era, the postindependence era, and the New Order era (Alamsyah, 2013).In Indonesia, hospitals, as a major component of the healthcare system, broadly provide services to the public, including medical services, medical support services, medical rehabilitation, and care services.These services are delivered through emergency units, inpatient units, and outpatient units.Healthcare services in hospitals now encompass not only curative but also rehabilitative aspects, integrating health promotion (preventive) efforts (Herlambang, 2016).
The mission of general hospitals in Indonesia is to provide quality and affordable healthcare services to the public, aiming to improve the overall health of the community.General hospitals are tasked with delivering efficient and effective healthcare services, prioritizing healing and recovery in a coordinated and integrated manner, along with emphasizing improvement, prevention, and referral efforts (Herlambang, 2016).Quality in healthcare services is crucial for healthcare organizations.The increasing awareness of health and healthcare services among the public urges every healthcare organization to be quality-conscious in providing services to service users.When addressing issues within healthcare organizations, especially those related to healthcare service quality, three main concepts consistently arise: access, cost, and quality.Of these, customer satisfaction is the most significant element.If customers are dissatisfied with the quality of the services provided, they may not return or seek alternative services, even if they are available, easily accessible, and within reach.Therefore, the quality of the services offered is essential in healthcare.However, quality must be viewed from the consumer's perspective, as service quality is the service received by the consumer (Herlambang, 2016).
Healthcare service quality is defined as the degree of perfection of healthcare services in accordance with professional standards and service standards, utilizing available resources in hospitals or health centers reasonably, efficiently, and effectively, and providing services safely and satisfying norms and ethics.To achieve healthcare service quality, the basis used to measure it is to meet the needs and demands of healthcare service users.If these needs and demands are successfully met, it can lead to satisfaction with healthcare services (Herlambang, 2016).According to Ibrahim as cited in Hardiyansyah (2011:40), service quality is a dynamic condition related to products, services, humans, processes, and the environment, where the quality assessment is determined at the time the service is provided.Service quality can be realized by providing services to patients as best as possible, meeting patients' expectations.Customer satisfaction is crucial for public services, and achieving the highest level of patient satisfaction is the primary Word of mouth, according to Hasan (2010:10), is praise, recommendations, and comments from customers about their experiences with service and product offerings that significantly influence customer decisions or purchasing behavior.The research object is Tamiang Layang Regional General Hospital in East Barito Regency.This hospital is frequented by both inpatient and outpatient patients.It is known that Tamiang Layang Regional General Hospital has provided optimal services.However, further observation by the researcher revealed some issues, particularly in the quality of service and the commitment to service quality held by some employees of Tamiang Layang Regional General Hospital.
The problem with service quality at Tamiang Layang Regional General Hospital is that the quality of healthcare human resources does not fully support health development, and the availability of safe, beneficial, and quality medical supplies is not evenly distributed, accessible, and accessible to the public.The gradual improvement of these facilities is needed.Furthermore, the absence of an online Hospital Information System supporting the acceleration of service provision to patients contributes to the perceived inadequacy of the quality of service provided.Several complaints from patients include dissatisfaction because personnel are overly protective, not competent in serving patients, lack of knowledge about doctors' practice schedules, inadequate facilities resulting in crowded rooms, delayed replacement of patients' infusions by some personnel, and absence of personnel during nighttime when patients need assistance.
The problem with commitment to quality is that Tamiang Layang Regional General Hospital has not consistently provided the same quality of service for each service.Changes in mindset, shifts in work culture, and improvements in governance (good corporate governance) that can cause a lack of uniformity in service quality commitment need to be addressed.This inconsistency in service quality commitment leads to patients feeling that the services provided by Tamiang Layang Regional General Hospital are not committed, as the quality of service varies.
Based on the background described above, the problem formulations that can be derived are: 1.Does Service Quality influence patient satisfaction at Tamiang Layang Regional General Hospital, Barito Timur Regency? 2. Does commitment to quality influence patient satisfaction at Tamiang Layang Regional General Hospital, Barito Timur Regency? 3. Does service quality influence Word of Mouth Intention at Tamiang Layang Regional General Hospital, Barito Timur Regency? 4. Does commitment to quality influence Word of Mouth Intention at Tamiang Layang Regional General Hospital, Barito Timur Regency? 5. Does patient satisfaction influence Word of Mouth Intention at Tamiang Layang Regional General Hospital, Barito Timur Regency?

LITERATURE REVIEW a. Service Quality
The demand from patients and the community for the quality of pharmacy services necessitates a shift in service paradigm from the old (drug-oriented) to the new paradigm (patient-oriented) with the philosophy of Pharmaceutical Care (Hartini and Sulasmono, 2017).Pharmaceutical Care practices are integrated activities aimed at identifying, preventing, and resolving drug-related problems and health-related issues.Currently, the reality is that many hospitals in Indonesia have not implemented pharmaceutical care activities as expected, given various constraints such as the capability of pharmacy personnel, limited knowledge of hospital management about the functions of hospital pharmacy, hospital management policies, and the limited knowledge of relevant parties regarding hospital pharmacy services.As a result of these conditions, hospital pharmacy services remain conventional, focusing solely on product-oriented aspects, limited to provision and distribution (Ministry of Health, 2019).
Service quality is a crucial aspect that needs attention from healthcare service providers such as hospitals.The quality of service packaging to be produced must be a marketing strategy for hospitals that offer services to their users (patients and their families).
Hospital management must continually strive to ensure that the service products offered remain sustainable, capturing new market segments.The superiority of a healthcare service product depends significantly on the uniqueness of the service quality demonstrated and whether it aligns with customer expectations or desires (Muninjaya, 2019).
Service quality is the level of excellence expected and the control over that excellence to meet customer desires (Lovelock, 2019).Essentially, the definition of service quality focuses on efforts to fulfill customer needs and desires, ensuring accuracy in delivery to match customer expectations.In other words, there are key factors influencing service quality, namely expected service and perceived service (Zeithalm, Berry, 2019).Quality should start from customer needs and end with customer perceptions (Kotler, 2019).This means that a good quality image is not based on the provider's perspective or perception but is based on the customer's perspective or perception.Customer perception of service quality is a comprehensive assessment of the excellence of a service.

b. Commitment to Quality
Quality commitment is a promise to ourselves or to others that is reflected in our actions to maintain the performance quality of employees.Quality commitment is the implementation of public services oriented towards the quality of results, perceived by individuals regarding products/services in terms of good/bad measures.Whatever field is the responsibility of civil servants, all must be carried out optimally to provide satisfaction to stakeholders.Quality public service plays a crucial role in creating an environment and society that is more prosperous, just, and inclusive (accessible to everyone).One of the challenges in creating quality public service is determining the target groups of the public service itself.The process of implementing quality management begins with analyzing identified problems, then developing a quality plan, carrying out work based on the quality plan, monitoring implementation, overseeing achievement, and designing improvement efforts to build the credibility of government institutions.There are many ways to continually improve the quality of service from civil servants to the public.Quality responsibility exists at every organizational level.At the top level, responsibility lies in the overall service quality of the institution to build institutional image and competitive excellence.At the strategic business unit level, quality responsibility is related to setting diversified quality targets for each working unit.At the functional level, responsibility lies in the quality of the results of each service provided in supporting units.Meanwhile, at the basic unit level, quality responsibility is related to activities/action plans implemented in each working unit.Factors that can drive or hinder efforts to improve the performance of creative, innovative, and quality-committed apparatus include: changing the mindset of apparatus, shifts in work culture, and improving governance (good corporate governance).

c. Patient Satisfaction
Understanding the needs and desires of patients is crucial in influencing patient satisfaction.A satisfied patient is a valuable asset because if patients are satisfied, they will continue to choose and use the services they prefer.However, if patients are dissatisfied, they are likely to share their negative experiences twice as strongly with others.To create patient satisfaction, hospitals must establish and manage a system to attract more patients and the ability to retain them.Patients are individuals receiving medical treatment from doctors and other healthcare professionals in a practice setting (Yuwono; 2018).Meanwhile, satisfaction is the feeling of pleasure someone derives from the comparison between the enjoyment of an activity and a product with their expectations (Nursalam;2018).Kotler (cited in Nursalam; 2018) states that satisfaction is the feeling of pleasure or disappointment that arises after comparing perceptions or impressions of the performance or results of a product with one's expectations.Westbrook & Reilly (cited in Tjiptono; 2017) argue that customer satisfaction is an emotional response to experiences related to a specific product or service purchased, retail outlets, or even behavior patterns (such as shopping behavior and buyer

RESEARCH METHOD
This research employs a quantitative approach, with the dependent variable being word of mouth intention (Y).Meanwhile, the independent variables, service quality (X1), commitment to human quality (X2), and patient satisfaction (Z), serve as Intervening Variables.The population in this study consists of inpatients at the Tamiang Layang District General Hospital, East Barito Regency, in 2022.The sampling technique used in this study is the Census Sampling Technique (saturation sampling), which is a sampling technique where all members of the population are used as samples.There were 122 inpatients in the Rose and Jasmine Wards selected as respondents due to their relevance to the scope of the research, and the data collection was conducted in January 2023.The data analysis method for this research utilizes descriptive statistical analysis and Partial Least Square data analysis using the Smart PLS 3 Statistics tool.From the data processing results with SmartPLS as shown in the table above, there are several indicators that have values less than 0.7 and are highlighted in red.Therefore, indicators with values less than 0.7 need to be eliminated to obtain a proper analysis.The eliminated items are Z.6.Thus, the modified outer loading is as follows:  From the data processing results with SmartPLS as shown in the table above, all indicators for each variable in this study have loading factor values greater than 0.70, indicating their validity.This suggests that indicators of variables with loading factor values exceeding 0.70 have a high level of validity, thus satisfying convergent validity.

Discriminant Validity
The next criterion used in evaluating the outer model is discriminant validity.The way to measure the outer model with discriminant validity is to look at the average variance extracted (AVE) value.A good model is required, if the AVE value of each construct is greater than 0.5 to be said to have good discriminant validity.The results of the AVE value can be shown in the table as follows: Based on the data processing that the researchers carried out, the results showed that the AVE value of each construct was greater than 0.5.From these results it can be proven that the AVE value has good discriminant validity.

Composite Reliability
In the measurement model, a reliability test is carried out.Reliability tests are carried out to prove the accuracy, consistency and correctness of the instrument in measuring a construct.To measure the reliability of a construct, it can be done in several ways, namely composite reliability.The interpretation of composite reliability is the same as Cronbach's alpha with a limit value of > 0.7 which is acceptable and a value of > 0.8 is very satisfactory.Construct reliability in the PLS reliability test is measured by two criteria, namely composite reliability and Cronbach alpha from the indicator block that measures the construct.A construct is declared reliable if the composite reliability value is greater than 0.7, while several limits regarding the Cronbach alpha value are greater than 0.6.The processing results using SmartPLS can be seen in the following table: Based on the data processing that the researchers carried out through the Smart PLS estimation program, the results showed that the value of each variable in reliability testing using composite reliability and Cronbach alpha testing for each construct or latent variable obtained a result of more than 0.7.This shows that the construct has met the composite reliability measurement criteria and Cronbach alpha has good reliability.Therefore, it can be concluded that the variables that have been tested are valid and reliable, so that after this we can continue to test the structural model.

Structural Model (Inner Model)
The next step after evaluating the construct or variable measurement model is to evaluate the structural model or (inner model).The inner model describes the relationship between latent variables based on substantive theory.R-square value for the construct, path coefficient value or t-values for each path to test the significance of the construct in the structural model.The R2 value for Patient Satisfaction is 0.725 or 72.5%, categorized as substantially very strong.Since the Adjusted R Square is greater than 72.5%, it can be interpreted that the influence of all exogenous constructs, including Service Quality and Commitment to Quality, is strong.This implies that Service Quality and Commitment to Quality can explain 72.5% of the influence on Patient Satisfaction, with the remaining percentage influenced by other variables not included in this study.As for the R2 value for the dependent variable Word of Mouth Intention, it is known to be 0.760 or 76%, meaning that the variables Service Quality, Commitment to Quality, and Patient Satisfaction can influence Word of Mouth Intention by 76%, and the remaining percentage is influenced by other variables.Since the Adjusted R Square is greater than 67%, it indicates that the influence of all exogenous constructs, including Service Quality, Commitment to Quality, and Patient Satisfaction, is strong.

F-Square (F 2 )
The F-Square test is conducted to assess the goodness of the model.The F-Square values of 0.02, 0.15, and 0.35 can be interpreted to determine whether the latent variable predictors have a weak, medium, or strong influence on the structural level.Source: Primary data processed.
From the results above it can be seen as follows: 1. Service Quality on Patient Satisfaction has an f2 value of 0.418, categorized as a strong influence of the latent predictor variable.
2. Commitment to Quality on Patient Satisfaction has an f2 value of 0.298, categorized as a strong influence of the latent predictor variable.3. Service Quality on Word of Mouth Intention has an f2 value of 19.952, categorized as a strong influence of the latent predictor variable.4. Commitment to Quality on Word of Mouth Intention has an f2 value of 0.209, categorized as a strong influence of the latent predictor variable.5. Patient Satisfaction on Word of Mouth Intention has an f2 value of 0.124, categorized as a strong influence of the latent predictor variable.

Hypothesis Testing Results
Hypothesis testing is conducted based on the results of the Inner Model testing (structural model), which includes outputs such as r-squared, parameter coefficients, and t-statistics.To determine whether a hypothesis can be accepted or rejected, consideration is given to the significance values between constructs, t-statistics, and p-values.Hypothesis testing in this research is carried out using the SmartPLS (Partial Least Squares) 3. Based on the table above, the hypothesis testing results are as follows: H1 Service Quality significantly influences patient satisfaction at the Tamiang Layang Regional General Hospital, East Barito District.This is evidenced by the P-Value being smaller than 0.05, specifically 0.000 < 0.05, with a positive original sample of 0.504 and a t-statistic of 4.361.Therefore, the hypothesis is accepted.H2 Commitment to quality significantly influences patient satisfaction at the Tamiang Layang Regional General Hospital, East Barito District.This is supported by the P-Value being smaller than 0.05, specifically 0.000 < 0.05, with a positive original sample of 0.426 and a t-statistic of 3.711.Hence, the hypothesis is accepted.H3 Service Quality significantly influences Word of Mouth Intention at the Tamiang Layang Regional General Hospital, East Barito District.This is demonstrated by the P-Value being smaller than 0.05, specifically 0.000 < 0.05, with a positive original sample of 0.860 and a t-statistic of 38.340.Therefore, the hypothesis is accepted.H4 Commitment to quality significantly influences Word of Mouth Intention at the Tamiang Layang Regional General Hospital, East Barito District.This is confirmed by the P-Value being smaller than 0.05, specifically 0.010 < 0.05, with a positive original sample of 0.086 and a t-statistic of 2.576.The hypothesis is accepted; however, when compared to the direct effect, the direct effect is larger than the indirect effect, as evidenced by the larger original sample and t-statistic.H5 Patient satisfaction significantly influences Word of Mouth Intention at the Tamiang Layang Regional General Hospital, East Barito District.This is supported by the P-Value being smaller than 0.05, specifically 0.014 < 0.05, with a positive original sample of 0.075 and a t-statistic of 2.497.Similarly, when compared to the direct effect, the direct effect is larger than the indirect effect, as evidenced by the larger original sample and t-statistic.Therefore, the hypothesis is accepted.

DISCUSSION
Service quality influences patient satisfaction at the Regional General Hospital of Tamiang Layang, East Barito Regency.It is known from the results of the analysis that service quality influences patient satisfaction at the Regional General Hospital of Tamiang Layang, East Barito Regency.The issue with service quality at the Regional General Hospital of Tamiang Layang, East Barito Regency, is that the quality of health human resources is not fully supportive of health development, and the availability of safe, beneficial, and high-quality medical resources is not evenly distributed, accessible, and affordable for the community.The gradual improvement of these facilities is necessary.Furthermore, the absence of an online Hospital Information System supporting the acceleration of service provision to patients has been identified, indicating the quality of the provided services.Several complaints lodged by patients include dissatisfaction due to overprotective staff, staff incompetence in patient care, lack of Commitment to quality affects patient satisfaction at the Regional General Hospital of Tamiang Layang, East Barito Regency.It is known from the results of the analysis that commitment to quality affects patient satisfaction at the Regional General Hospital of Tamiang Layang, East Barito Regency.The issue with quality commitment is that the Regional General Hospital of Tamiang Layang, East Barito Regency, has not consistently provided the same quality of service for each of its services.Changes in mindset, shifts in work culture, and improvements in governance (good corporate governance) can lead to inconsistent quality commitment, causing patients to perceive the services as lacking commitment.The services provided by the Regional General Hospital of Tamiang Layang, East Barito Regency, are sometimes good and sometimes not.Staff should provide quality orientation as intended.They should be highly effective and efficient in serving patients, and those providing services should be innovative in their service implementation.
Service quality influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.It is known from the results of the analysis that service quality influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.The issue with service quality at the Regional General Hospital of Tamiang Layang, East Barito Regency, is that the available human health resources do not fully support health development implementation.Additionally, safe, beneficial, and high-quality medication and health supplies are not uniformly, affordably, and accessible to the public.The gradual improvement of facilities provision is necessary.Furthermore, the absence of an online Hospital Information System supporting the acceleration of service provision to patients affects the quality of services provided.It is known that some complaints from patients include dissatisfaction because the staff is overly protective, the staff is not reliable in serving patients, lack of knowledge about doctors' practice schedules, insufficient facilities, resulting in crowded rooms, delayed replacement of patients' infusions by some staff, and staff not being present at night when patients need assistance.Therefore, hospital staff should perform their duties well, ensuring good performance.The hospital should have features that facilitate patients in administrative tasks.The staff should be highly reliable in serving patients.Before taking action, the staff will confirm with the patient's family.The staff on duty must have strong endurance to serve patients well.The staff should possess highly professional service skills, perform their duties with great care, and hope that patients can perceive the services in line with reality.
Commitment to quality influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.It is known from the results of the analysis that commitment to quality influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.The issue with quality commitment is that the Regional General Hospital of Tamiang Layang, East Barito Regency, has not provided consistent quality service in each instance.Changes in the mindset of officials, shifts in work culture, and improvements in governance (good corporate governance) can lead to variations in quality commitment services.Consequently, patients may feel that the services provided by the Regional General Hospital of Tamiang Layang, East Barito Regency, lack commitment because the services provided are sometimes good and sometimes less satisfactory.
Patient satisfaction influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.It is known from the results of the analysis that patient satisfaction influences Word Of Mouth Intention at the Regional General Hospital of Tamiang Layang, East Barito Regency.The phenomenon observed is that several complaints from patients indicate dissatisfaction, as they feel that the staff is excessively protective, unreliable in patient care, unaware of doctors' practice schedules, experiencing a lack of facilities, resulting in overcrowded rooms.Additionally, some staff members are delayed in replacing patients' infusions, and they are not present during the night when patients need assistance.As a result, several patients and visitors feel disappointed and dissatisfied with the service and commitment of the staff at the Regional General Hospital of Tamiang Layang, East Barito Regency.
goal of marketing.When patients are satisfied with the services they receive, they are likely to return for further services and recommend the hospital to friends and family.(BASetiono, 2017), Commitment to quality is a promise to oneself or others reflected in actions to maintain the quality of employee performance.Commitment to quality is the implementation of public services oriented toward the quality of results perceived by individuals in the form of good/bad measures of products/services.According to Kotler and Keller (2016:139), patient satisfaction is the feeling of pleasure or disappointment that arises after comparing the performance (results) of a product estimated against the expected performance.In the concept of patient satisfaction, two elements influence it: expectations and performance.Expectations are the patient's thoughts about what they will receive when consuming a product, while performance is the patient's perception of what they receive after consuming a product.
knowledge about doctors' practice schedules, insufficient infrastructure, resulting in crowded rooms, delayed replacement of patient infusions, and staff absence during nighttime when patients need assistance.Therefore, hospital staff should perform their duties well, ensuring good performance.The hospital should have features that facilitate patients in administrative processes, and the staff should be highly competent in patient service.Before taking action, the staff should confirm with the patient's family.Staff on duty must have strong immunity to serve patients well.

Table 4 .
AVE Value and AVE Root

2581-8341 Volume 06 Issue 12 December 2023 DOI: 10.47191/ijcsrr/V6-i12-06, Impact Factor: 6.789 IJCSRR @ 2023 7489 * Corresponding Author: Jakiroh Volume 06 Issue 12 December 2023 Available at: www.ijcsrr.org Page No. 7479-7491Table 8 .
Q-Square Value 2.0 software.The values can be observed from the results of bootstrapping.The rules of thumb applied in this study include a significance level (p-value) of 0.05 (5%) and positive beta coefficients.The hypothesis testing results of this research are presented in the table below, and the model outcomes can be depicted as shown in the table below: ISSN: