The Effect Of The Mediation Role Of Value Co-Creation On Loyalty At Hospital

Abstrak 

This research analyzed the mediation of value co-creation on patient participation and customer relationship management toward patients' loyalty at the Obstetrics and Gynaecology Polyclinic of Islamic Hospital of Hj. Siti Muniroh Tasikmalaya. This quantitative methodology used a cross-sectional survey and primary data from the questionnaire. The sample size was 271 patients. The sampling technique used purposive sampling, a sampling technique with the criteria. The analysis technique was Partial Least Square (PLS). The result indicated that the patients participation and customer relationship management toward loyalty had a mediation effect from the value co-creation variable. Patient participation and CRM affect value co-creation in outpatients at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital of Tasikmalaya, both partially and simultaneously.

 

INTRODUCTION

The COVID-19 pandemic that hit Indonesia, especially areas in Java and Bali, caused several vital industrial sectors to experience paralysis due to the hampering of company operational activities and weakening people's purchasing power, thus causing the Consumer Price Index (CPI) to experience deflation for 3 (three) consecutive months throughout the third quarter of 2020 (BPS, 2020). Currently, various policies are being implemented by the government to suppress the spread of the virus and reduce the worst risks due to the virus, from organizing vaccinations and restricting community activities to enforcing health protocols. However, the opposite is true for the pharmaceutical and health services sectors.

As one of the places of health services, hospitals are one of the referrals in handling patients, especially patients with positive COVID-19 status. However, hospitals must maintain service standards because they relate to many people's lives. In the midst of the booming condition of COVID-19-positive patients, several hospitals are still overwhelmed due to patient overload, causing the level of medical services to decline and resulting in a decrease in patient loyalty. 

Recent developments have emerged from negative public stigma regarding the COVID-19 pandemic; people who want to visit/seek treatment experience fear of being exposed to the virus, and there is fear of negligence of health workers, especially those who handle COVID-19 patients so they can spread the virus. Thus, the stigma given will worsen the situation and the spread of the disease itself. COVID-19 patients admitted that they felt depressed by the negative stigma that is developing today due to the photos being disseminated by certain parties. Medical officers who handle COVID-19 patients also experience discriminatory actions from the public because they are afraid of carrying the virus, and so on. This is also because people often get negative news (hoaxes) about COVID-19, even the effects of COVID-19 vaccination (Bali et al. Department, 2020).

The World Health Organization (WHO) has recorded 10 (ten) variants of the COVID-19 virus, of which 4 (four) are under strict surveillance. One of them is the Delta variant, which now reaches 76% of the variants circulating in 22 provinces in Indonesia with a faster transmission rate than other variants (CNBC Indonesia, 2021). Therefore, the negative stigma that occurs significantly impacts public trust, especially in hospitals as providers of health facilities that handle patients exposed to COVID-19. In addition, there is a negative stigma in patients during the COVID-19 pandemic or even after the positive rate decreases. Patients are often ignored, and the medical treatment process is sometimes treated differently; this is because health workers may consider patients exposed to COVID-19, even though lab results have not been obtained, or even the pain suffered is not a symptom of COVID-19. So that this makes patients uncomfortable with the services they receive. In addition, patients who test positive for exposure to the virus experience fear, anxiety, and guilt or even get discrimination even though they have recovered and recovered from COVID-19 (klikdokter.com). Therefore, the Tasikmalaya Islamic Hospital should conduct socialization with the public, straighten out incorrect information, and continue to improve its medical services. This creates community satisfaction, especially for patients who have used medical services at the hospital.

Loyalty is a reference that patients feel their medical needs are met. Especially in health services, patient participation is essential. The patient's participation refers to the level of effort and involvement of the patient, both physically and mentally, in experiencing the medical services he receives. Vivek et al. (2012) consider the active participation of customers as an antecedent to influence a person's involvement in shaping the creation of an innovation of a product or service. Therefore, if the services received are by or felt as expected, medical services are perceived as ideal, and desires and expectations are fulfilled, resulting in strong patient loyalty. As Mursid & Wu (2021), Ubud et al. (2017), and Hossain et al. (2019) have researched, they state that patient participation can affect loyalty. In this case, patients will recommend hospitals, create a positive image, and maintain the hospital's credibility.

The hospital should maintain patient participation while maintaining a good relationship with the patient. However, based on the initial observations made on patients of the Tasikmalaya Islamic Hospital, information was obtained that patient participation in seeking information related to hospital services and the communication process between patients and health workers was not optimal, making patients feel less satisfied with the existing medical services. 

Based on the results of initial observations on 30 patients of the Tasikmalaya Islamic Hospital, the patients did not play an active role in seeking information related to the medical services owned by the Tasikmalaya Islamic Hospital, with a percentage of 83% and the remaining 17% seeking information. The high number of patients who do not seek information is due to the limited information shared by the hospital. However, as many as 60% of patients share information they know with others. In terms of relationships with the hospital, patients still have limitations in interacting with the hospital; for example, as many as 80% do not interact intensely with the hospital in medical services. 

 Customer relationship management with customers/patients will make patients comfortable and persistent, gradually increasing their loyalty to the hospital. As Maulana and Putri (2018) research state, if relationship management with customers is good, it will also cause loyalty to increase. In addition, with customer relationship management, it is possible to maintain good health services and the value of the co-creation process by the Tasikmalaya Islamic Hospital with patients following expectations, and loyalty will be created.

The initial observations made on the patients of the Tasikmalaya Islamic Hospital resulted in the conclusion that the communication created by the hospital was not optimal, so a good relationship between the patient and the hospital was not created.

Based on the initial observations of 30 patients of the Tasikmalaya Islamic Hospital, the integrated process between humans and the application of technology in medical services is still not optimal, which is 83% considered less than optimal. Thus, a good relationship between patients and the hospital is not optimal, whereas as many as 57% stated so. In addition, 77% of the patients sampled in the preliminary observation responded that the information technology support with the communication process of the Tasikmalaya Islamic Hospital was still not optimal.

Hospitals can provide the health services needed and follow patient expectations. This can create value co-creation that can create loyalty. The research of Maduka (2016) and Raza et al. (2020) concluded that value co-creation can affect customer loyalty. Hospitals should continue to strive to increase value added. Patients and the community get medical services and a good experience when visiting or being treated at the hospital. Value co-creation is the hospital's effort to provide patients' medical needs so that patient satisfaction is created and is expected to build high loyalty.

In line with this, Harkison's (2018) research states that the impact of value co-creation has moved organizations to rethink their focus on services and products and look to involve their customers in shaping the experience, not just looking at consumers as sales objects. Co-creation refers to an interactive process involving at least 2 (two) actors involved in a specific form of mutually beneficial collaboration and creating value for those actors (Frow et al., 2015). Based on the initial observations of 30 patients at the Islamic Hospital of Tasikmalaya, there is still a limited amount of capital to support the medical service process at the Islamic Hospital, with a percentage of 90%. Meanwhile, the interaction built is still not optimal, and there is a desire for patients to share knowledge.

Patients can contribute together with the hospital in creating an innovation in medical products and services that will later impact the formation of a memorable experience, as in the research of Chathoth et al. (2016) regarding consumers and companies creating innovations in goods/services. In addition, co-creation activities began with a shift in the view of initially product-centric consumers to experience-centric (Ramaswamy & Ozcan, 2018). Therefore, the hospital must reconsider the role of the patient in shaping an experience for satisfaction and expectation (Chathoth et al., 2016).

The researcher is interested in conducting in-depth studies on the influence of patient participation, customer relationship management (CRM), and value co-creation on patient loyalty at the Tasikmalaya Islamic Hospital. Based on the description of the background of the research above, the formulation of this problem is the effect of the mediation role of value co-creation on patient participation and Customer Relationship Management (CRM) on outpatient loyalty at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital Tasikmalaya.

Loyalty

Patient loyalty, according to Oliver (2010: 156), is a profoundly enduring customer commitment to resubscribe or re-purchase the selected product/service consistently in the future, although the influence of the situation and marketing efforts have the potential to cause behavioral changes (Andr et al., 2016). In addition, Griffin (2010: 67) states that loyalty is aimed at consumer behavior by making regular purchases based on decision-making units. Based on several definitions of loyalty, it can be concluded that patient loyalty is the patient's consistency in making purchases, in this case, using medical services from the hospital and making it possible to make repurchases and recommend them to others.

Customer loyalty can be used as a management strategy because the ultimate goal of a business is the formation of profits. Profit can be achieved through business strategy, namely through the formation of solid customer loyalty. The concept of loyalty needs to be measured to see the strength of the concept through the dimension of the concept size. According to Griffin (2010: 67), there are 4 (four) dimensions of consumer loyalty, including: 

Make regular repeat purchases, which is the average repurchase by repurchasing a lot of products or services and buying additional services or products; 

Purchase across product and service lines, i.e., buying other products and services but from the same company; 

Refers to others, namely recommending or promoting products to others by recommending service providers or products to others or conveying positive things to others; 

Demonstrates immunity to the pull of the competition, which is to show the immunity of the product in question in competition by demonstrating product superiority or testing other services or products.

Patient Participation

Customer participation is a necessary customer behavior role (in-role) in creating value co-creation (Yi & Gong, 2013). Moreover, customer participation can also be defined as customer behavior that creates and delivers the value of the services offered by the company (Anabila, 2019). Meanwhile, other researchers argue that customer participation is customer collaboration when a service occurs. The company and the customer use resources to interact to get benefits (Grnroos & Voima, 2013). Patient participation is an interaction between patients and the health care system or health professionals, where patients play an active role in providing information to help solve problems and share views and priorities for treatment (Longtin et al., 2010). Based on some of the above definitions, it can be said that customer participation is the role of customer behavior necessary to create service value delivery during the interaction that benefits the company and the customer.

Yi and Gong (2013) stated that the indicators of customer participation are : 

The search for information on the customer's activeness in searching for information such as features procedures, especially the search for information about what they need and how to get it; 

Sharing information provides information to the company or employees about what services they need, usually in the form of consultations;

Responsible behavior: Customers must be able to work together and receive direction or procedures from the company or employees in order to create value; 

Personal interaction refers to the personal relationships between customers and employees, such as politeness, friendliness, and mutual respect, because a positive social environment will positively influence value co-creation.

Customer Relationship Management

Customer relationship management (CRM) is a strategy that is imperative to improve the company's ability to innovate and seek competitive competition (Lin, Chen and Chiu, 2010). CRM can also be said that customer relationship is a way to improve customer satisfaction through the medium of analysis of customers, detailing information to improve the company's competitiveness, which can be measured through dimensions of customer center and customer satisfaction (Wang, Hu and Yu, 2010). Based on some of the definitions mentioned above, it can be said that customer relationship management is a company's effort to increase customer satisfaction by directly contacting customers.

Several indicators related to Customer Relationship Management, according to Rosmayani (2016), can be measured the following indicators, which are as follows:

Creating customer value;

Customer knowledge, customer center, and satisfaction;

Performance of customer relationship management;

Information technology;

Value Co-Creation

Value creation is performing a series of actions to increase the feasibility value of goods/services. Storbacka and Lehtinen (in Rita Kusumadewi, 2015: 27) define value creation as the process by which the customer meets his needs. The value is the difference between total customer value and total customer cost. Total customer value is a collection of benefits expected by customers from a particular product or service (Tjiptono, 2020). Based on this definition, it can be concluded that value co-creation is a relationship approach between consumers and businesses to create new value and involve both parties.

Several essential elements can measure co-creation value, which are as follows:

Equity, i.e., companies are willing to share control for the benefit of their customers and want to play their part in creating value (Ranjan and Read, 2016);

Interaction between the company, in this case, the hospital and its patients. With interaction, it is an opportunity to understand, share, and serve the media needs of patients (Ranjan and Read, 2016);

Knowledge Sharing, namely sharing patient knowledge, ideas, and creativity (Ranjan and Read, 2016).

RESEARCH METHOD 

This study uses a quantitative approach with a research design cross-sectional survey using primary data that will be obtained directly through the distribution of questionnaires from respondents. Researchers use this approach to analyze the relationship between patient participation, customer relationship management (CRM), value co-creation, and patient loyalty at the Obsgyn Polyclinic at the Tasikmalaya Islamic Hospital. The population in this study is 845 outpatients at the Polyclinic Obstetrics and Gynaecology Tasikmalaya Islamic Hospital. This study calculated the research sample size using the Slovin formula, with the following formulation (=5%): (Wiratna, 2014).

n = N / 1 + Ne2

n= 845 / 1 + 845 (0.05)2

n= 271

Based on the formulation of the Slovin calculation above, the study sample size was 271 outpatients at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital of Tasikmalaya. The purposive sampling technique determines samples used as a data source based on specific criteria. The data analysis technique uses the Partial Least Square (PLS) calculation.

RESULT AND DISCUSSION

Test Research Instruments 

Convergent validity is used to prove that the respondent can understand the statement on each latent variable in the same way as the researcher intended. The loading factor value above 0.70 is considered valid (Juliansyah Noor, 2014, p. 157). Based on the analysis results, the loading factor value of each construct indicator variable was more than 0.7. Thus, the data is valid. Furthermore, a discriminatory validity test was conducted to prove the respondents did not confound the questions on each latent variable. The validity of the discrimination is satisfied if the average variance extracted (AVE) of the extracted mean-variance must be higher than the correlation involving the latent variable (Kock & Lynn, 2012). The results of the discrimination validity analysis showed that the AVE CRM value was 0.776 higher than the extracted value, both with patient participation (0.730), co-creation (0.737), and loyalty (0.734). The AVE Loyalty value of 0.829 was higher than the value extracted, with patient participation (0.640) and co-creation (0.740). The AVE value of patient participation was 0.766, more significant than the value extracted with the value of co-creation (0.706). Thus, the validity of the discrimination is fulfilled.

The Standardized Root Mean Square Residual (SRMR) < 0.10 or 0.08, then the model is considered suitable. In other words, there is a match between the observed correlations. Thus, the SRMR value is 0.031.

NFI or normal fit index produces values between 0 and 1. The closer to one, the more suitable the model is. The results of the analysis show that the NFI value is 0.627

Hypothesis Testing

The Effect of Patient Participation and CRM on Value Co-Creation

In the structural model, I describe the relationship between patient and CRM participation in value co-creation, which is stated in the hypothesis that patient and CRM participation affect value co-creation either partially or simultaneously. Based on the results of data processing for structural model I, the following equation is obtained:

Y = 0.237X1 + 0.342X2

Based on the structural equations that are formed, it can be explained as follows:

The degree of contribution or influence of patient participation (X1) on the Co-Creation Value (Y) was 0.237. With the increase in patient participation (X1), the effect on the Co-Creation Value (Y) will increase by 0.237.

The degree of contribution or influence of CRM (X2) on Value co-creation (Y) is 0.342. With the increase of CRM (X2), its influence on co-creation value (Y) will increase by 0.342.

Based on the R square value, 0.657 was obtained, which means that together, the influence of patient and CRM participation on co-creation value was 65.7%, and the remaining 34.3% was explained or influenced by other variables

Simultaneous Hypothesis Testing

With the test criterion F, Ho is rejected, and Ha is accepted if F counts less than F in the table. The F test can be performed using the following formulations:

Criteria for determining significance:

If the null hypothesis is rejected and the alternative hypothesis is accepted.

If the null hypothesis is accepted and the alternative hypothesis is rejected.

F = 206.87

Based on the calculations, the value was 206.87, more significant than 1.98. These results show that rejection means simultaneously patient and CRM participation affects value co-creation.

Partial Hypothesis Testing

Partial Influence of Patient Participation in Value Co-Creation

The results of the partial test of patient participation in the value of co-creation in outpatients at the Polyclinic of Obstetrics and Gynaecology of the Islamic Hospital of Tasikmalaya obtained the coefficient of patient participation pathway (X1) to the value of co-creation (Y) was 0.237, the value was 3.276 and the value with a significance level of () 5% was 1.65. A value more significant than the value indicates that it is rejected, which means that patient participation affects the co-creation value with a pathway coefficient of 0.237, where each increase in patient participation will increase the co-creation value by 0.237. The study's results follow previous research by Hossain et al. (2019), which explained that patient participation affects the creation of patient value.

Partial Impact of CRM on Value Co-Creation

The results of the partial test of CRM on the co-creation value obtained the coefficient of CRM path (X2) to the co-creation value (Y) was 0.342, the value was 5.117, and the value with a significance level () of 5% was 1.65. A value more significant than the value indicates that it is rejected, which means that the CRM affects the co-creation value by a path coefficient of 0.342, where each increase in CRM will increase the co-creation value by 0.342.

The Effect of Patient Participation, CRM, and Value Co-Creation on Loyalty

This structural model describes the relationship between patient participation, CRM, value co-creation, and outpatient loyalty at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital of Tasikmalaya. Furthermore, the hypothesis states that patient participation, CRM, and value co-creation directly and indirectly affect loyalty.

The indirect influence or mediation test can be seen from the indirect influence of patient participation on loyalty through value co-creation. Based on the results of data processing, the following equations are obtained:

Z = 0.318X1 + 0.266X2 + 0.364Y

Based on the model drawings and formed structural equations, it can be explained as follows

The influence or contribution of patient participation (X1) on the loyalty variable (Z) was 0.318. The higher the patient participation, the more patient loyalty will increase by 0.318.

The influence or contribution of CRM (X2) on the loyalty variable (Z) was 0.266. The higher the patient participation, the more patient loyalty will increase by 0.266.

The influence or contribution of value co-creation (Y) to the loyalty variable (Z) is 0.364. The higher the co-creation value, the more patient loyalty will increase by 0.364.

Based on the R square value, 0.515 was obtained, which means that together, the influence of patient participation and CRM and co-creation value on loyalty was 51.5%, and the remaining 48.5% were explained or influenced by other variables. Here is a calculation of each variable's direct and indirect influence or contribution to the purchase decision.

Criteria for determining significance:

If the null hypothesis is rejected and the alternative hypothesis is accepted.

If the null hypothesis is accepted and the alternative hypothesis is rejected.

F = 76.1

Based on the calculations, the value was 76.1, which was greater than the value of 1.98. These results show that rejection means simultaneously patient participation, CRM, and value co-creation affect patient loyalty at Tasikmalaya Islamic Hospital.

Partial Hypothesis Testing

Partial Influence of Patient Participation in Loyalty

The results of the partial test of patient participation in value co-creation were obtained, and the coefficient of patient participation pathway (X1) to loyalty (Z) was 0.318, a value of 3.501, and a value with a significance level () of 5% of 1.65. A value more significant than the value indicates that it is rejected, which means that patient participation affects loyalty with a pathway coefficient of 0.318, where each increase in patient participation will increase the co-creation value by 0.318. The study's results follow previous research by Hossain et al. (2019), which explained that patient participation affects patient loyalty.

CRM's Partial Impact on Loyalty

The results of the partial test of CRM on loyalty were obtained in that the coefficient of the CRM path (X2) to loyalty (Z) was 0.266, the value was 4.528, and the value with a significance level () of 5% was 1.65. A value more significant than the value indicates that it is rejected, which means that the CRM affects loyalty by a path coefficient of 0.266, where each increase in CRM will increase loyalty by 0.266. The study's results follow research by Maulana et al. (2018), which explained that patient participation affects patient loyalty.

Partial Impact of Value Co-Creation on Loyalty

The results of the partial test of the value of co-creation on loyalty were obtained that the coefficient of the co-creation value path (Y) to loyalty (Z) was 0.304, the value was 5.068, and the value with a significance level () of 5% was 1.65. A value more significant than a value indicates that it is rejected, which means that the value co-creation affects loyalty with a path coefficient of 0.304, where each increase in CRM will increase loyalty by 0.304. The study's results follow research by Maduka et al. (2016), which explained that creating patient value affects patient loyalty

Mediation Hypothesis Testing

Effect of patient and CRM participation on loyalty mediated by value co-creation 

They are testing the mediation hypothesis of the value co-creation variable on the effect of patient participation on loyalty. The results of hypothesis testing using the Sobel Test are as follows. t= 

tx1-y-z= = 1.86 

A t-count value of 1.86 was obtained, more significant than the t-table of 1.62, with a confidence level of 95% or =5%. Therefore, it can be concluded that H0 is rejected or, in other words, patient participation affects loyalty mediated by value co-creation in outpatients at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital Tasikmalaya.

Effect of patient and CRM participation on loyalty mediated by value co-creation

The results of hypothesis testing using the Sobel test (Sobel Test) obtained a t-count value of 5.48, more significant than the t-table of 1.62, with a confidence level of 95% or =5%. So, it can be concluded that H0 is rejected or CRM affects loyalty mediated by value co-creation in outpatients at the Obstetrics and Gynaecology Polyclinic of the Islamic Hospital of Tasikmalaya.

CONCLUSION

Based on the results of the research, several conclusions can be drawn. Firstly, patient participation and Customer Relationship Management (CRM) significantly influence value co-creation among outpatients at the Obstetrics and Gynecology Polyclinic of the Islamic Hospital of Tasikmalaya. This influence is evident both when the variables are considered individually (partially) and when they are considered together (simultaneously). This finding suggests that patient involvement in their healthcare process and effective CRM strategies are crucial in enhancing the value co-creation process in this setting.

Secondly, the research indicates that patient participation, CRM, and value co-creation collectively influence outpatient loyalty at the Obstetrics and Gynecology Polyclinic of the Islamic Hospital of Tasikmalaya. Each of these factors contributes independently to building loyalty among patients and, in combination, highlights the importance of a holistic approach to fostering strong relationships and loyalty within the healthcare environment.

Lastly, it was also found that patient participation, CRM, and value co-creation notably impact outpatient loyalty at the Home Obstetrics and Gynecology Polyclinic. This suggests that creating value through active patient engagement and maintaining effective patient relationships are vital for ensuring their continued trust and loyalty to the clinics services.

Based on the study's conclusions, several recommendations are made regarding the research variables affecting outpatients at the Obstetrics and Gynecology Polyclinic of the Islamic Hospital of Tasikmalaya. Firstly, regarding patient participation, it is advised that the Islamic Hospital of Tasikmalaya enhances patient interaction. This includes improving the relationship between health workers and patients and vice versa. Additionally, health workers should focus on elevating the quality of services provided to outpatients at the Obstetrics and Gynecology Polyclinic.

Secondly, regarding Customer Relationship Management (CRM), the Islamic Hospital of Tasikmalaya should focus on strengthening its relationship management with patients. This involves maintaining good relationships with patients and building trust through delivering quality medical services, particularly for outpatients at the Obstetrics and Gynecology Polyclinic. By doing so, the hospital can foster a more trusting and reliable connection with its patients.

Thirdly, regarding value co-creation, the Islamic Hospital of Tasikmalaya is encouraged to increase the sharing of knowledge and experience with patients concerning Obstetrics and Gynecology (Obgyn). This approach allows patients to gain valuable insights and knowledge while at the hospital, enriching their overall experience and contributing to value co-creation.

Furthermore, the hospital should focus on providing comprehensive and high-quality medical services to improve patient loyalty. This includes continually upgrading health and pharmaceutical facilities to meet better patient needs, especially in Obstetrics and Gynecology. A commitment to delivering maximum medical services is critical to fostering stronger patient loyalty.

Finally, it is recommended that future research explore similar analyses with different research subjects and locations. Researchers should also consider diversifying research models and variables. Additionally, conducting a more in-depth study on value co-creation and other factors influencing patient loyalty could provide further valuable insights.

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