EVALUATION OF OUTPATIENT SATISFACTION WITH PHARMACEUTICAL SERVICES IN THE ERA OF NATIONAL HEALTH INSURANCE

Background: The National Health Insurance (JKN) system has been able to improve the health status of the Indonesian people. However, efforts are still needed to accelerate the achievement of health indicators to catch up with other countries. Therefore, the researchers were interested in conducting research related to evaluating outpatient satisfaction with pharmaceutical services in the era of national health insurance at the PKU Muhammadiyah Gamping Hospital. Aim: The purpose of this study is to determine the profile of outpatient satisfaction and at what dimensional pointes outpatients are less satisfied with pharmaceutical services by using national health insurance at PKU Muhammadiyah Gamping hospital Method: This research is a non-experimental descriptive study with a cross sectional approach. Sampling is carried out prospectively by the purposive sampling method through questionnaires given to the target population. The number of statement items in this study is 29 satisfaction items and 29 expectations items in terms of 5 dimensions. Findings: The level of satisfaction of outpatients with pharmaceutical services in national health insurance users at PKU Muhammadiyah Gamping included the responsiveness dimension of 95.52%, the empathy dimension of 90.49%, the assurance dimension of 90.32%, the reliability dimension of 87.12%, and the tangible dimension of 86.40%. The result of the average value of the respondent's overall satisfaction level was 89.97%. Based on the average results of the value of the outpatient satisfaction level with the pharmaceutical services of national health insurance users at PKU Muhammadiyah Gamping Hospital, this value is included in the category of "very satisfied."


INTRODUCTION
Consumer satisfaction or patient satisfaction can be regarded as a benchmark to determine the quality of services provided by hospitals or hospital pharmacy installations (Larasanty et al., 2019;Swain & Kar, 2018). The patient evaluates the health services provided at a hospital in the hope that they are in accordance with a hospital health order (Grange et al., 2020;Uppal et al., 2020). Patient satisfaction with health services depends on the services provided by the hospital. However, if the services provided by the hospital are not as expected by the patient, it is necessary to carry out a special evaluation of the hospital pharmacy installation services carried out by the hospital (Andriani et al., 2022;Astuti et al., 2023).
The National Health Insurance (JKN, Jaminan Kesehatan Nasional) is a social security program that is mandatory in nature where the contributions are paid by the Central Government or Regional Government to the community by providing social insurance guarantees. The government's efforts to improve the quality of health by providing JKN (National Health Insurance) are expected to improve the quality of life for the community for a better time. With the JKN program, it can provide benefits in the form of health services that include promotive, preventive, curative and rehabilitative services (Mumu et al., 2020;Putri & Noer, 2019).
The difference in the satisfaction profile of JKN PBI and Non-PBI patients lies in the health services provided by health workers to patients using JKN or the National Health Insurance. A growing problem in today's society is complaining about the poor quality of service and this is also associated with the level of satisfaction of patients who use JKN PBI tends to be lower than patients with Non-PBI JKN, according to Ratnasari et al. (2020) satisfaction level a function of differences between perceived and expected performance. If the performance falls short of expectations, the customer will be disappointed and if the performance meets expectations, the customer will be satisfied.
So far, PKU Muhammdiyah Gamping Hospital has never conducted research related to the evaluation of outpatient satisfaction with pharmaceutical services in the era of national health insurance. Therefore, based on the background, the researchers were interested in conducting research related to evaluating outpatient satisfaction with pharmaceutical services in the era of national health insurance at the PKU Muhammadiyah Gamping Hospital. This study aims to determine the profile of satisfaction of outpatients with pharmaceutical services using national health insurance, to find out at what dimension points outpatients feel dissatisfied with pharmaceutical services using national health insurance, and to determine the effect of the type of JKN service (Non PBI and PBI) on patient satisfaction in JKN services at PKU Muhammadiyah Gamping Hospital. Hopefully, this study can give a deeper insight into the application of JKN program in general and JKN services implementation in regional scope, specifically.

METHODS
Non-experimental analytic research with quantitative data collection which aims to analyze the performance of services performed by pharmacists to consumers/patients receiving services. The method used in this study was cross sectional for the period September -November 2023 at the Outpatient Installation of PKU Muhammadiyah Gamping Hospital. This research is a descriptive cross sectional study. The research design aims to determine the level of patient satisfaction and the level of patient expectations for pharmaceutical services in the outpatient pharmacy installation at PKU Muhammadiyah Gamping Hospital using the questionnaire. The questionnaire was prepared following each dimension of SERVICE QUALITY , namely tangibles, reliability, empathy, assurance and reliability. Each dimension statement is given a score based on a Likert scale (Novaryatiin, 2018): Quite satisfied 3 4 Satisfied 4 5 Very satisfied 5 After that, measuring the Patient Satisfaction Level (TKP) was carried out by calculating the percentage of each indicator with a range of evaluation scales for the satisfaction level of respondents (patients) (Yuliani et al., 2017): Furthermore, to find out which dimension points need to be repaired by PKU Muhammadiyah Gamping Hospital, an Importance Performance Analysis is carried out which is the result of calculating the X value (average score of satisfaction level) which consists of quadrant analysis and gap analysis. Quadrant analysis has a function to show the relationship between the assessment of the level of importance and the level of patient satisfaction.
In the analysis in this study, using a Cartesian diagram to map the attributes of service quality.

Figure 1. Cartesian Diagram
The sampling method was carried out by purposive sampling method. The total sample that met the inclusion and exclusion criteria was 100 respondents. The inclusion criteria in this study were patients who were willing to become respondents and patients who received services at outpatient pharmacy installations and used JKN services at PKU Muhammadiyah Gamping Hospital while the exclusion criteria in this study were patients who could not complete the questions on the questionnaire given independently. Data were processed using statistical applications. This research received ethical approval from the Research Ethics Commission of PKU Muhammadiyah Gamping Hospital number 168/KEP-PKU/IX/2022.

RESULTS AND DISCUSSION
The research was conducted at the Outpatient Pharmacy Installation at PKU Muhammadiyah Gamping Hospital. The distribution of valid questionnaires was distributed to 100 respondents according to predetermined characteristics. The number of sample members used in this study corresponds to a 10% precision level of the population. The number of respondents is 100 respondents. This study uses a minimum number of samples using the Lemeshow formula (Rahma & Airlangga, 2020).
Respondents in this study were JKN patients and had received outpatient pharmaceutical services at PKU Muhammadiyah Gamping Hospital. In this study, researchers grouped respondents based on gender, age, occupation, last education and JKN membership status (PBI/non-PBI). The following are the characteristics of the 100 respondents in the table.

Evaluation of Outpatient Satisfaction with Pharmaceutical Services in the Era of National Health Insurance
Gender can affect the scale of community satisfaction with pharmaceutical services in general towards dissatisfaction in groups of young female patients with communication services, and the performance of health services provided in a hospital (Woods & Heidari, 2003). Even so, this study shows that the correlation analysis between satisfaction levels and gender does not have a significant relationship between them.
The results of the study showed that the majority of respondents were >56 years old. This could be due to declining health levels, requiring routine health services (Nisa' et al., 2021). This study shows that there is no significant relationship between the age of the respondents and the level of satisfaction according to the results of the correlation analysis of the pharmaceutical services that have been provided.
Respondents with higher education can have an effect because they have extensive information and are better informed than respondents with lower education (Muhammad et al., 2020). In this study, there was no significant relationship from the results of the analysis between the level of satisfaction of the respondents and the level of education received by the respondents.
According to Muhammad et al. (2020) said that there is a relationship between the level of patient satisfaction with work. Respondents who have a job will criticize more often and are always demanding of the services provided compared to respondents who do not have a job. In this study, the results of the correlation test were negative (-0.250). The results of the negative correlation analysis indicated that there was a relationship that was reversed or not in the same direction with the variables so that the variables analyzed had the same relationship between the type of work of the respondents and the level of patient satisfaction.
From the results of the correlation analysis in this study it was found that there was no significant relationship between respondent satisfaction and JKN membership status at PKU Muhammadiyah Gamping Hospital. The results of the research on patient satisfaction with pharmaceutical services are based on average performance and expectations for 5 (five) service dimensions: From the table above, it can be seen that the one with the lowest level of suitability is the tangible dimension. This can be interpreted that the services provided are not in accordance with patient expectations. However, in terms of the tangible dimension, it is included in the very satisfactory criteria, even though the level of conformity is the lowest.
Then the responsiveness dimension has the smallest gap value. This can be interpreted that the pharmaceutical services that have been provided have met patient expectations in terms of responsiveness. This dimension also has the highest level of conformity and is included in the very satisfying category.
The data that has been collected is then tabulated, non-parametric analysis is carried out using the Mann Whitney test showing that the type of JKN service (non-PBI and PBI) does not affect patient satisfaction with JKN services (H0 is rejected) with a p-value of 0.827. Nonetheless, the results of the multivariate analysis on the variables of the type of JKN service, age, gender, last education, and occupation on patient satisfaction with JKN services produce a Standardized Coefficient which shows that the level of patient satisfaction with JKN services increases in the non-PBI group with older ages have a better education and have a job. Meanwhile, gender does not affect the level of patient satisfaction with JKN services at PKU Muhammadiyah Gamping Hospital. To describe the average respondent's satisfaction with outpatient pharmacy services at the PKU Muhammadiyah Gamping Hospital, it is necessary to carry out an analysis called Importance Performance Analysis (IPA). Determining the X and Y axes and the coordinates of each attribute is one of the things that must be done before making a Cartesian diagram. The determination of the X axis is obtained by calculating the average performance score along the Y axis obtained by calculating the average expected score. After the X and Y axes are obtained, a Cartesian diagram is created using statistical data.

Figure 4. Cartesian Diagram Test Results
Based on the Cartesian diagram above, it shows that most of the performance of pharmaceutical services in the outpatient pharmacy installation at PKU Muhammadiyah Gamping Hospital has met consumer/patient expectations. This result is in accordance with the results of the average level of expectation with patient satisfaction of 89.97%, meaning that most of the respondents were very satisfied with the pharmaceutical services provided by the outpatient pharmacy installation.

CONCLUSION
Profile of JKN patient satisfaction with outpatient pharmaceutical services at PKU Muhammadiyah Gamping Hospital with an average level of suitability of performance with expectations of the tangible dimension of 86.40%, the reliability dimension of 87.12%, the responsiveness dimension of 95.52%, the assurance dimension of 90.32%, and the empathy dimension of 90.49%. Based on the results of the IPA analysis, there are no statement items or attributes that are a top priority for improvement by the Outpatient Pharmacy Installation at PKU Mummadiyah Gamping Hospital. Nonetheless, optimization of pharmaceutical services can still be carried out on the accuracy and timeliness of services in the assurance dimension, responsiveness to patient complaints in the responsiveness dimension, and the ability to explain the use of specific drugs to patients (Reliability dimension). The statistical analysis results show that the type of JKN service (Non-PBI and PBI) did not affect patient satisfaction with JKN services at PKU Muhammadiyah Gamping Hospital.
Pharmacists should continue to provide good pharmaceutical services and pay attention to pharmaceutical services in the Outpatient Pharmacy Installation at PKU Mummadiyah Gamping Hospital, and for future researchers it is hoped that they will be more comprehensive in conducting research and accompanied by more in-depth interviews.