Service quality as a driver of perceived value satisfaction and revisit intention in Indonesia

Abstract

Recent literature on healthcare quality shows the important of patient-centred design, hence more contextualized and patient-perspective research is needed to assess service quality. Hence, this study aimed to analyse the relationship and explores the influence of service quality in national central public hospital and how they are perceived and impact outpatient satisfaction, perceived value, and revisit intention in Indonesia. This mixed-method study had a sample size of 770 outpatients for the quantitative phase and 12 outpatients for the qualitative phase from national central public hospital in Indonesia. The quantitative analyse the construct of service quality dimensions and incorporates them with the literature to develop a conceptual model that suits and represents a developing country. The qualitative phase explores the relationship between each construct in the conceptual model and provide the meaning and in-depth explanation of the model results. The five dimensions of service quality were tangibility, assurance, empathy, reliability, and responsiveness. These dimensions have a positive and significant impact on patient perceived value and satisfaction. The quantitative results confirm that patient satisfaction and patient perceived value significantly impact outpatient’s revisit intention and can significantly mediate the influence of service quality on revisit intention; however, patient perceived value does not significantly impact patient’s satisfaction. The qualitative results explain, service quality provided by the hospital influence patient perceived value of choosing the hospital, and perceived value does not considerably impact patient satisfaction. In addition, although waiting time has been widely studied globally, empirical evidence on its influence within the Indonesian healthcare context remains limited. In this study, waiting time was found to have the most substantial impact on outpatient satisfaction and revisit intention. While the healthcare providers and the government in Indonesia can increase patient perceived value by improving the service quality factors. Practitioners should invest in building trust and communication to reach out to their patients and increase patient loyalty.

Introduction

A primary priority for healthcare systems across the world has always been to provide the greatest quality medical services while dealing with limited medical resources. A good healthcare system must be able to handle the intricate links between price, quality, and resource allocation¹. In addition, the need for health care stems from the desire to improve one’s health, and it is a component of a system that will evolve because of personal preferences and requirements. It was reinforced by a recent study that revealed patients may not necessarily see a problem as serious when staff members feel that the quality of a certain service feature is inadequate². This demonstrated that healthcare providers should employ patient-centred designs to ensure smooth continuation of services or treatment. Recent changes to health care policy also place an emphasis on “consumer-driven” healthcare, and in a patient-centred healthcare system, needs and preferences should be the determining factors. In general, the role of the patient has changed from one of a passive recipient of care to one in which they play a more active role in the process of giving care³.

The demand for health care and the services offered may be observed and quantified with the appropriate evaluation methods. After all, quality is an assessment of a healthcare service’s capacity to satisfy the needs and expectations of its patients. Patient satisfaction is a trustworthy and straightforward metric for evaluating the quality of healthcare services. It can have a significant impact on the services offered by physicians, nurses, and other healthcare workers. Patient satisfaction might potentially be a significant component in analysing the intervenable aspect of revisit intentions^4–7. There is virtually little study on patient experiences with service quality in developing countries, including Indonesia. The majority reside in Iran, Pakistan, Bangladesh, and India⁸. Therefore, in addition to bridging the literature gap, we want to develop a model to assess the impact of service quality on patient perceived value, patient satisfaction, and revisit intention to the hospital, as well as explain the relationship between service quality provided, patients’ expectations and satisfaction, and the intention to return to use the treatment.

Indonesia’s healthcare system, while rapidly developing, still faces challenges such as uneven distribution of services, overburdened public facilities, lower digital integration, and limited health literacy among patients^9–11. Additionally, Indonesia implements a universal health coverage scheme (JKN) through BPJS Kesehatan, where financial coverage is high, but service disparities across regions and facilities remain significant¹². These systemic factors influence how patients perceive service quality and how they interact with providers. For example, a published research found that Indonesian outpatients place high importance on the physical appearance of hospital staff, staff attentiveness, and administrative simplicity, dimensions that are not always prioritized in Western instruments¹³. Similarly, another published research identified additional quality dimensions in Indonesians hospital services, including medication availability, facility layout, religious sensitivity (e.g., prayer rooms), and the role of administrative officers, elements rarely addressed in global models¹⁴. Additionally, patients in rural areas often place significant value on personal familiarity and empathy, sometimes more than on factors like speed or advanced technology¹⁵.

Literature review

Dimensions of service quality

SERVQUAL is a multidimensional research technique designed to elicit customer perceptions and expectations. Models that support SERVQUAL’s diagnostic usefulness serve as a conceptual basis for scale development. The instrument has taken over as the standard and most often used measurement scale across all service quality categories, across a variety of scenarios, and inside strong cultural settings⁸. The SERVQUAL model was first developed by A. Parasuraman, L. Berry, and V. Zeithaml in 1988. Service measurement at that time was difficult to quantify and appeared ethereal. But as time went on, it became clear how crucial the model was in providing a competitive edge, which had a significant influence on the US market in the early 1990s. The SERVQUAL model has shown to be a reliable and consistent approach by some authors throughout the time. Perceived quality differs from objective quality since the latter entails objective evaluation based on observable and verifiable set standards¹⁶. To measure service quality, most of the study in service quality field use SERVQUAL model⁸, which in this study consisted of 5 dimensions including: tangible, reliability, responsiveness, assurance, and empathy¹⁷.

Relationship between service quality, perceived value, patient satisfaction, and revisit intention

According to Parasuraman theory¹⁸, service quality is the difference between what customers anticipate from the service and how they perceive the experience. The Gap Model, which was first developed by Parasuraman and his associates, is the most illustrative piece of study on the issue^19,20. It is challenging to assess the technical quality of the outputs (results) and the process of providing the services (functional quality)²¹. In addition, heterogeneity, intangibility and inseparability of production and consumption as the three unique features of services make service quality be an abstract and elusive construct¹⁷. Therefore, evaluating customers’ perceptions about quality is an effective approach to assess quality²². Based on their perceptions of what they provide and receive in return, customers evaluate the usability of products and services using the concept of customer perceived value¹⁶. Before choosing to employ a healthcare service, a patient evaluated the perceived value of the service in the context of healthcare²³. Whereas patient satisfaction is defined as the difference between patients’ expectations and the actual performance of services received by patients²³. Therefore, in the study direction process, service quality established the parameters to assess the healthcare services, then there are two stages of evaluation followed. First, before using the service (perceived value) and second, after using the service (satisfaction).

To better understand the dynamics among service quality, perceived value, patient satisfaction, and revisit intention, it is essential to situate this study within the broader paradigm of patient-centred and consumer-driven healthcare. Patient-centred care emphasizes the tailoring of health services to individual needs and preferences, which enhances satisfaction and overall health outcomes. Meanwhile, consumer-driven healthcare recognizes patients as active participants who seek quality and value in their healthcare choices. This study integrates these perspectives by examining how service quality influences patients’ perceptions and behaviours in Indonesian public hospitals, capturing the evolving role of patients not merely as passive recipients but as empowered consumers. The sequential mixed-method design enriches this investigation by combining quantitative rigor with qualitative depth, allowing for a comprehensive understanding of patient experiences and contributing to a conceptual model that is both theoretically grounded and contextually relevant to developing country healthcare systems. Hence, to further understand the relationship between service quality, perceived value, patient satisfaction and revisit intention, the study posits the following hypotheses:

H1

Service quality positively effects patient perceived value.

H2

Service quality positively effects patient satisfaction.

H3

Patient perceived value positively effects patient satisfaction.

H4

Patient perceived value positively effects revisit intention.

H5

Patients’ satisfaction positively effects revisit intention.

This literature shows the importance of service quality on patient perceived value, patient satisfaction, and patient revisit intention. This study was guided by a conceptual framework (Fig. 1) drawn from other researchers conducted on the relationship of these variables in patients setting. The conceptual framework depicted the impact of service quality on patient’s perceived value, satisfaction and intention to revisit the public hospital in Indonesia.

Fig. 1.

The conceptual model.

Methodology

Research design: mixed-method approach

Mixed method is a study design in which the researcher gathers and analyses data, integrates results, and draws inferences utilising both quantitative and qualitative approaches in a study²⁴. This study utilised a sequential explanatory design (Fig. 2). In this paradigm, the qualitative component contributes to the interpretation of quantitative data. The goal is to explain a phenomenon, interpret unexpected outcomes, or investigate specific results in further depth²⁵.

Fig. 2.

Research design: a sequential explanatory design.

(Sources: Adapted from the Creswell and Plano Clark’s reference book²⁶.

Researchers divided the study into two parts based on this approach. In the first phase (Phase I), a questionnaire was used to obtain quantitative data on outpatient service quality, perceived value, satisfaction, and revisit intention. The study used Structural Equation Modelling (SEM) to investigate the link between each component in the model. Then, in the second phase (Phase 2), qualitative research was conducted in a purposefully selected sample utilising an in-depth interview with outpatients, with the goal of providing more insight into the patterns seen in the quantitative analysis.

Phase 1: quantitative study

The quantitative phase investigates the relationships between all variable components in the proposed model (Fig. 3). This phase begins with a consultation discussion with researchers, health policy experts, medical specialists, and language experts. While language specialists in English/Bahasa aided with the translation process, health policy and medical professionals worked to ensure that the items utilised were appropriate for the Indonesian healthcare setting and that the dimensions were consistent and well defined. The questionnaire is organised into two sections: socio-demographic characteristics of the sample (Table 1), and scales for each assessed construct. The questionnaire has 32 items scored on a five-point Likert scale ranging from “Strongly disagree” (1) to “Strongly agree” (5). There are four constructs or latent variables in this study which are service quality, perceive value, patients’ satisfaction, and revisit intention. Service quality referred to the SERVQUAL model which were measured by 5 quality dimensions. The following dimensions are Tangibles; Reliability; Responsiveness; Assurance; and Empathy¹⁸. Several studies have been conducted using SERVQUAL model which have proven the usefulness of this model in analysing service quality in hospitals. Table 2 provides a description of the constructs and their scales.

Fig. 3.

The hypothesizes model.

Table 1.

Demographic characteristics of the quantitative samples.

Demographic characteristics	Category	Sample (N = 770)
		Frequency	Percentage (%)
Age Group	< 45 years old	404	52.5%
	> 45 years old	366	47.5%
Gender	Male	280	36.4%
	Female	490	63.6%
Marital status	Single	133	17.3%
	Divorced	21	2.7%
	Married	616	80%
Educational Level	Primary school	140	18.2%
	Junior high school	98	12.6%
	Senior high school	387	50.3%
	Diploma’s degree	16	2.1%
	Bachelor’s degree	66	8.6%
	Master’s degree	63	8.2%
Income	< Minimum monthly wages (IDR 4.6 million)	665	86.4%
	>Minimum monthly wages (IDR 4.6 million)	105	13.6%
Occupation	Wage labor	188	15.3%
	Housewife	319	41.4%
	Farmer	125	16.2%
	Entrepreneurs	31	4%
	Private sector employee	62	8.1%
	Government employee	31	4.1%
	Teacher	19	2.5%
	Student	27	3.5%
	0thers	38	4.9%
Outpatient department	Internal medicine department	116	15.1%
	Neurology department	89	11.6%
	Surgical department	93	12.1%
	Eye department	20	2.6%
	Anesthesia department	51	6.6%
	Dermatology department	45	5.8%
	Orthopedic department	29	3.8%
	Nutrition department	30	3.9%
	ENT department	109	14.2%
	Others	188	24.3%

Table 2.

Study instrument in the quantitative phase.

Dimension	Item	Code	References
Tangibility	Neat appearance of employees	Tan1	Adopt from the literature*
	Visual appealing facilities	Tan2
	Neat appearance of polyclinic service	Tan3
	Professional appearance	Tan4
	Modern equipment	Tan5
Assurance	Have the knowledge to answer patients’ questions	Ass1	Adopt from the literature*
	Able to instil confidence in patient	Ass2
	Constantly courteous	Ass3
	Ability to handle patients’ problems	Ass4
Empathy	Given individual attention	Emp1	Adopt from the literature*
	Understand the specific needs of patients	Emp2
	Convenient consultation hours	Emp3
Reliability	A sincere interest in solving problem	Rel1	Adopt from the literature*
	Maintains error-free records	Rel2
	Provides services as promised time	Rel3
Responsiveness	Offers prompt services to patients	Res1	Adopt from the literature*
	Willing to help patients	Res2
	Responding quickly	Res3
Perceived value	The hospital provides high-quality services	PV1	Adopt from the literature**
	My effort to get to this hospital was well-deserved	PV2
	Overall, I was satisfied with this hospital fee	PV3
	The hospital offers a reasonable price for its services	PV4
	The hospital’s services are worth the money spent	PV5
	The hospital offered good value for my money	PV6
Patients’ satisfaction	I am satisfied with the health care provided	PS1	Adopt from the literature**
	The hospital has met al.l my expectations	PS2
	Compared with other hospitals, the level of satisfaction was high	PS3
	Choosing this hospital has proven a wise decision	PS4
	Overall, I am satisfied with this hospital	PS5
Revisit Intention	I consider the hospital the first choice	RI1	Adopt from the literature**
	I will continue to use the services by this hospital	RI2
	I will keep in touch with the hospital	RI3

* Adopt from the literature¹⁹ , ** Adopt from the literature²⁹.

The construct model had tested using the questionnaire to gather empirical data from sample of 770 outpatient via purposive sampling in general hospitals in Palembang City. A sample size of 770 qualified to testify the statistical significance. The sample size calculation for quantitative study estimated based on a generally accepted ratio to minimize problems with deviations from normality is at least 5–10 respondents for each parameter estimated in the model as per various literatures for structural equation modelling rule^8,27,28. In addition, the theory of SEM used in this study is a subject-to-parameter to be estimated by Hair, which the sufficient to estimate parameters confidently is 10:1. Based on proposed hypothesized model in this study, there are 46 parameters, so the sample size was 460 as a standard for this study. The sample had diverse backgrounds regarding age, gender, education, and working background. Specifically, female respondents accounted for 63.6%. The age distribution according has a high representation of adults age (< 45 years old) than pre-elderly age (45–59) and seniors age (60 and above), which accounted for 52.5% of the respondents. Regarding education, most respondents had completed the government’s 12-year compulsory education with minimum of completing senior high school which accounted for 50.3%, and only 18.9% of respondents attended higher education. Moreover, most of respondents 41.4% are housewives, 16.2% are farmers, 15.3% are wage labours, 8.1% are private sector officer, 4.1% are government officer, 4% are entrepreneurs, 3.5% are students, 2.5% are teachers and 4.9% claim others. The distribution of the respondents’ characteristics is shown in Table 1.

To evaluate the hypothesized structural relationships, statistical hypothesis testing was performed using CB-SEM via AMOS software. Each hypothesized path was tested individually. The null hypothesis for each structural path was that the standardized regression weight (β) equals zero, while the alternative hypothesis was that β ≠ 0. A significance level of α = 0.05 was used throughout the analysis. Model adequacy was assessed using a combination of fit indices, including Chi-square (χ²), Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), and Goodness of Fit Index (GFI). In light of the potential issue of multiplicity, which refers to the increased risk of Type I error when multiple hypotheses are tested simultaneously, caution was exercised in interpreting the results. Although no formal statistical correction such as the Bonferroni or Benjamini–Hochberg procedures was applied, the analysis emphasized both statistical and practical significance. Attention was given not only to p-values but also to the magnitude and direction of standardized path coefficients, as well as to the overall model fit. This approach was intended to ensure that the findings were meaningful and valid, both from a statistical and theoretical standpoint.

Phase 2: qualitative study

The qualitative phase explains the factors that influence service quality in the public hospital context and how these factors impact the outpatient’s satisfaction and intention to revisit. To achieve this goal, an In-depth interview using a semi-structured questions was used. Semi-structured interviews were conducted using a guide based on the SERVQUAL dimensions; tangibility, reliability, responsiveness, assurance, and empathy while allowing flexibility for additional themes relevant to the Indonesian context. To collect relevant, rich, and extensive data on the factors that influence individual decisions after receiving healthcare services, twelve in-depth interviews with public hospital outpatients were purposively sampled following Patton’s purposeful sampling approach, ensuring variation across hospital departments with different patient volumes, as well as diversity in age, gender, and treatment experiences. Interviews were held after treatment completion to capture fully experienced perspectives (Table 3). The interviewed group included four females and eight males with ages ranging from 20 to about 60 years. They experienced various medical problems. The diversity in participants’ medical treatment backgrounds helps identifying the demand and reason of outpatients for seeking care.

Table 3.

Demographic characteristics of the qualitative samples.

No	Name	Age	Gender	Salary	Job	Department
1	A	43	Female	>minimum monthly wages	Housewife	ENT
2	B	37	Female	>minimum monthly wages	Government officer	ENT
3	C	43	Male	< minimum monthly wages	Farmer	ENT
4	D	51	Male	< minimum monthly wages	Wage labour	Eye
5	E	62	Male	< minimum monthly wages	Wage labour	Eye
6	F	47	male	< minimum monthly wages	Unemployment	Tooth
7	G	35	male	< minimum monthly wages	Housewife	General surgery
8	H	52	male	< minimum monthly wages	Farmer	General surgery
9	I	28	male	>minimum monthly wages	Airport staff officer	Orthopedy
10	J	61	female	< minimum monthly wages	Government officer retired	Internal medicine
11	K	50	female	< minimum monthly wages	Government officer	Internal medicine
12	L	38	male	>minimum monthly wages	Police officer	Neurology

Although the demographic composition of the qualitative sample differs from that of the quantitative phase, this difference was an intentional and methodological decision that aligns with the principles of a sequential explanatory research design. The purpose of the qualitative phase was to enrich and clarify the statistical findings by exploring the contextual and experiential aspects of outpatient satisfaction and revisit intention. Therefore, participants for the in-depth interviews were selected purposively, not to replicate the characteristics of the quantitative sample, but to reflect a broad range of perspectives based on their care experiences. In particular, the sampling strategy ensured variation across different hospital departments, including both departments with high patient volumes and those with lower volumes, in order to capture diverse service delivery contexts. This allowed the study to explore how service quality may be perceived differently depending on the nature and complexity of care received in each department. The differences between the two samples do not undermine the validity of the findings. Instead, they offer complementary insights that deepen the understanding of the quantitative results. The integration of the qualitative and quantitative data took place during the interpretation stage, where themes emerging from interviews were used to explain, support, or nuance the patterns identified through statistical analysis, consistent with the purpose of follow-up qualitative inquiry in mixed-methods research.

The interview guideline was divided in two-part, general characteristic question and construct model question. Each interview was conducted in person and lasted 15–20 min. The responses and viewpoints were captured on audio and then categorized into themes for the study. This research utilized the researcher checking method to ensure the quality of the response, so missing data or information which need clarification was further asked through the interview. With differences in the background, context, and department, the researcher presented its analysis in the format of case studies, with participants were made anonymous to ensure the facts and information were provided without distortion.

To analyse the qualitative data in sequential explanatory design, the researcher followed data analysis and coding procedures suggested by Creswell³⁰ and Patton³¹. The methods allow understanding of people or events “from those we cannot observe”³². Additionally, it makes it possible to gather data from additional sources and raises the trustworthiness of study results³³. The investigation was started with data transcription from audio recording into the document, as proposed by Creswell³⁴. After reading the documents, the coding procedure was carried out by segmenting the information. The qualitative materials were categorised into four themes in accordance with the five dimensions of service quality: tangibility, assurance, empathy, reliability, and responsiveness. To ensure original content and prevent any bias, the qualitative narrative and data interpretation were carefully translated and produced based on facts and information perceived from the participants using Brislin³⁵ backward translation method.

Results

Quantitative findings

Internal reliability and validity results

Internal reliability was calculated using the Cronbach’s Alpha coefficient test at a benchmark of 0.7. for the validity test, the value of 0.5 for AVE and 0.7 for CR were the standard^36–38. All measured constructs met the criteria for internal reliability and validity (Table 4). Subsequently, Confirmatory Factor Analysis (CFA) were conducted. In this research, the CFA criterion is 0.5, which is reliable according to a previous study³⁹. After removing three items that could not pass the 0.5 benchmarks, namely Patient perceived value 1 (0.49 < 0.5), Patient perceived value 2 (0.47 < 0.5), and patient perceived value 4 (0.3 < 0.5) during CFA analysis, other items continued to the CFA analysis. Through CFA analysis, the researchers observed that the values of CMIN/DF = 3.929, CFI = 0.897, GFI = 0.965, RSMEA = 0.062, and sig test value of model 0.000 (< 0.05), hence the analytical data were compatible with the hypothesis model at 95% confidence.

Table 4.

Construct reliability and validity: cronbach’s Alpha, average variance extracted (AVE) and composite reliability (CR).

Factor	Cronbach’s Alpha	AVE	CR
Service quality-tangibility	0.989	0.839	0.963
Service quality-assurance	0.978	0.839	0.963
Service quality-empathy	0.947	0.839	0.963
Service quality-reliability	0.967	0.839	0.963
Service quality-responsiveness	0.918	0.839	0.963
Perceived value	0.980	0.965	0.988
Patient satisfaction	0.975	0.857	0.967
Revisit intention	0.978	0.915	0.97

Structural equation models

After performing Confirmatory Factor Analysis (CFA), the researchers performed a linear structural model (SEM) analysis to test the research hypotheses and measure the impact of factors on each other. Based on the results of the SEM analysis, the conformity assessment results of the model were satisfactory: CMIN/df = 3.401 (< 5), CFI = 0.838 (>0.9), GFI = 0.950 (>0.9), RMSEA = 0.056 (< 0.08), P-value test value relevance = 0.00 (< 0.05)³⁹, hence, at 95% confidence, the data are suitable for the SEM analysis model. The results are presented in Table 5.

Table 5.

Research hypotheses results in SEM Analysis.

Hypothesis	Path	S. E	t count	Path coefficient	P-value	Results
H1	SQ → PPV	0.061	10.687	0.655	< 0.001	accepted
H2	SQ → PS	0.083	12.214	1.014	< 0.001	accepted
H3	PPV → PS	0.057	−0.319	−0.018	0.750	Not accepted
H4	PPV → RI	0.053	0.160	3.034	0.002	accepted
H5	PS → RI	0.041	0.447	10.992	< 0.001	accepted
Information: H1 Service quality positively effects patient perceived value. H2 Service quality positively effects patient satisfaction. H3 Patient perceived value positively effects patient satisfaction. H4 Patient perceived value positively effects revisit intention. H5 Patient satisfaction positively effects revisit intention.

At 95% confidence interval, the results support 4 hypotheses and reject 1 hypothesis (Table 5). In conclusion, Service Quality has a positive and significant effect on patient perceived value, indicated by a t count value of 10.687 > 1.96 and a positive path coefficient of 0.655. This means that the better the service quality, the higher the patient perceived value, and vice versa, the worse the service quality, the lower the patient perceived value. Regarding Service Quality has a positive and significant effect on patient satisfaction, indicated by a t count value of 12.214 > 1.96 and a positive path coefficient of 1.014. This means that the better the service quality, the higher the patient satisfaction, and vice versa, the worse the service quality, the lower the patient satisfaction. Meanwhile patient perceived value has negative and no significant effect on patient satisfaction, as indicated by the t count value – 0.319 < 1.96. This means that good or bad patient perceived value has no effect on patient satisfaction. Moreover, in terms of revisit intention, patient perceived value and patient satisfaction has a positive and significant effect on revisit intention with t count value 3.034 (0.160 Path Coeff) and 10.992 (0.447 Path Coeff) respectively. This means that the better the patient perceived value and satisfaction, the higher the revisit intention.

Qualitative findings

Service quality’s dimension explanation

In this research, an in-depth interview with the outpatients had been performed at the hospital by face to face with the researcher. This phase generated rich and depth data to understand the impact of service quality on outpatient’s perceived value, satisfaction, and revisit intention. To ensure original content and prevent any bias, the narrative and data interpretation had been carefully translated and produced based on facts and information perceived from the participants. Moreover, Fig. 4 shows the themes in the qualitative phase.

Fig. 4.

Qualitative results: themes map.

First, Outpatients commonly say that the service quality in this hospital in terms of tangibility aspects is good enough. The physical facilities and equipment in the hospital is great according to their function and appearance, the hospital employee dress appropriately professional, neat, and friendly. There are some different in the opinion of the patient from reliability aspects, some said there is no problem in the waiting time from their arrival until their turn to get the treatment or services, but those who get a problem, is in the pharmacy department section. They said there is no information from the pharmacy staff due to limited staff and high demand of hospital prescription medicine. Despite of the differences, they do agree that the hospital has a long que and waiting time in the department whether that is a small or big department. Researchers believe this happens because of the large number of patients who come to this hospital in one day, considering that this hospital is a national level referral hospital where patients do not only come from one city but from other provinces or islands. The participants in this study never experienced delayed services because they received information about their doctor’s schedule and treatment through hospital staff, and the time of the procedure was notified usually before starting treatment, and the doctor explained what kind of service the patient received. This prove that the responsive aspect in this hospital is good from the outpatient’s perspective. According to the outpatients’ interview results, the assurance aspect in the hospital needs to be improved in some sides. There is a staff or physician who introduce themselves before performing a service or treatment, but most patient said usually there is no introduction from the staff, and they do directly perform the service. The researcher believes this could happen due to limited time and space in the department, so the timeline is important for both patient and staff. Although that is the reason behind, the introduction is important to build a trust between the patient and the staff and probably can reduce some information imbalance. Moreover, regarding sufficient information about medical conditions and treatments, the information is easy to understand and detailed. Regarding the care and attention shown by hospital staff as empathy aspect in the service quality dimension is quite good. Ready to help if needed and friendly towards patients.

Second, regarding patients’ opinions about the quality of service or treatment before coming to the hospital, on average patients expect the service at this hospital to be very good in accordance with the name of the hospital as a national level reference so that patients can be healthy and feel comfortable while undergoing treatment in hospital. Then in the current situation, participants in this study saw that the facilities and equipment in the hospital were of good quality and the existing services were quite good. However, if we look at the efforts that patients have made to come to the hospital, some answered that they were very reluctant to come to this hospital, but for their health they had to come for treatment. This can happen because of the long distance from the hospital and the patient’s home. This is also supported by the fact that there are still many patients who work independently, such as labourers and farmers who really need time to work to earn a living. In terms of hospital costs, all outpatients are patients who are insured with national health insurance, so they do not incur out-of-pocket costs for hospital services. Overall, outpatient’s perception of the continuous use the service in the future is quite good consider the expertise of the staff and high-quality equipment. Even though most of them do mention the need of improvement in the que time process.

Third, all the patients agreed that the service or treatment at this hospital is good overall, when compared to other hospitals, the facilities and equipment at this hospital are more complete and there are more specialist doctors, making it easier not to have to change services, but there are long waiting times in the polyclinic. From the treatment or services provided and positive experiences, most of the outpatients mentioned the positive part is that the hospital has an expert doctor, complete tools and equipment for the services needed.

Finally, on average, this hospital was not their first choice for treatment, but was the result of a referral from the previous health care system. Some outpatients only come to this hospital if they need to control their current condition, but most outpatients are willing to come to this hospital if they need services in the future, considering the expertise of the doctors and the complete range of medical equipment. In terms of relationships with hospital staff, all patients agreed that they had a pleasant experience with the relationship during their treatment.

According to the interview data, patients hope that the service at this hospital in the future will be even better, some of the problems found are the lack of facilities such as chairs in the department waiting room, the difficulty of meeting a doctor directly, only communicating with the doctor’s assistant. In terms of waiting times and queues, the hospital should pay more attention. all the patients agreed on three priority improvements: more attention in increasing the number of waiting rooms or facilities in existing waiting rooms, more efficient waiting times and queues, and a schedule to meet doctors directly.

Discussions

This study examines the influence of service quality on patient perceived value, satisfaction, and revisit intention from an outpatient viewpoint at a national referral hospital. The study presents the results of testing the construct model between all the variables studied (service quality, perceived value, satisfaction, and revisit intention) and elaborates on the rationale for quantitative model testing using structural equation modelling through qualitative results obtained through in-depth interviews with outpatients at the studied hospital. This research confirms that there is a significant and positive relationship between the variable constructs (Table 5). However, patient perceived value has a negative and no significant effect on patient satisfaction, as indicated by the t count value − 0.319 < 1.96. This indicates that whether a patient perceives value positively or negatively has no influence on their satisfaction. More precisely, service quality had a favorable and substantial influence on patient perceived value and contentment, which corresponded to patient perceived value and satisfaction having a positive and significant impact on outpatients’ return intention. This study is inevitably contributed to addressing the gap in research on healthcare service quality from the perspective of patients in Indonesia. Most studies found that when hospitals are full, people perceive higher service quality but are less satisfied with the process in seeking treatment. This study investigated and described this issue in the second phase using a qualitative study that included face-to-face in-depth interviews with patients conducted utilizing an exit interview system.

Moreover, the findings from this study shows that patient perceived value does not significantly impact the satisfaction of the patient with negative and no significant impact. This finding contradicts the results of other studies tested the relationship between these two variables^40–43. The researcher hypothesizes that the reasons might be due to respondent health condition, the outpatient received treatment at the hospitals because of their health is at risk, they might not feel satisfied yet because the treatment is still ongoing. The satisfaction feeling typically occurs after the treatment process has done or shows the results of the health improvement. Regardless, the researcher believes this finding does not necessarily indicate low-quality service, but rather that the patient expectation has not been met, which led to the dissatisfaction.

This finding contributes to the ongoing theoretical discussion on the complex relationship between perceived value and satisfaction. While traditionally, perceived value has been understood as a strong predictor of satisfaction^16,44, our results suggest that in healthcare, particularly in developing countries, the perceived value of care may not directly translate into immediate satisfaction, especially when care is ongoing and outcomes are not yet visible. This supports the idea that expectation-disconfirmation theory²³ may operate differently in healthcare, where expectations are dynamic and often emotionally charged. Moreover, the disconnect between perceived value and satisfaction may be understood through the lens of service-dominant logic⁴⁵, which posits that value is co-created rather than delivered unilaterally. In contexts where patients have limited involvement or control over service delivery, their ability to “co-create” value is reduced, potentially weakening the value-satisfaction link. This is especially relevant in public healthcare settings in developing countries, where resources are limited and service provision is standardized.

Second, the quantitative results confirm that tangibility, reliability, assurance, responsiveness, and empathy have a considerable impact on both patient perceived value and patient satisfaction before and during the treatment, the service quality has a positive and high significant impact on both perceived value and satisfaction. This aligned with the results from in-depth interview stage, the service quality dimension, SERVQUAL by Parasuraman influences the patient’s perceived value and patient satisfaction with the health services provided at the hospital. From the tangibility side, the physical evidence of the services such as physical facilities, appearance of personnel, instruments, or equipment in providing service, physical representations of the service have a good impression to the studied participants. The outpatients do agree that the hospital is reliable. Reliability involves consistency of performance and dependability, which means the firm performs services right the first time (re: health care/hospital). It also involves their honour towards promises such as accuracy in billing, keeping records properly, performing services at the designated time. The hospital staff has a good focus on the willingness or readiness to provide services and giving prompt service including setting appointments, whereas their response involving timeliness of the service in the polyclinic need to be improved. The employees have a good knowledge and courtesy that can encourage confidence and trust for the patient as prime elements of assurance. All the outpatient mentioned the caring and personalized attention as a crucial part from empathy aspect has been caried out nicely by the hospital staff. Therefore, although the qualitative phase emphasizes the problem of the waiting time and que line in the polyclinic site, hospital and healthcare industry as general should prioritize the problem behind long waiting time such the shortage of medical and hospital staff, limited space of the waiting room, and or the waiting time schedule bulletin that can be accessed in the polyclinic public space.

The results also challenge the assumption that high-quality service, is sufficient to produce satisfaction. Our study supports recent findings in the healthcare service literature that point to the non-linear relationship between functional service quality and emotional satisfaction, where external factors such as trust, institutional reputation, or access barriers mediate this relationship^46,47. This nuanced understanding adds to the growing body of work that calls for context-sensitive models of patient satisfaction, particularly in under-researched regions such as Indonesia.

Furthermore, many scholars^48–50 have asserted that the perceived service value established by a patient is a comprehensive evaluation of a health care that is based on patients’ opinions of what they’ve gained and invested. Patients’ contentment and loyalty have been highlighted by several researchers^51,52 as the effects of perceived service value for patients. In addition, Perceived value has been identified as one of the most important measures for gaining a competitive advantage⁵³ and has been argued to be the most important indicator of repurchase intentions and is a factor in patient loyalty^54,55. The way patients perceive the overall medical treatment process affects perceived value⁵⁶. This study supports the previous research finding that patient perceived value has a positive and significant impact on revisit intention; that is, the better the patient perceived value, the higher the revisit intention, and vice versa; the worse the patient perceived value, the lower the revisit intention. Even though, according to the qualitative results, the patient will continue to seek treatment in this studied hospital only, when necessary, most outpatients are willing to return or revisit the hospital in the future due to the medical equipment and medical experts provided. The researcher believes this is due to the great distance between the hospital and the patient’s living region.

Third, quantitative data showed that the patient satisfaction is highly influenced by the service quality provided by the hospital and directly impact the revisit intention of the patient to use the hospital service in the future. The better the patient satisfaction, the higher the revisit intention, and vice versa, the worse the patient satisfaction, the lower the revisit intention. This empirical association has also been supported by several research in the healthcare industry^57–59. Following by results from recent study which confirmed that patient perceived value and patient satisfaction significantly impact customer loyalty^29,42,60. The qualitative result also shows the crucial roles of the patient satisfaction with the potential revisit intention. The satisfaction that they have because of the services provided, the improvement on health, the medicine provided lead to the trust that they have to the medical doctor, polyclinic staff and hospital itself. This result in the patient intention to revisit the hospital in the future if they need to seek for the services or treatments.

Conclusion, Limitation, and future research

The findings of this study lead to the following conclusions: first, service quality has a positive and significant effect on patient perceived value; the better the service quality, the higher the patient perceived value; and vice versa, the worse the service quality, the lower the patient perceived value. Second, service quality has a positive and substantial influence on patient satisfaction; the better the service quality, the higher the patient satisfaction; conversely, the poorer the service quality, the lower the patient happiness. Third, patient perceived value has no negative or significant influence on patient satisfaction, implying that both good and bad patient perceived value have no effect on patient satisfaction. Fourth, patient perceived value has a positive and substantial influence on revisit intention; the higher the patient perceived value, the greater the revisit intention; conversely, the lower the patient perceived value, the lower the return intention. Finally, patient satisfaction has a favorable and considerable impact on return intention. The higher the patient satisfaction, the greater the intention to revisit; conversely, the lower the patient satisfaction, the lower the intention to revisit.

The results of this study show that overall, the measured evidence is good, however, hospital employees who have a neat appearance, hospital facilities have visual appeal and hospital employees who have a professional appearance still need improvement. In terms of assurance aspect provided by the hospital, overall is good, but in terms of hospital employees being able to instil trust in patients, and hospital employees are always polite, there is still need for improvement. Overall empathy is good, but in terms of consultation hours it still needs improvement, and the hospital situation is good, but in terms of providing services according to the promised time, there is still need for improvement. Last in the service quality dimension and quite important aspect is responsiveness of the hospital staff, overall responsiveness is good, but in terms of offering fast services to patients it still needs improvement.

Thus, other variables such perceived value and satisfaction has been good generally, however in terms of providing high-quality services according to the patient efforts to get to the hospital still need improvement. This can lead to patient satisfaction considering the long waiting time and comfort in the waiting room which needs to be improved to meet patient expectations before receiving treatment. This results to the overall value of return visits from the outpatient side, the results have been good when the patient consider the great and complete equipment and medical tools in the studied hospital but in terms of considering the hospital as the first choice among all health services in case of illness is still become a problem.

There are very few limitations to the current investigation. First, data were gathered from the National Central Public Hospital Dr. Mohammad Hoesin in Palembang, where the patient was believed to be prevalent. This is based on the premise that patient profiles and conditions were the same in other cities and regional towns beyond Palembang, which may not be representative of the entire country. Second, limitations may develop when the patient does not recollect adequately. However, the research approach for this study stipulated that the recall be performed at the hospital following the service to reduce the effect of recall bias.

Author contributions

A.N. did the data collection, analysis, wrote the main manuscript text and prepared figures and tables. P.V. provided ideas, data curation, provided supervision and funding. All authors reviewed the manuscript.

Data availability

The datasets obtained and/or analysed during this study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and the Indonesians regulations. This study was approved by the Institutional Review Board of Sriwijaya University (IRB No.342/UN9.FKM/TU.KKE/2023). All participants provided written informed consent to participate in the study through acceptance of the invitation.