Gap Analysis o f The Quality o f Outstanding Services t hat Influence Patient Satisfaction

This paper was aimed to identify factors the gap of quality service of outpatient that affect expectation of consumer in Outpatient Unit or Instalasi Rawat Jalan at Fatmawati General Hospital. this research uses post-poitivis approach and qualitative method to identify the factors analysis of quality service that affect expectation of consumer in Fatmawati General Hospital Outpatient by considering service quality by provider perspective (Gap 1-4). Service quality of gap 1-4 theory by Valerie Zeithaml, Leonard Berry, and Parasuraman (1990) is used to support the factors analysis. In fact, the expectation of consumer affected by quality service that has been delivered by provider. The indeks of consumer expectation has decreased through three years, it implies that there are obstacles of quality service must provider face. The quality service that has been delivered dosen’t fit and propper to consumer needs. discussion result of this research show some factual of service quality obstacles i.e research of management, infeasibility perception, performance measurement, technology job-fit,communication eksternal media, and gap between management expectation and consumer expectation


INTRODUCTION
Improving health services is an important task to achieve service targets as a national development agenda. Because in the current era of globalization, economic growth has increased, so that this makes the community's demands for health services increase, this makes the quality of health services need to be improved to achieve national development [5] . Optimal national development will be achieved if the improvement in public health is realized. Therefore, it is necessary to improve the quality of health services that can improve the health of people's lives [12]. And making the improvement of the quality of hospital services a necessity that must be realized in order to achieve the national development agenda.
The health service agenda is a national development agenda that is contained in the rules for minimum service standards for hospitals as a reference for services provided by hospitals in providing services to the community. Especially in the outpatient installation, which is the front line unit that describes the image of hospital services in providing services to the community.
To carry out outpatient service standards, the hospital determines the quality of hospital services covering two main things, namely as the fulfillment of health product specifications or service technical standards by management and secondly as an art of service, namely as the provision of services that can meet patient expectations and [13]. This shows that the health service agency (hospital) must establish a plan to improve the quality of health services as a performance plan to achieve patient satisfaction with the services provided by the Outpatient Installation.
Community satisfaction is a necessity that must be achieved by public service providers because the quality of service is the impact on what is felt by customers with the desired expectations. Community satisfaction is a response to the compatibility between the desired expectations and the actual results obtained during the service. [6]. Therefore, if the perceived service is as expected, the service quality is perceived to be good and satisfactory. If the service received exceeds consumer expectations, then the service quality is perceived as an ideal quality. Conversely, if the service received is lower than expected, the service quality is perceived as bad.
Referring to the data obtained regarding the achievement of service performance indicators, the Fatmawati General Hospital is in position 23 with performance achievements below 80% (minimum indicator achievements). As in the following data: The quality of service provided by an organization can be measured by using a service quality gap approach through a gap of 1-5. The gap 1-4 is an analytical approach to measuring service quality provided by internal management to customers. The Gap 1-4 approach is used to measure the extent to which management is prepared to provide quality services to the community. While gap 5 is the concept of service quality to measure the level of community satisfaction with the services expected by customers with the perceived reality.
Outpatient health services are hospital units that are always visited by the community, therefore it is necessary to improve the quality of installation management services to the community to achieve management targets and customer satisfaction.
The purpose of this study is to analyze the quality of outpatient services using a gap analysis approach (1-4), so that it can determine the extent of management's readiness in providing quality services for outpatient installations at Fatmawati Hospital. This writing was made by considering several studies from several literatures.

METHOD
This study uses a qualitative approach, by means of data analysis as a process of simplifying data that is outlined in a simple form so as to make narrative information that is easy to understand. And the use of this research method is qualitative, where the method approach used will be generated through analytical data so that in the future the results presented are researcher analysis.
The presentation of the data used in this study is in the form of narrative text which is designed to be arranged systematically which is used to determine whether the conclusions drawn are correct or not. In carrying out this research, the researcher tries to enrich the understanding through the social phenomena that will be studied by using a literature study. This research method is carried out by taking secondary data sourced from journals, books, news, articles, service data and the results of previous research that have issues that are relevant to the research theme to be carried out.
This study will measure the quality of service that is reviewed with a service quality gap approach of 1-4. This study takes a related point of view measuring service quality from the point of view of internal management (Outpatient Installation, Fatmawati Hospital) as a service provider. Furthermore, this study will describe what factors can affect the quality of services provided by the internal management of the Outpatient Installation in serving customers, namely the gap between expectations and management perceptions, management perception gaps with service quality standards, service quality standards gaps with the provision of services. services and gaps in service quality delivery with external communication to customers.

RESULTS AND DISCUSSION
The implementation of services provided by government agencies must be provided with good service quality. Service quality is a very important thing in the implementation of public services, because the quality of service will reflect the extent to which the performance of the bureaucracy provided by the Outpatient Installation, RSUP Fatmawati in providing services to the community. This is inseparable that the bureaucracy must run according to nature, which is oriented to the interests of the community.
From the data obtained, the number of visitors to the Outpatient Installation is the unit that always gets the highest visits every year. This should be a special concern for fatmawati hospital agencies in providing quality products and services to provide a sense of satisfaction to the community. because the outpatient installation is the front line that reflects the image of hospital services in the eyes of the community. The number of visits to the outpatient installation service is as follows:

Yearly Outpatient Installation Service visit 2015-2018
Based on table 2.2 above that the number of customer visits who visit to get outpatient services is always high, it can be seen that in 2015 the total number of visits to outpatient installations was 329,036 people, in 2016 was 329,622 people, in 2017 the total number of visits to the installation outpatient services were 338,250 people and in 2018 the total visits were 293,325. so that the total customer visits of outpatient installations for the period 2015-2018 were 1,290,233 visitors.
The facts regarding the high number of visitors who access outpatient services in outpatient installations contradict the preparation and implementation of outpatient management in serving and providing quality service to customers. The high number of visitors in outpatient installations cannot be matched by good public service delivery by the internal management of outpatient installations. This can be seen from the public response related to outpatient installation services which are presented in the data regarding the community satisfaction index (IKM) as follows:

Source : Community Satisfaction Index for Outpatient Installation 2017-2019
Based on table 2.3 above, the results of the community satisfaction index show that the community satisfaction index for outpatient installations tends to decrease in the last 3 years from 2017-2019.
The decline in the community satisfaction index illustrates that the quality of services provided does not meet customer expectations and this decrease in community satisfaction indicates a decrease in the quality of services provided by the management, resulting in service delivery that does not reach the expected community satisfaction target.
In fact, the problem that occurs regarding the decline in the quality of services provided by the management of the outpatient installation is the impact of the service quality process provided by the internal management of the outpatient installation. The results of the community satisfaction index are caused by management performance that is not in accordance with customer expectations. Basically the target to be achieved in providing quality service is customer satisfaction. Because community satisfaction is a response to the quality of service they receive, if the quality of health services refers to the level of perfection of health services, the quality of services provided will lead to a sense of satisfaction in patients [14].
From the results of the mapping of the provision of service quality that there are several things that cause community satisfaction regarding the provision of outpatient services to decrease this is because there is a gap between the expected service and the perceived service . The causes are [21]: 1. The existence of bureaucratic services, support for facilities and infrastructure as well as information and technology systems, and socialization of limited service procedures. So this will affect the speed of service provided. 2. Incompetent resources and do not understand service procedures 3. The provision of service quality that is not in accordance with the announcement of the service agreement, such as notification of officers regarding delays in patient handling. Where this is very important for patients to get fast service in accordance with the standard outpatient waiting time <60 minutes The findings of the problems in outpatient services above are the factors that cause gaps due to the nonfulfillment of customer expectations with perceived service, due to tangible factors , reliability and responsiveness of service personnel.
And the facts about the factors causing the service gap regarding customer expectations with those felt by customers because employee performance is not able to meet customer expectations so that services do not reach customer expectations, and the provision of infrastructure and technological tools that are not appropriate to support the performance of employees, as well as a service system that is not in accordance with standards [11] The factors that cause customer satisfaction is not achieved due to the gap between expectations and perceived customers. And according to Susiyati [25] that The cause of gap 5 cannot be separated from how the process of providing and implementing service quality provided by internal management is seen from the perspective of gap 1-4, namely the gap between customer expectations and management perceptions, the gap between management perceptions and standards, the gap between standards and service delivery. , and the gap between service delivery and external communication.
From the research findings that the problem of service quality in outpatient installations is related to the low commitment of hospital management to employees by giving rewards to employees who excel and routine performance evaluations that are carried out regularly [10]. And related to this, the obstacles to the quality of outpatient service installations are: [10]: 1. The service expected by patients is still much higher than the patient's expectations perceived by management. This is because there are several factors that cause a gap between customer expectations and management perceptions, such as the absence of implementation of periodic management research applied by management, and the lack of attention to management research as a findings that are important to improve service quality, and the absence of implementation of customer complaints and how these complaints should be followed up by management 2. The existing performance standards are lower than the patient's expectations perceived by management, this is because there is an inappropriate perception by management to set standards in accordance with management findings related to customer expectations. So that hospital management does not have a strategic method to set standards to improve the quality of outpatient services. 3. The process of delivering services to patients is not regulated in the existing performance standards in hospitals.
This problem is a gap between service standards and service delivery. Where the executor does not carry out his duties according to standards. From the results of research mapping conducted by Andi [8], it is stated that the problem of gaps that occur related to standards with service delivery is that health workers, namely doctors, nurses, and administrative officers are not appropriate in providing services according to the standard of providing prescription drugs to patients. So when referring to service standards there are problems regarding the accuracy of services provided by outpatient installation employees. 4. External communication of hospital management to patients is still lower than the service received, this is due to the lack of media that can be accessed by customers to obtain information about services provided such as media hot line service, customer service and complaints. Where these media can facilitate external communication between customers and management. 5. The expectations of customer patients are higher than the services received, this is due to the lack of facilities and operating systems that can support employee performance, such as the use of electronic medics, and hospital management information systems which are indispensable to support the duties of employees. 6. The expectations of patients perceived by the medical team as frontline officers are still much higher than the expectations of patients perceived by management, this causes a gap between management expectations and customer expectations which will lead to role conflicts faced by employees in carrying out their duties.
The constraints faced by the management of the outpatient installation above are factors that can affect the quality of outpatient installation services to customers so that these constraints can also affect customer satisfaction.
Customer satisfaction is a person's feeling of pleasure or disappointment with the response to a product obtained from the expected product performance/results. If performance meets expectations, then the customer is satisfied. Conversely, if the performance does not meet expectations, the customer is not satisfied [3].
Customer satisfaction is the target of service quality. An achievement of the service quality implementation process to be achieved by the service provider organizational unit that has an orientation to meet customer needs. Therefore, there are several factors that can affect the level of customer satisfaction Customer satisfaction can be measured, one of which is the process of providing quality service by the hospital's internal management to customers. Because the quality of service in terms of internal management gaps 1-4 are factors that can affect customer satisfaction.
Seeing the fact that the outpatient installation unit as a unit that always gets the highest visits and becomes the frontline that describes the image of hospital services, it is necessary to increase the role of service quality by internal management such as primary care development starting with employee competence, facilities and education, as well as the application of management research. and how to follow up on research and the application of external