Analysis of Factors Affecting Outpatient Loyalty at Ananda Bekasi Hospital with Satisfaction as an Intervening Variable

: This study aims to examine the factors that influence outpatient loyalty at Ananda Bekasi Hospital with satisfaction as an intervening variable. The method used in this study is a quantitative method using a causal research survey approach. This research was conducted at Ananda Bekasi Hospital with a total sample of 257 outpatients from an average patient population per month of 5,000 people served by outpatient services. The data analysis technique in this study used the Structural Equation Modeling - Partial Least Square (SEM-PLS) method with the help of the SMART PLS 4.0 Application and the SPSS Version 25 Application to carry out research data analysis. In this study, instrument testing was carried out by conducting validity tests, reliability tests, outer models, inner models and hypothesis testing.


INTRODUCTION
Service to patients is a service activity carried out in a hospital with the aim of being able to provide services according to the needs, desires and expectations of patients.If the service received by the patient is in accordance with the needs, desires and expectations of the patient, it can be interpreted that the service can provide satisfaction to the patient.According to (Akbar & Ahmad, 2020) , that quality health services are health services that can satisfy every consumer or user of these services.Based on what was conveyed by (Kotler et al., 2021), that customer satisfaction can depend on the perceived performance of a product in providing value relative to buyer expectations.
Patient satisfaction is an important measure for health service providers, in this case hospitals where hospitals must be able to meet the needs and expectations of patients, so that patient satisfaction can help in providing an overview of the quality of health services and the patient's desire to return to health services in the same place.Quality services provided to patients can provide satisfaction at an optimal level and make these patients have loyalty because of the satisfaction of the services they receive.
Consumer loyalty is a form of consumer loyalty to use a product or service continuously, because it has high satisfaction with the product or service used.According to (Kotler et al., 2021) , most studies show that higher levels of customer satisfaction lead to greater customer loyalty, which in turn results in better company performance.Services to patients that are in accordance with patient expectations at the hospital based on quality standards to meet the needs and desires of these patients will be able to provide satisfaction so that they can make these patients loyal to the hospital Patient loyalty is one of the goals that must be achieved by the hospital in maintaining its patients from other hospital competitors.With the success of building patient loyalty, the continuity of the hospital will still be able to survive in the current uncertain economic conditions.The higher the level of patient satisfaction, the higher the patient's loyalty to the hospital Many factors can affect loyalty patients and in this study, researchers associated loyalty patient with five factors that can influence it, namely Doctor's Medical Services, Medical Services Other Power, Facilities, Ease of Access, Waiting Time Service and Satisfaction as an Intervening Variable.
In this study, the researcher put forward several problem formulations with a focus on the following problems: 1.Does the doctor's medical service affect loyalty? 2. Does the service of other medical personnel affect loyalty? 3. Does the facility affect loyalty? 4. Does ease of access affect loyalty? 5. Does service waiting time affect loyalty?6.Does satisfaction affect loyalty?7. Does the doctor's medical service affect loyalty through satisfaction as an intervening variable?8. Does the service of other medical personnel affect loyalty through satisfaction as an intervening variable?9. Does the facility affect loyalty through satisfaction as an intervening variable?10.Does ease of access affect loyalty through satisfaction as an intervening variable 11.Does service waiting time affect loyalty through satisfaction as an intervening variable?12.What is the service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to satisfaction?13.What is the service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to loyalty?

LITERATURE REVIEW Satisfaction
Satisfaction is a person's feeling of pleasure or disappointment that arises after receiving the service he has received, considering the expected results.If the results are below expectations, the customer is dissatisfied, and if the results meet expectations, the customer will be satisfied.According to Kotler in (Williams, 2014) , stated that satisfaction is a person's feelings of pleasure or disappointment resulting from comparing product perceptions performance or results in relation to expectations.
Consumer satisfaction can be created through quality, service and value.(Tse & Wilton, 1988) , argues that customer satisfaction and dissatisfaction are customer responses to perceived discrepancies between previous expectations and actual service performance after using them.According to (Tjiptono, 2017), consumer satisfaction is a situation shown by consumers when they realize that their needs and desires are as expected and well fulfilled.
In the services provided to patients, the main goal is to provide satisfaction to patients so that what the patient hopes for can be realized because the services they receive are in accordance with what they expect.According to (Zeithaml et al., 2018), there are 5 dimensions that describe customer satisfaction, namely: 1. Reliability Reliability is the ability to perform the promised service reliably and accurate.

Responsiveness
Responsiveness is the willingness to help customers and provide prompt service.

Assurance
Assurance dimension relates to the knowledge and courtesy of employees and their ability to inspire trust and confidence.

Empathy
Empathy related to caring, individual attention given to customers so that it is closely related to genuine and close attention to each customer.

Tangibles
Tangibles are the company's ability to provide the best service for customers, such as the appearance of physical facilities, equipment, personnel, and communication materials, and these are concrete things.That is, these qualities can be seen and felt directly by patients.

Loyalty
Loyalty is behavior for doing activities that are repeated as a result of something that is received by someone because they feel satisfaction with something that feels good in the form of product or services.The characteristics of consumer loyalty can be in the form of regular repeat purchases, either buying products, services and can even refer people.(Macstravic, 1994), argued that the benefits of loyalty for patients are to improve quality because loyalty encourages continuity of care, improves disclosure of medical information by patients so that doctors can make better diagnoses, are more obedient to medical advice, are better in terms of prevention, adequate treatment time, reducing costs to find other doctors, trust and confidence in providers associated with loyalty.
Loyalty patient is response about commitment patient for loyal return get treatment to Hospital when patient and family need service health.Very loyal customer important, because with maintain quality service expected will make customer return again as stated by (Kotler et al., 2021), that the only one the assets we have that is happy people with our service and ready come back and pay for it very again.That is, customers is a must asset guarded, because Loyal customers are one that can support continuity something service.

Service
Service can be interpreted as a form of activity provided by service providers to service recipients with the aim of providing satisfaction to customers or patients in terms of hospital services for the services provided.Service standard is a measure that has been determined as a basis for providing the best service to consumers.The service standard that has been determined becomes a standard reference that can be set forth in an SPO (Standard Operating Procedure) as a way to achieve service quality.Quality is a dynamic condition associated with products, services, people, processes and the environment that meet or exceed the expectations of those receiving the service.
Medical services are a series of activities provided to patients according to predetermined medical service standards and usually in these services optimal resources and facilities are used, (https://upk.kemkes.go.id/new/layanan/pelayanan-medis, nd).The purpose of the medical service itself is none other than trying to cure the disease and the service actions carried out must also be in accordance with applicable procedures and can be accounted for.

Doctor
According to the KBBI (Big Indonesian Dictionary), a doctor is someone who is an expert in disease and treatment and can provide health services for patients.Doctors are health workers who are the patient's first point of contact in solving patient health problems.In the current hospital business, besides the name of the hospital itself, the doctor is one of the assets that is very influential in his role in enhancing the image of the hospital.Most patients will complain about the doctor's service not because of the doctor's ability, but because the patient feels they are not being cared for.Doctors should always be willing to listen carefully and not show haste and lack empathy.
According to (Tacoh et al., 2019) , there is a relationship between the services provided by doctors and the dimensions of satisfaction, namely responsiveness, reliability, assurance, concern and dimensions of direct evidence to patients.According to research from (Salman , 2019) ,that doctors have an important role in increasing patient satisfaction.Based on (Pangerapan et al., 2018) ,that doctors' medical services are closely related to patient loyalty on the dimensions of tangibles, reliability, responsiveness and empathy .

Other Medical Personnel
A health worker is any person who is devoted to the health sector and has knowledge and/or skills through education in the health sector which for certain types requires authority to carry out health efforts, (P.Republik Indonesia, 2014).These health workers consist of several groups, including nurses, pharmacists, midwives, radiographers, analysts and other health workers.And in terms of service to patients, besides doctors, other medical personnel also have a very important role in providing services to patients and it is hoped that the services provided by these other medical personnel will be able to provide satisfaction to the patients they serve.
Medical personnel such as nurses and other health workers are highly demanded to be able to provide the best in their services, both in terms of service and ability or competence.With competence according to standards, it can be used as a reference that these officers can serve patients well so that they are expected to provide satisfaction to patients.Based on research (Alya & Latunreng, 2021), that the competence and discipline of nurses affects patient service satisfaction.According to ( Darwin et al., 2020) competence has an indirect effect on satisfaction through service quality.Based on research (Zainaro et al., 2020) there is a relationship between nurse performance and patient service satisfaction.According to research from (Mursyid et al., 2022) , that there is a significant relationship between patient experience and loyalty to the services they receive, especially by medical staff, nurses, doctors and pharmacists.

Facility
In hospital services, the facilities needed can be in the form of non-health facilities and health facilities that can support services so that the facilities provided are expected to have a positive impact in the form of satisfaction in supporting services.Facilities are anything that can facilitate and expedite the implementation of a business and are the facilities and infrastructure needed to carry out or expedite an activity.According to (P.Republik Indonesia, 2016) in Government Regulation of the Republic of Indonesia Number 47 of 2016 concerning Health Service Facilities , that a health service facility is a tool and/or place used to carry out health service efforts, both promotive, preventive, curative and rehabilitative carried out by the central government, regional government, and/or the community.
Based on research conducted by (Yesinda & Murnisari, 2018) , there is a partial effect of facilities on patient satisfaction, so that the better the facilities provided to patients can support the patient's trust in continuing to seek treatment so that they become loyal patients.Thus, good and complete health service facilities are needed in fostering patient satisfaction.Meanwhile, according to (Saputra, 2018), facilities and service quality together have a significant influence on patient satisfaction where facility is an added value for companies in obtaining satisfaction, because facilities are services in physical form which besides being felt can also be seen.

Ease of Access
Ease of access is the patient's expectation of the services he will get.The easier the access provided by the hospital, the higher the level of satisfaction with the service and vice versa, if the access to the service received is not as expected, it will cause patient dissatisfaction and can cause the patient to be reluctant to come back when the patient or his family needs it.return service.According to (Davis, 1989) ease of access is a level where a person believes that using a system can be used easily without requiring a lot of effort.
According to research from (Yohani & Nurul, 2022), that the service provided to customers is excellent access and is able to make customers feel satisfied.Meanwhile, based on research from (Munfaqiroh et al., 2022) that ease of access has no significant positive effect on loyalty where if customers find it easy to use technology alone it does not necessarily guarantee their loyalty so convenience does not become a benchmark for customer loyalty.Convenience has a significant positive effect on satisfaction, which means that the convenience of technology is designed according to or has exceeded customer expectations, so that customers feel satisfied.Convenience does not have a significant positive effect through satisfaction on loyalty, which means that customer loyalty cannot be obtained through customer satisfaction with the convenience of mobile genius technology.

Waiting Time
Waiting time is the time used by patients to get health services from the place of registration to entering the doctor's examination room.Patient waiting time is one of the potential components that can cause dissatisfaction, thus making the patient disloyal to the hospital.According to the RI Ministry of Health Number 129/Menkes/SK/II 2008 the waiting time for outpatient services is the time it takes from the patient registering at the outpatient registration place (TPPRJ) until being called for an examination service by a doctor at the destination polyclinic, with a standard service waiting time Outpatient care is determined to be an average of ≤ 60 minutes, (MK Republik Indonesia, 2008).
Waiting time has a positive and significant effect on customer satisfaction based on research conducted by (Anggaraeni, 2021).According to (Nurfadillah et al., 2021), that there is an influence between waiting time for outpatients on patient satisfaction services and this proves that the waiting time for outpatients will increase which will lead to a feeling of dissatisfaction with the services provided by officers.Based on research conducted by (Ayodeji & Rjoub, 2021) , that an increase in waiting time satisfaction will increase loyalty as when customers are satisfied with the services offered and they will recommend them to others.

Framework
Based on the review of the theoretical basis and the results of previous research, a research model framework can be developed as shown in Figure 1 which aims to verify whether Loyalty is influenced by Doctor's Medical Services, Other Medical Services, Facilities, Ease of Access and Waiting Time for Services.Do Doctor's Medical Services, Other Medical Services, Facilities, Ease of Access and Service Waiting Time Affect Loyalty with Satisfaction as Intervening Variables.Do Doctor's Medical Services, Other Medical Services, Facilities, Ease of Access and Service Waiting Time simultaneously influence Satisfaction and do Doctor's Medical Services, Other Medical Services, Facilities, Ease of Access and Service Waiting Time simultaneously affect Loyalty.

Research Hypothesis
Based on previous research related to Loyalty, Satisfaction, Doctor's Medical Services, Medical Services Other Power, Facilities, Ease of Access and Waiting Time Service in the framework model in Fig 1, the hypothesis can be drawn as follows: H 1 : Service medical doctor influential to loyalty H 2 : Service power other medical influences to loyalty H 3 : Facility influential to loyalty H 4 : Convenience access influential to loyalty H 5 : Waiting time service influential to loyalty H 6 : Satisfaction influential to loyalty H 7 : Service medical doctor influential to loyalty through satisfaction as an intervening variable H 8 : Service power other medical influences to loyalty through satisfaction as an intervening variable H 9 : Facility influential to loyalty through satisfaction as an intervening variable H 10 : Convenience access influential to loyalty through satisfaction as an intervening variable H : Waiting time service influential to loyalty through satisfaction as an intervening 11 variable H 12 : Service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to satisfaction H 13 : Service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to loyalty

RESEARCH METHODS
The research design is an overall plan of research that includes things that will be carried out by researchers starting from making hypotheses and operational implications to the final analysis, data which is then concluded and given suggestions.A research design states both the structure of the research problem and the plan of inquiry that will be used to obtain empirical evidence about the relationships in the problem.In this research design, researchers used a quantitative method by using a survey of patients who had received services.
This study was to examine the effect of Variable X1 (Physician's Medical Services), Variable X2 (Services of Other Medical Personnel), Variable X3 (Facilities), Variable X4 (Ease of Access), Variable X5 (Waiting Time) and Variable Z (Satisfaction) on Variable Y (Loyalty).To analyze the effect of each of these variables, the authors use SmartPLS and SPSS applications.
The research was carried out based on the research instrument in the form of a questionnaire which was distributed to respondents online according to the number of samples taken from the population using the Judgment Sampling method which is part of the sampling method of non-probability sampling.This sampling method includes selecting subjects who are considered to have an advantage or are in the most appropriate position to provide the required information, (Manurung et al., 2021) .
This research was conducted at Ananda Bekasi Hospital in the period from November 2022 to with December 2022.The population in this study are patients take care as many as 5,000 people and the number of samples is appropriate with Table of Isaac and Michael many i.e. 257 patient.Data collection is done by circulating questionnaire to respondents online which contains a list of statements to patient of outpatient services at Ananda Hospital Bekasi.
Next stage after collected data, then processed and produces output based on the processed results to be carried out analyzed.Data analysis is adjusted to the research objectives to be achieved in research.Structural Equation Modeling (SEM) is currently estimated to be the most dominant multivariate method.Researchers used the SMART PLS and SPSS applications to analyze research data and test instruments by testing the reliability validity, outer models, inner models and hypothesis testing.

RESULTS AND DISCUSSION 1. Analysis Characteristics of Respondents a. Age
Based on research on 257 patient of outpatient services at Ananda Hospital Bekasi, the age of the respondent can be seen in Table 1 and Figure 2 following: Based on Table 1 and Figure 2, it is known that the age of the majority of respondents is at the age of 36-45 years, namely as many as 168 people (65.4 %).This shows that the patient of outpatient services visiting to Ananda Bekasi Hospital at most in the range age 36-45 years.

b. Frequency Visit
Based on research on 257 patient of outpatient services at Ananda Hospital Bekasi, frequency visit respondents can be seen in Table 2 and Figure 3 below This:   Table 2

. Respondents Based on Visits Figure 3 Respondents Based on Visits
Based on Table 2 and Figure 3, it is known that the majority responders patientof outpatient services with frequency visit to Ananda Bekasi Hospital was > 5 times, namely 138 people (53.7 %).This shows that the patient of outpatient services visiting to Ananda Bekasi Hospital is old patients.

c. Domicile
Based on research on 257 patient of outpatient services at Ananda Hospital Bekasi, domicile respondents can be seen in Table 3 and Figure 4   Based on Table 3 and Figure 4, it is known that the majority patient respondents of outpatient services domiciled in Bekasi City, namely as many as 176 people (68.5 %).This shows that the patient of outpatient visiting is originating patients from around Hospital Because located in the city of Bekasi.

Instrument Test
Questionnaire is the instruments used in this study.A good questionnaire must meet two requirements, namely valid and reliable.To find out whether the data generated from these measuring instruments can guarantee the quality of the research so that conclusions about the relationships between variables can be trusted, accurate, and reliable so that the research results can be accepted, then the validity test and reliability test are carried out.Respondents used in the research instrument trial were 30 respondents who were taken from within the population and will reused as part of 257 research samples.To test whether the instruments used in research are valid and reliable so conducted validity test and reliability test processed using SmartPLS 4.0.

a. Validity Test 1) Covergent Validity
The convergent validity value is the loading factor value which describes the magnitude of the relationship between latent variables and their indicators.The indicator is considered valid if the outer loading variable has a loading value greater than 0.7 (> 0.7 and all items in study This can meet the requirements of convergent validity or declared valid.

2) Discriminant Validity
Discriminant validity testing in this study used the cross loading value and the Average Variance Extracted (AVE) value.For mark cross loading more from 0.7 up to study the can said to be valid.For more AVE value from 0.5 up to can is said to be valid and all variables have achieved discriminant validity so that it can be interpreted that all variables from each item are able to explain their latent variables.

b. Reliability Test 1) Composite Reliability (rho_a)
The composite reliability value of all variables is above 0.7 which consists of doctor's medical service variable (0.922 > 0.7), other medical personnel service variable ( 0.954 > 0.7), facility variable (0.923 > 0.7), ease of access variable (0.910 > 0.7) , service waiting time variable (0.843 > 0.7), service satisfaction variable (0.977 > 0.7), loyalty variable (0.953 > 0.7) so that it can be concluded that the items from each of these variables are reliable and feasible to use in this study.

Results Classic assumption test a. Normality Test
Testing the normality of the data using Kolmogorov-Smirnov test (Kolmogorov-Smirnov Test) by looking at the significance of the resulting residuals and it can be seen that the normality test using the Kolmogrov-Smirnov method is significant at 0.07 > 0.05, it can be concluded that the regression method in this study has met the assumptions of normality.

b. Heteroscedasticity Test
Heteroscedasticity is a condition where there is an unequal variance of the residuals for all observations in the regression model.Heteroscedasticity Test Results obtained the significance value of all variables > 0.05 so that it can be concluded that there was no heteroscedasticity in this study.

Analysis Structural Equation Modeling (SEM) a. Outer Model Testing (Measurement Model) 1) Convergent Validity
Convergent Validity is done by looking at item reliability (validity indicator) which is indicated by the loading factor value.In this study the loading factor limit used was 0.7 with the results of the loading factor can be shown in Table 4 below this: From the results of data processing with SmartPLS shown in Table 4, that the majority of indicators for each variable in this study have a loading factor value greater than 0.70 and are said to be valid.In addition there are 5 indicators that have a loading factor value of less than 0.70, namely the first on the Facility variable there is 1 indicator, namely X3.1 showing 0.696, the second on the Ease of Access variable there is 1 indicator namely X4.2 showing 0.668, the third on the Satisfaction variable there are 3 indicators namely Z5.1 shows 0.686, Z5.2 shows 0.651 and the last one at Z5.3 shows 0.693.This shows that variable indicators that have a loading factor value greater than 0.70 have a high level of validity, so that they meet convergent validity.Meanwhile variable indicators that have a loading value of less than 0.70 have a low level of validity so that these variable indicators need to be eliminated or deleted from the model.The loading factor values after the indicators X3.1, X4.2, Z5.1, Z5.2 and Z5.3 have been eliminated can be shown in After done counting return with indicators X3.1, X4.2, Z5.1, Z5.2 and Z5.3 eliminated then got the loading factor values above 0.70 up has a high level of validity and meets convergent validity.

2) Discriminant Validity
Discriminant Validity is done by looking at the cross loading value which shows the magnitude of the correlation between each construct with its indicators and indicators from other block constructs.The results of cross loading can be shown in Table 6: Cross loading statement items from doctor's medical service variable, service power medical others, facilities, convenience access, time waiting, satisfaction and loyalty shows that the correlation value of the construct with its indicators is greater than the correlation value with other constructs.Thus, all constructs or latent variables already have good discriminant validity, where the indicators in the construct indicator block are better than indicators in other blocks.
Next step that is do evaluation by comparing the AVE root value with the correlation between constructs.The AVE value of a variable must be more than 0.5 to state that discriminant validity is achieved.In this study, the AVE value and the AVE square root for each construct can be shown in Table 7 below this: Based on Table 7, all constructs show an AVE value that is greater than 0.50, with the smallest value being 0.6 19 for the Waiting Time variable Service (X5) and the biggest 0.7 57 for Loyalty (Y).This value meets the requirements in accordance with the specified minimum AVE value limit of 0.50.

3) Composite Reliability
In addition to being measured by assessing convergent validity and discriminant validity, the outer model can also be measured by looking at the reliability of the construct or latent variable as measured by the value of composite reliability.The construct is declared reliable if the composite reliability has a higher value of 0.7 (> 0.7), then the construct is declared reliable.Results of data processing or SmartPLS output for composite reliability values can be shown in Table 8.From the output of SmartPLS in Table 8, it shows that the composite reliability value for all constructs is above the value of 0.70.With the resulting value, all constructs have good reliability in accordance with the minimum value limit that has been required.

b. Inner Model Testing (Structural Model)
The inner model can be evaluated by looking at the r-square (indicator reliability) for the dependent construct and the t-statistical value of the path coefficient test.The higher the r-square value means the better the prediction model of the proposed research model.The path coefficients value indicates the level of significance in hypothesis testing.Tests performed is Testing Variant Analysis (R2) or Determination Test, namely to find out the influence of the independent variables on the dependent variable, the value of the coefficient of determination can be shown in Table 9.Based on the r-square value in Table 9 shows that service medical doctor, service power medical others, facilities, convenience access and time Wait able to explain the variability of the satisfaction construct of 80.4 %, and the remaining 19.6 % is explained by other constructs outside those examined in the study this.For service medical doctor, service power medical others, facilities, convenience access, time Wait and satisfaction can explain the variability of the loyalty construct by 66.8 %, and the remaining 33.2 % is explained by other constructs outside those examined in the study.

Results Statistical Testing a. Hypothesis test
Hypothesis testing is carried out based on the results of testing the Inner Model (structural model) which includes the output r-square, parameter coefficients and tstatistics.To see whether a hypothesis can be accepted or rejected by considering the significance value between constructs, t-statistics, and p-values.Testing the research hypothesis was carried out with the help of SmartPLS 4.0 software.These values can be seen from the bootstrapping results.The rules of thumb used in this study are tstatistics >1.96 with a p-value significance level of 0.05 (5%) and the beta coefficient is positive.The results of this research model can be described as shown in Figure 5.The value of hypothesis testing in this study can be shown in Table 10 for see results testing influence in a manner direct.

1) Hypothesis Test First
service beta coefficient Physician Medical on Loyalty of 0.0 65 and t-statistics of 0.9 91 and a p value of 0.322.From these results it is stated that there is no significant and positive effect so that the first hypothesis is rejected.This proves that Service Medical Doctors are not proven to have a significant and positive effect on loyalty.

2) Hypothesis Test Second
The test results show that the beta coefficient value of Other Medical Personnel Services on Loyalty is 0.090 and the t -statistic is 1.073 and the p value is 0.284.From these results it is stated that there is no significant and positive effect so the second hypothesis is rejected.This proves that the Services of Other Medical Personnel are not proven to have a significant and positive effect on loyalty.

3) Hypothesis Test Third
The test results show that the beta coefficient value of Facility on Loyalty is -0.036 and the t -statistic is 0.442 and the p -value is 0.658.From these results it is stated that there is no significant and positive effect so the third hypothesis is rejected.This proves that facilities are not proven to have a significant and positive effect on loyalty.

4) Hypothesis Test Fourth
The test results show that the beta coefficient value of Ease of Access to Loyalty is 0.1 0 9 and the t -statistic is 1.729 and the p value is 0.084.From these results it is stated that there is no significant and positive effect so that the fourth hypothesis is rejected.This proves that Ease of Access is not proven to have a significant and positive effect on loyalty.

5) Hypothesis Test Fifth
The test results show that the value of the beta coefficient is Waiting Time t to Loyalty of 0.034 and t-statistics of 0.433 and a p value of 0.665.From these results it is stated that there is no significant and positive effect so that the fifth hypothesis is rejected.This proves that Waiting Time not proven to have a significant and positive effect on loyalty.

6) Hypothesis Test Sixth
The test results show that the beta coefficient value is Satisfaction t to Loyalty of 0.615 and t-statistics of 6.586 and a p value of more small of 0.05 (< 0.05) .From these results it is stated that there is a significant and positive influence so that the sixth hypothesis is accepted.This proves that Satisfaction proved to have a significant and positive influence on loyalty.The value of hypothesis testing in this study can be shown in Table 11 for see results testing influence in a manner no direct.7) Hypothesis Test Seventh service beta coefficient Physician Medicine towards Loyalty through satisfaction as an intervening variable of 0.128 and a t-statistic of 3.031 and a p value greater than small of 0.05 (<0.05) from these results it is stated that there is a significant and positive influence so the seventh hypothesis accepted.This proves that Service Medical Doctors are proven to have a significant and positive influence on loyalty through satisfaction as an intervening variable.

8) Hypothesis Test Eighth
The test results show that the beta coefficient value of Other Medical Personnel Services on Loyalty through satisfaction as an intervening variable of 0.177 and a t-statistic of 3.869 and a p value greater than small of 0.05 (<0.05).From these results it is stated that there is a significant and positive influence so that the eighth hypothesis accepted.This proves that the Services of Other Medical Personnel have a significant and positive influence on loyalty through satisfaction as an intervening variable.

9) Hypothesis Test Ninth
The test results show that the value of the beta coefficient of Facility on Loyalty through satisfaction as an intervening variable 0.103 and a t-statistic of 2.310 and a p value greater than small from 0.05.From these results it is stated that there is a significant and positive influence so the ninth hypothesis accepted.This proves that facilities have a significant and positive influence on loyalty through satisfaction as an intervening variable.

10) Hypothesis Test Tenth
The test results show that the beta coefficient value of Ease of Access to Loyalty through satisfaction as an intervening variable of 0.134 and a t-statistic of 4.048 and a p value greater than small of 0.05 (<0.05).From these results it is stated that there is a significant and positive influence so the tenth hypothesis accepted.This proves that Ease of Access has a significant and positive effect on loyalty through satisfaction as an intervening variable.

11) Hypothesis Test Eleventh
The test results show that the value of the beta coefficient is Waiting Time t to Loyalty through satisfaction as an intervening variable of 0.106 and a t-statistic of 2.425 and a p value greater than small of 0.05 (<0.05).From these results it is stated that there is a significant and positive influence so the eleventh hypothesis accepted.This proves that Waiting Time proved to have a significant and positive influence on loyalty through satisfaction as an intervening variable.

b. Simultaneous Test (Test F)
The F test was carried out to see the effect of all the independent variables together on the dependent variable.The level used is 0.5 or 5%, if the significant value of F <0.05 it can be interpreted that the independent variables simultaneously affect the dependent variable or vice versa (Ghozali, 2018) .The Simultaneous Test (F Test) was carried out to determine the effect of the simultaneous independent variables namely X1, X2, X3, X4 and X5 on the bond variable, namely variable Z and the effect of the simultaneous independent variables namely X1, X2, X3, X4, X5 on the dependent variable, namely variable Y.
The results of the simultaneous tests that have been carried out can be seen in Table 12 and Table 13.Recap results from the simultaneous tests that have been carried out can be seen in Table 14.Based on the results of statistical tests on Table 12 and Table 13, it can be seen that the F value is for the hypothesis twelfth and thirteenth hypotheses respectively of 199.565 and 70.018 with the same significance value of 0.000 which means less than 0.05.So it can be concluded that the hypothesis twelfth and thirteenth is as following:

1) Hypothesis Test twelfth
The test results show that the F value is 199.565 and with a significance value of 0.000 which means it is less than 0.05.So it can be concluded that all variables X1, X2, X3, X4 and X5 together have a significant influence on satisfaction .From these results it is stated that there is a significant and positive influence so the twelfth hypothesis accepted.This proves that the service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to satisfaction.

2) Hypothesis Test Thirteenth
The test results show that the F value is 87.158 and with a significance value of 0.000 which means it is less than 0.05.So it can be concluded that all variables X1, X2, X3, X4 and X5 together have a significant influence on loyalty.From these results it is stated that there is a significant and positive influence so the thirteenth hypothesis accepted.This proves that the service medical doctor, service power medical others, facilities, convenience access, time wait and satisfaction in a manner simultaneous influential to loyalt.Following is summary from results testing hypothesis as shown in Table 15.Source: Processed primary data (2022)

Discussion
There are three Twelve hypotheses were tested using the Structural Equation Modeling (SEM) method with SmartPLS 4.0 software, as well as helped with SPSS Ver 25 software.The results of this research is as follows: a. Results of testing the first hypothesis prove that Service Medical doctors have no significant and positive influence so that the first hypothesis is rejected.This proves that Service Medical Doctors are not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the service medical doctor who has been given by the Hospital.These results are contrary to the results of previous research conducted by (Situmorang, 2020) , where the results of his research prove a significant relationship between doctor's services in the dimension of responsiveness and patient loyalty.b. Results of testing the second hypothesis prove that the services of other medical personnel have no significant and positive effect so the second hypothesis is rejected.This proves that the services of other medical personnel are not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the service power other medical that has been given by the Hospital.These results are contrary to the results of previous research conducted by (Afifah et al., 2019) , where the results of his research proved the relationship between caring for nurses and patient loyalty at XX Palembang Hospital .c. Results of testing the third hypothesis prove that facility no significant and positive influence so the third hypothesis is rejected.This proves that the facility not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the facilities which has been in Hospital.These results are contrary to the results of previous research conducted by (Ramadhani et al., 2020) , where the research results prove that e -banking facilities have an effect on positive and significant to loyalty BRI customers at Simpang Units Lemonade.d. Results of testing the fourth hypothesis prove that convenience access no significant and positive influence so that the fourth hypothesis is rejected.This proves that convenience access not proven to have a significant and positive effect on loyalty.These results are due to the majority of respondents not feeling quite satisfied with the whole access which is in Hospital.These results are in accordance with previous research conducted by (Munfaqiroh et al., 2022), where the results of his research prove that convenience does not have a significant positive effect on loyalty and convenience is not a benchmark for customer loyalty.e. Results of testing the fifth hypothesis prove that time Wait no significant and positive influence so that the fifth hypothesis is rejected.This proves that time Wait not proven to have a significant and positive effect on loyalty.This result is due to the fact that most of the respondents were not satisfied enough with the time Wait service given by Hospital.The results are appropriate with study previously conducted by (Estrada et al., 2022) that The absence of the effect of waiting time on patient loyalty indicates that waiting time results in longer outpatient services at X Hospital but does not affect patient loyalty to come to the hospital.f. Results of testing the sixth hypothesis prove that satisfaction there is a significant and positive influence so the sixth hypothesis accepted.This proves that satisfaction proved to have a significant and positive influence on loyalty.These results are due to the majority of respondents being satisfied with the whole service provided by the Hospital.These results are in accordance with previous research conducted by (Wibowo, 2019), where the results of his research prove that consumer satisfaction has a significant positive effect on consumer loyalty.And in accordance with study previously carried out by ( Chandra, 2018), where the results of his research prove that customer satisfaction has a positive and significant effect on customer loyalty.g. Results of testing the seventh hypothesis prove that service medical doctor effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect so the seventh hypothesis accepted.These results are due to the majority of respondents being loyal to Hospital Because satisfied with the service medical doctor received at hospital.These results are in accordance with previous research conducted by (Estrada et al., 2022) The effect of physician interpersonal communication on patient loyalty indicates that good communication between doctors and patients influences patient loyalty to come to the hospital .Study earlier other that is according to (Widodo & Prayoga, 2022) that f the actor that influences satisfaction and loyalty is service longitudinality, impression First patient and family-centered traits in implementation service.Loyalty is based on satisfaction and trust patient to established health service providers slowly.The relational relationship between doctor and patient is also a factor increase satisfaction to lead to loyalty.h.Results of testing the eighth hypothesis prove that service power other medical influences on loyalty through satisfaction as an intervening variable there is a significant and positive effect so that the eighth hypothesis accepted.These results are due to the majority of respondents being loyal to Hospital Because satisfied with the service power any other medical treatment he received at hospital.These results are in accordance with previous research conducted by (Ardian et al., 2022) where the results of his research prove that The quality of nursing services or the quality of nursing care plays an important role in increasing patient satisfaction, because the quality of nursing care provided by nurses is able to significantly influence the level of patient or client satisfaction.plays an important role in maintaining patient loyalty or loyalty, satisfaction also mediates between service quality and loyalty.i. Results of testing the ninth hypothesis prove that facility effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect so the ninth hypothesis accepted.These results are due to the majority of respondents being loyal to Hospital Because satisfied with the facilities received at hospital.These results are in accordance with previous research conducted by (Kusnadi, 2022) where the results of his research prove that Facilities (X2) have a significant positive effect on loyalty (Y2) through visitor satisfaction (Y1).And according study earlier from (Devi & Untoro, 2019), that process quality, infrastructure quality, and interaction quality directly affect customer loyalty directly or use the customer satisfaction variable as a mediating variable .j. Results of testing the tenth hypothesis prove that convenience access effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect so the tenth hypothesis accepted.These results are due to the majority of respondents being loyal to Hospital Because satisfied with convenience access received at hospital.These results are in accordance with previous research conducted by (Susanti & Parera, 2021), where the results of his research prove that the ease of using M-Banking is able to create customer satisfaction and loyalty at a bank, customers will be satisfied and loyal in using it because they don't spend their time doing transactions at service offices.k. Results of testing the eleventh hypothesis prove that time Wait effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect so the eleventh hypothesis accepted.These results are due to the majority of respondents being loyal to Hospital Because satisfied with time Wait received at hospital.These results are in accordance with previous research conducted by (Ayodeji & Rjoub, 2021), where the results of his research prove that WTS (waiting time satisfaction) increase will increase loyalty, because when customers are satisfied with the services offered, they will be satisfied and recommend these services to others.l. Results of testing the twelfth hypothesis prove that service medical doctor, service power medical others, facilities, convenience access and time wait in a manner simultaneous there is a significant and positive influence to satisfaction so the twelfth hypothesis accepted.This result is because most of the respondents are satisfied to quality whole services they receive at hospital.These results are in accordance with previous research conducted by (Ginting & Herman, 2020) , where the results of his research prove that the facilities and quality of service simultaneously have a significant impact on patient satisfaction at Embung Fatimah Hospital.Study earlier other that is according to (Agustina & Sakawati, 2020), that quality service have significant influence to satisfaction patients at the Happy General Hospital, Makassar City.
m. Results of testing the thirteenth hypothesis prove that service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous there is a significant and positive influence to loyalty so the thirteenth hypothesis accepted.These results are due to the majority of respondents being loyal because whole quality services they receive at hospital.These results are in accordance with previous research conducted by (Susnita, 2020), where the research results prove that service quality and satisfaction together have a positive and significant effect on customer loyalty.And based on research conducted by (Novianti et al., 2018) prove that the quality of service directly has a positive and significant effect on customer satisfaction and on customer loyalty.

CONCLUSION
Based on the results of the research that has been described, it can be concluded regarding the Analysis of Factors Affecting Outpatient Loyalty at Ananda Bekasi Hospital with Satisfaction as an Intervening Variable.These conclusions include the following: 1. Service Medical doctors have no significant and positive influence so that this proves that the Service Medical Doctors are not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the service medical doctor who has been given by the Hospital.2. The services of other medical personnel have no significant and positive effect so that this proves that the services of other medical personnel are not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the service power other medical that has been given by the Hospital.3. Facility no significant and positive influence so that these things prove that the facility not proven to have a significant and positive effect on loyalty.These results are due to the fact that most of the respondents are not quite satisfied with the facilities which has been in Hospital.4. Convenience access no significant and positive influence so that this proves that ease access not proven to have a significant and positive effect on loyalty.These results are due to the majority of respondents not feeling quite satisfied with the whole access which is in Hospital.5. Waiting time no significant and positive influence so these things prove that time Wait not proven to have a significant and positive effect on loyalty.This result is due to the fact that most of the respondents were not satisfied enough with the time Wait service given by Hospital.6. Satisfaction there is a significant and positive influence so that this proves that satisfaction proved to have a significant and positive influence on loyalty.These results are due to the majority of respondents being satisfied with the whole service provided by the Hospital.7. Service medical doctor effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect where these results are due to the majority of respondents to be loyal to Hospital Because satisfied with the service medical doctor received at home illness and physician relational relations with the patient is also a factor increase satisfaction to lead to loyalty.8. Service power other medical influences on loyalty through satisfaction as an intervening variable there is a significant and positive effect where results it is caused because most of the respondents became loyal to Hospital Because satisfied with the service power any other medical treatment he received at home pain and the level of patient satisfaction also needs to be maintained and improved because patient satisfaction plays an important role in maintaining patient loyalty, satisfaction can also mediate between service quality and loyalty 9. Facility effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect so that the results are due to the majority of respondents being loyal to Hospital Because satisfied with the facilities received at hospital.10.Convenience access effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect where the results are due to the majority of respondents to be loyal to Hospital Because satisfied with convenience access received at hospital.11.Waiting time effect on loyalty through satisfaction as an intervening variable there is a significant and positive effect where the results are due to most of the respondents became loyal to Hospital Because satisfied with time Wait received at hospital.And repair time Wait will increase loyalty, because when customers are satisfied with the services offered, they will be satisfied and recommend the service to others.12. Service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous there is a significant and positive influence to satisfaction so that most of the respondents feel satisfied to quality whole services they receive at hospital.13.Service medical doctor, service power medical others, facilities, convenience access and time Wait in a manner simultaneous there is a significant and positive influence to loyalty so that most of the respondents became loyal because whole quality services they receive at hospital. below: Source: Primary data processed using SmartPLS 4.0 (2022) Figure 5. Research Model Results , service power medical others, facilities, convenience access and time Wait in a manner simultaneous influential to loyalty F = 87.158Sig = 0.000 b Accepted

Table 3 . Respondents by Domicile
c. Multicollinearity Test Multicollinearity test to test whether the regression model has a correlation between independent variables.Based on the results of the multicollinearity test between the independent variables, namely X1 to X5 on the hypothesis and the results show that all VI F values are less of 10 and Tolerance more from 0.01 up to can said No multicollinearity occurs.
d. Autocorrelation Test The autocorrelation test was carried out by the Durbin Watson (DW) test with the decision criteria: 1.65 < DW < 2.35, meaning that there is no autocorrelation; 1.21 < DW < 1.65 or 2.35 < DW < 2.79 means it cannot be concluded and DW < 1.21 or DW > 2.79 means there is autocorrelation.The results of the autocorrelation test obtained a Durbin Watson value of 2.156 where the value is greater than 1.65 and less than 2.35 (1.65 < 2.156 < 2.35) so it can be concluded that there is no autocorrelation in this regression.