Law Number 17 of 2023 concerning Health defines a hospital as a health service facility that offers inpatient, outpatient, and emergency services along with comprehensive individual health services through promotion, prevention, curative, rehabilitative, and/or palliative health services (Ministry of State Secretariat of the Republic of Indonesia, 2023). Dr. Saiful Anwar Regional General Hospital in East Java Province (RSSA) is one of the government hospitals that provides services including medical care, nursing, midwifery, pharmaceutical services, and supporting services (RSUD Saiful Anwar, 2023). Pharmacy services at RSSA are carried out by the Hospital Pharmacy Installation (IFRS), which is a work unit that has service units located near healthcare service areas such as outpatient care, inpatient care, emergency services, and operating rooms, referred to as the pharmacy service unit (UPF).

The General Outpatient Pharmacy Service Unit (UPF RJU) is part of the Pharmacy Installation that serves regular non-BPJS outpatient patients, program medication patients, and patients with insurance other than BPJS. The decrease in the number of outpatient pharmacy patients at the General Outpatient Pharmacy Service Unit (UPF RJU) has been occurring since February 2024. Compared to January, the decline is quite significant, and the trend has continued to decrease until May 2024. The adjustment of registration fees is suspected to have contributed to the decrease in the number of visits to the hospital, particularly at the UPF RJU. Another factor that is suspected to contribute to the decrease in the number of visits is the availability of other healthcare facilities in the city of Malang that offer services similar to those of RSSA, indicating competition in healthcare services. Another factor is the availability of a wider variety of medications at other pharmacy services (drugstores), which allows patients to choose treatments other than at RSSA. Based on field data phenomena, it shows the level of patient loyalty towards the General Outpatient Pharmacy Service Unit. This has sparked an interest in conducting a study on the factors that influence patient loyalty.

There are various aspects that influence the success of a hospital's business, one of which is patient loyalty. According to Kotler & Keller (2009), consumer loyalty can be defined as the consumer's effort to maintain loyalty to a product, which is then followed by repeat purchases. One of the factors that influence customer loyalty according to Hasan (2014) is the quality of the product or service (service quality). To assess service quality, it can be done through several dimensions, including tangible evidence, reliability, responsiveness, assurance, and empathy (Tjiptono, 2019). The results of the research on the influence of service quality on loyalty conducted by Ardiyanto & Tabrani (2018), Asnawi et al. (2019), Bukhari et al. (2018), Fatima et al. (2018), Hakim et al. (2019), Hasan & Putra (2018), Nafisa & Sukresna (2018), Oktoriani et al. (2023), Sulistyo & Gumilar (2019), Kurniawan et al. (2022), Vigaretha & Handayani (2018) concluded the same thing, namely that service quality has a positive and significant effect on patient loyalty. But the results differ from the above studies, Sektiyaningsih et al. (2019), Winata et al. (2022) concluded that service quality does not affect patient loyalty. Similarly, research by Andreano & Pardede (2023)

and Surachman & Agustina (2023) concluded that service quality has a negative and significant impact on patient loyalty.

According to Tazkiya et al. (2019), the corporate image is a combination of consumer perceptions and attitudes that reflect the characteristics of the company. In hospital services, the image of the hospital is a tangible manifestation of customer perceptions of the services provided through what customers receive (Tekwana, 2019). In an effort to generate a positive image sustainably, the orientation of the hospital needs to focus on patients who are essentially the buyers of service. The key is through the improvement of service quality (Hasibuan et al., 2020). The results of the research conducted by Hasan & Putra (2018), Sektiyaningsih et al. (2019), Akob et al. (2021) concluded that service quality positively affects the image of the hospital.

Patients are more likely to accept products from hospitals with a positive reputation (Hasibuan et al., 2020). Customers will be more inclined to trust and stick with a hospital that has a positive reputation (Tekwana, 2019). It is anticipated that the hospital's reputation will improve its performance since it is one of the elements affecting patient loyalty (Binendra & Prayoga, 2022). According to studies by Akob et al. (2021), Dayan et al. (2021), Sulistyo & Gumilar (2019), and Nafisa & Sukresna (2018), patient loyalty is positively impacted by the hospital's reputation.

Customer satisfaction is a post-purchase phenomenon that reflects the extent to which consumers like or dislike a service after experiencing it (Hosseini & Behboudi, 2017). In healthcare services, patient satisfaction is closely related to the quality of service. Patient evaluation of medical care is an important part of initiating the improvement process in healthcare services. Patient expectations of healthcare providers and the actual patient experience are important factors that influence patient evaluations of healthcare services (Goetz et al., 2019). Research conducted by Afrizal & Suhardi (2018), Akob et al. (2021), Ardiyanto & Tabrani (2018), Asnawi et al. (2019), Fatima et al. (2018), Hakim et al. (2019), Nafisa & Sukresna (2018), Oktoriani et al. (2023), and Sulistyo & Gumilar (2019) concluded that service quality positively affects patient satisfaction.

Patient satisfaction is one of the crucial factors in the success of service, which can be achieved through the provision of quality services that can enhance patient loyalty (Wulandari et al., 2024). Patient loyalty is a sign and persistence of patient contentment with the hospital's services and facilities, as well as with continuing to be a patient there (Sari et al., 2019). Research conducted by Afrizal & Suhardi (2018), Akob et al. (2021), Ardiyanto & Tabrani (2018), Bukhari et al. (2018), Hasan & Putra (2018), Kartika et al. (2023), Meesala & Paul (2018), and Oktoriani et al. (2023), concluded that patient satisfaction positively affects patient loyalty.

A study on the impact of service quality on patient loyalty mediated by hospital image and patient satisfaction at the Outpatient Pharmacy Service Unit of the Pharmacy Installation at RSUD Dr. Saiful Anwar, East Java Province, is intriguing given the phenomenon and the findings of prior research. The goal of this study is to comprehend and examine how service quality affects RSSA's hospital reputation, patient satisfaction, and patient loyalty.

This study was carried out at RSUD Dr. Saiful Anwar's General Outpatient Pharmacy Service Unit (UPF RJU). Based on the average number of patients per month, the study's population consists of 1500 outpatients at UPF RJU. Using the Slovin algorithm, the sample size was determined to be 93.75 respondents, rounded to 94 respondents. Purposive sampling is the sample strategy used in this investigation. One sampling method with particular implications is purposeful sampling.

The structural equation modeling (SEM) approach was used to examine the data gathered for this investigation. One kind of multivariate analysis is SEM. A technique for examining multiple variables at once is multivariate analysis. Partial Least Squares (PLS) is the data analysis tool utilized. Measurement model testing and structural model testing can be done simultaneously with PLS, a variance-based structural equation modeling (SEM) tool (Sholihin & Ratmono, 2021).

This study examines the variables that affect patient loyalty at the General Outpatient Pharmacy Service Unit (UPF RJU) RSSA. In order to evaluate the correlation between the variables of service quality, hospital image, patient happiness, and patient loyalty, 94 respondents were chosen and given access to the questionnaire online. The findings of the study indicate that patient loyalty is not directly impacted by the service quality component. The five indicators of service quality are physical evidence, assurance, responsiveness, empathy, and reliability. According to this study, the empathy indicator has not yet been able to affect patient loyalty, but it does have a significant impact on service quality. These findings align with earlier studies by Winata et al. (2022) and Andreano & Pardede (2023).

Patient satisfaction and the hospital's reputation are impacted by the service quality element. According to this finding, patient satisfaction increases with increased service quality, and the hospital's reputation also improves. These findings undoubtedly corroborate a number of earlier research, like those by Akob et al. (2021), which claim that patients' perceptions of a hospital will improve the higher the quality of care demonstrated by several measures. Because all services that have a direct impact on patients must be of a high caliber. Patient satisfaction and service quality are strongly associated in the healthcare industry because when patients receive high-quality care, they will feel that their expectations of the hospital have been fulfilled.

Patient loyalty is influenced by patient satisfaction and hospital image. According to these findings, patient loyalty will increase with the hospital's reputation and level of patient satisfaction. This is consistent with earlier research by Oktoriani et al. (2023), which found that patient loyalty at RSUD X increases with the hospital's reputation. Bukhari et al. (2018) and Sulistyo & Gumilar (2019) both reported similar findings. According to research by Kartika et al. (2023), Kijima et al. (2021), and Sari et al. (2019), patient loyalty is impacted by patient satisfaction.

The impact of service quality on patient loyalty is not mediated by the mediating variable in this study, which is hospital image. This finding indicates that patient loyalty is unaffected by higher service quality, which improves the hospital's reputation. Although the impact of the hospital's image on loyalty was previously described as good, the hospital's image has not yet been able to significantly mediate the relationship between patient loyalty and service quality. The findings of this investigation corroborate those of Winata et al.'s earlier study at Ukrida Hospital from 2022.

The impact of service quality on patient loyalty is mediated by the subsequent mediating variable, which is patient satisfaction. This finding implies that higher service quality, which promotes high patient satisfaction, will have an impact on patients' high levels of loyalty. Prior research by Andreano & Pardede (2023), Novianti et al. (2018), Winata et al. (2022), and Vigaretha & Handayani (2018) concluded that patient satisfaction can function as a mediator that mediates the quality of service towards patient loyalty. The findings of this

study corroborate these findings. This demonstrates that providing patients with high-quality services will increase their satisfaction and loyalty.

Improvements in hospital image indicators and patient satisfaction can directly increase patient loyalty, according to the study's findings, which show that these factors have a positive impact on patients in the General Outpatient Pharmacy Service Unit of RSUD Dr. Saiful Anwar. Additionally, patient loyalty is not impacted by service quality, suggesting that some aspects of service quality require modification in order to promote patient loyalty. The addition of the hospital image mediator in the relationship between service quality and patient loyalty does not enhance the influence on patient loyalty. On the other hand, the addition of patient satisfaction as a mediator in the relationship between service quality and patient loyalty is able to enhance the influence on patient loyalty. This proves that good service quality will make patients feel satisfied, thereby fostering patient loyalty.

This study provides important implications for hospitals, particularly as input for leadership policies on improving service quality and patient satisfaction, as well as an effort to evaluate the quality of hospital services. This effort is important for building a good image of the hospital and patient loyalty

There are various restrictions on this study. Initially, only one hospital pharmacy service unit provided the data, which limited the findings' applicability to other hospital services. Second, additional patient groups that might exhibit varying degrees of loyalty are not included in this study, which solely concentrates on routine outpatient patients. To get better information and findings, further research can be done.

We would like to express our gratitude to the Supervising Lecturers of the Master's in Management at Universitas Wisnuwardhana Malang, the Hospital Management, and the Head of the Pharmacy Installation at RSUD Dr. Saiful Anwar for granting permission to conduct the research