The Effect of Quality of Medical Service on Patient Satisfaction and Intent to Revisit: For Public Hub Hospitals in Republic of Korea

Background: The purpose of this study was to construct and test structural equation modeling of the causal relationship between quality of healthcare, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals. Methods: In this study, data of 2,951 outpatients and 3,135 inpatients were collected using the “2018 Regional Hub Public Hospital Operational Evaluation.” A structural equation model was used to understand the relationship between patient satisfaction and intent to revisit, and bootstrap analysis was performed. Results: In the direct effect, outpatients were presented in the order of doctor's communication, hospital environment, and patient satisfaction. Inpatients are doctor’s communication, staff consideration, and patient satisfaction are shown in this order. In the indirect effect, the outpatients were presented in the order of doctor's communication, staff consideration, and the hospital's environment. Inpatients were presented in the order of staff consideration, nurse’s communication, doctor’s communication, and patient satisfaction. Conclusions: Regional hub public hospitals need high-quality medical services and efforts from all departments to treat patients with sincerity to improve patient satisfaction and increase intent to


Background
With the improvement of living standards, convenience in access to various information, and rapid aging of society, quantitative and qualitative demands and expectations of medical services are increasing. In addition, the sharp increase in the number of medical professionals and institutions has made competition between medical institutions inevitable. The increasing level of consciousness and expectations of citizens as well as the number of medical services consumers means that only medical institutions meeting these expectations can be managed sustainably. In response to such social trends, the healthcare market is shifting from being supplier-oriented to customer-oriented [1]. Customer-oriented marketing is a common concept in business administration which aims to identify and satisfy customers' needs [2]. The medical industry was previously dominated by a supplier-oriented market where patients visited hospitals without receiving patient-oriented medical services. Currently, however, the customeroriented market is widespread because hospitals survive only when they understand the diverse needs of medical consumers and provide high-quality medical services desired by customers [3]. The essence of customer-oriented marketing in healthcare organizations is to provide quality services to medical consumers. Medical institutions in Korea continue to increase in number. Thus, for the maintenance and survival of healthcare institutions by achieving a competitive advantage, a customer-oriented marketing strategy that satis es the needs of customers by providing quality medical services, leading to revisit, is required.
Healthcare institutions are obligated to provide safety and quality medical services to patients before considering their management and operation. Donabedian [4] divided healthcare quality into "professional skills of the healthcare provider" and "the patient's perception of the served medical service." Bopp [5] also categorized healthcare quality into the technical quality of the medical provider and the functional quality perceived by the patient, the medical consumer and argued that the latter is more important than the former in evaluating healthcare quality. The medical provider-centered quality concerns the level of capacity to provide professional medical skills such as pro ciency in medical skills and accurate diagnosis, while the quality perceived by the patients means, in addition to medical skills, the functional quality that indicates the extent to which the patient's demands such as those for facilities, equipment, physical environment, and communication are satis ed [1]. Woolley et al. [6] found that patients may report "perception of satisfaction" despite a poor medical treatment outcome. In another study by Zifko-Baliga and Krampf [7], if the patient did not recognize that an accurate diagnosis and treatment was provided by the medical provider, the quality of healthcare is not high. The quality of healthcare services, in particular, signi cantly depends on the criteria used in the evaluation by the patients themselves. As patients' needs are diverse and advanced, subjective evaluation based on the patient's position is considered more important in evaluating the quality of healthcare [8]. Hwang and Shim [9] showed that the quality of healthcare perceived by patients affects patients; satisfaction and thus their use of medical services in the future. This means that patient satisfaction, in addition to the quality of healthcare, is signi cant in terms of hospital pro tability. Patient satisfaction with a hospital leads to an intent to revisit the hospital, for public as well as private hospitals.
The dramatic increase and development of private hospitals have led to a rapid decrease in the proportion and role of public hospitals. Recently, the functions and roles of public hospitals have decreased as a result of avoidance phenomenon due to several reasons: low quality of healthcare failing to meet the expectations of medical consumers, the image that they are old-fashioned, di culty in obtaining capable medical staff, and the perception that they treat only the vulnerable. They also experience di culties in management due to deteriorating nancial conditions [10]. Public hospitals are expected to perform functions such as maintaining the medical and social safety net, implementing policies established by central and local governments, and conducting activities for the public interest of the local community. Speci cally, they provide healthcare services for the vulnerable and disabled people, services in maternal-child health (which is in short supply due to low pro tability), mental illness, infectious diseases, and emergency care. The maintenance of public hospitals is very important because they are responsible for areas that are considered di cult to service by private hospitals. However, the depublicization occurring in the healthcare eld, like in other elds, and the decrease in the government's investment in public health led to the nancial deterioration of public hospitals [11]. Jinju Medical Center is an excellent example of this outcome. The center was established in 1910 and played the role of a public hospital caring for the health of local residents. However, it closed due to the accumulation of de cits resulting from severe nancial deterioration. The decline in the local populations, A phenomenon in which patients are concentrated in large hospitals due to the expansion of medical insurance coverage in South Korea, and intensi cation of competition among hospitals are additional factors complicating the management of local medical centers [12]. Therefore, the pro tability should not be overlooked if the regional hub public hospitals aim to improve the health of local residents, provide quality medical treatment, and perform the function of a medical safety net that is di cult to perform by private hospitals. The Korean government, accordingly, attempted to develop a system to develop regional hub public hospitals while promoting the reform of the public healthcare system. The government's policies to develop regional hub public hospitals include the "Comprehensive Plan for the Expansion of Public Health and Medical Care" in 2005, "Plan for Development of Regional Hub Public Hospital" in 2010, "Plan for Improvement of Public Health Care by Development of Regional Medical Center" in 2013, "Master Plan for Public Health Care" in 2016, and "Comprehensive Plan for Development of Public Health Care" in 2018, which aimed to re-establish the functions and roles of regional hub public hospitals in the provision of high-quality medical care, medical safety net, and medical care for the vulnerable. If regional hub public hospitals pursue the medical safety net function, which is not provided by private hospitals, and pro tability, they need to develop measures to increase the revisit rate by improving the quality of medical care and patient satisfaction by re ecting social trends.
Many studies have investigated the effect of quality of medical care service on patient satisfaction and intent to revisit. However, the studies on the use of regional hub public hospitals were limited due to limited available data. There have been no studies, in particular, examining all the regional hub public hospitals across the country as well as both outpatients and inpatients.

Purpose
The purpose of this study was to investigate the in uence of the quality of healthcare perceived by patients who use regional hub public hospitals on their satisfaction and intent to revisit. This study, based on the results, intends to help generate appropriate pro ts, in addition to performing the function of a medical safety net and providing treatment to the vulnerable, which are the goals of regional hub public hospitals, by increasing patient satisfaction and intent to revisit.

Research Model
This study measured the direct effect of the quality of healthcare perceived by patients on patient satisfaction and intent to revisit in inpatients and outpatients who used regional hub public hospitals as well as the indirect effect of quality of healthcare on intent to revisit through the parameter of patient satisfaction. The research model was developed under the assumption established from the literature review that the quality of healthcare perceived by the patient has a structural causal relationship with patient satisfaction and intent to revisit. In this model, patient satisfaction was a mediating variable reinforcing the relationship between the quality of medical service as an independent variable and the intent to revisit as a dependent variable. The quality of healthcare was composed of physician's practice service, nurse's practice service, medical staff's kindness and consideration, and the hospital's physical environment. The gender, age, education, and health status of patients were controlled in the analysis.

Data and Participants
This study utilized the results of the patient satisfaction survey from data collected through the "2018 Evaluation for Operation of Regional Hub Public Hospital" conducted by the Ministry of Health and Welfare and the National Medical Center. Patient satisfaction was divided into outpatient and inpatients satisfaction, and the survey was commissioned to a specialized survey institution. The participant population of the survey was patients over the age of 18 who used regional hub public hospitals from May 2017 to April 2018. After excluding 1,152 patients who provided no response or incomplete responses 6,086 patients were included in the analysis (response rate: 84.0%), with 2,951 outpatients and 3,135 inpatients. The survey was conducted by investigators of a specialized research survey institution through telephone using a structured self-reported questionnaire.

Instruments
In this study, the quality of healthcare, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals were measured using a structured questionnaire which was developed by academic experts, public o cials, and practitioners of public hospitals. The "survey of patient satisfaction" was adapted from the "2018 Evaluation for Operation of Regional Hub Public Hospital" hosted by the Ministry of Health and Welfare and the National Medical Center. The measurement method for each variable is as follows. The measurement method for each variable is as follows:

Quality of Healthcare Service
The measurement instrument was developed through review and opinion collection by a team of related academics, researchers, and practitioners. The "quality of healthcare service" for the outpatient group was composed of three items: physician's practice service, medical staff's kindness and consideration, and the hospital's physical environment; for inpatient groups, it consisted of the above three items and an additional item of "nurse's practice service." The items were answered using a four-point Likert scale (1=not at all, 2=sometimes, 3=mostly, 4=always) and an 11-point Likert scale. The degree of consistency among items was measured using Cronbach's α, which were .901 for "physician's practice service," .821 for "medical staff's kindness and consideration," and .796 for "physical environment of hospital" in the outpatient group and .886 for "physician's practice service," .887 for "nurse's practice service," .842 for "medical staff's kindness and consideration," and .824 for "physical environment of hospital" in the inpatient group.

Patient Satisfaction and Intent to Revisit
The data for patient satisfaction and intent to revisit were extracted from the "Survey of Patient Satisfaction" from the "2018 Evaluation for Operation of Regional Hub Public Hospital". These variables were measured using one item, which was rated on a scale from 0 to 10. Higher scores indicated higher patient satisfaction and intent to revisit.

Analysis
First, for the veri cation of data normality and the identi cation of the demographic characteristics of the participants, descriptive statistics and frequency analysis were performed. Second, reliability analysis, correlation analysis, and multicollinearity analysis of the variables were conducted. Third, con rmatory factor analysis was conducted to con rm the model's goodness-of-t and validity for the structural equation model analysis. Fourth, the structural equation model was used to identify the goodness-of-t of the nal model and the effect of quality of healthcare perceived by patients on the relationship between patient satisfaction and intent to revisit. The bootstrap analysis was conducted to test the mediating effect of patient satisfaction. Statistical analyses were performed using SPSS 23.0 and AMOS 24.0 programs.

Ethical Consideration
Previously, this study was exempted for review from the Institutional Review Board of Korea University to which the rst author belongs.

Goodness-of-Fit Test of Research Model
The association analysis among major variables showed that the association among all latent variables were signi cant with P<0.01. The multicollinearity problem was not found because the Variance In ation Factor was under 10; it was under four for all the measured variables in the outpatient group, and under six for all the measured variables in the inpatient group.
The convergence validity and discriminant validity were tested to determine whether the target concept or attribute was measured. The average variance extraction (AVE) and the concept of construct reliability (CR) were used to test validities. The validities were supported because AVE values were 0.5 or higher and CR values were 0.7 or higher in both the outpatient and inpatient groups. That is, the better the physician's and nurse's practice service, medical staff's kindness and consideration, and physical environment of the hospital, the more likely they are to increase patient satisfaction. It was also found that the better physician's practice service and physical environment of the hospital were likely to increase patient satisfaction and intent to revisit. Thus, the better physician's and nurse's practice service, staff's kindness and consideration, and physical environment of the hospital, the more likely they are to increase patient satisfaction. It was also found that the better physician's practice service and the staff's kindness and consideration were likely to increase patient satisfaction and intent to revisit.

Analysis of the Mediating Effect
This study used covariance structural analysis to con rm the overall in uence among factors as a causal effect. The total, direct, and indirect effects were measured to determine the effect of the independent variable "quality of healthcare" on the dependent variable "intent to revisit," which revealed the importance of the mediating variable of "patient satisfaction." The total effect was expressed as the sum of all direct and indirect effects of the independent variable on the dependent variable. The direct effect re ected the direct relationship between the independent and dependent variables; the indirect effect represented the effect of the independent variable on the dependent variable through a mediating variable by regression analysis. Table 2 shows the analysis results of the total, direct, and indirect effects in the outpatient group. The values of the standardized direct effect on "patient satisfaction" were 0.377 for "physician's practice service," 0.303 for "medical staff's kindness and consideration," and 0.186 for "physical environment of hospital," which were statistically signi cant. The values of the standardized direct effect on "intent to revisit" were 0.243 for "physician's practice service," 0.036 for "medical staff's kindness and consideration," 0.049 for "physical environment of hospital," and 0.522 for "patient satisfaction" where the values for "physician's practice service," "physical environment of hospital," and "patient satisfaction" were statistically signi cant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable "patient satisfaction" were 0.197 for "physician's practice service," 0.158 for "medical staff's kindness and consideration," and 0.097 for "physical environment of hospital," which were statistically signi cant. "Patient satisfaction" was found to mediate the relationship between quality of healthcare perceived by patient ("physician's practice service," "medical staff's kindness and consideration," and "physical environment of hospital") and intent to revisit. The direct effect on "intent to revisit" was highest for "patient satisfaction," followed by "physician's practice service," "physical environment of hospital," and "medical staff's kindness and consideration." The indirect effect on "patient satisfaction" through "intent to revisit" was highest for "physician's practice service," followed by "medical staff's kindness and consideration" and "physical environment of hospital." The total effect was highest for "physician's practice service," followed by "medical staff's kindness and consideration," and "physical environment of hospital." These results indicated that "physician's practice service" is the most signi cant factor in uencing "patient satisfaction" and "intent to revisit." Table 3 shows the analysis results of total, direct, and indirect effects in the inpatient group. The values of the standardized direct effect on "patient satisfaction" were 0.223 for "physician's practice service," 0.236 for "nurse's practice service," 0.290 for "medical staff's kindness and consideration," and 0.182 for "physical environment of hospital," which were statistically signi cant. The values of the standardized direct effect on "intent to revisit" were 0.191 for "physician's practice service," 0.040 for "nurse's practice service," 0.096 for "medical staff's kindness and consideration," -0.013 for "physical environment of hospital," and 0.498 for "patient satisfaction" where the values for "physician's practice service," "medical staff's kindness and consideration," and "patient satisfaction" were statistically signi cant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable of "patient satisfaction" were 0.111 for "physician's practice service," 0.117 for "nurse's practice service," 0.145 for "medical staff's kindness and consideration," and 0.090 for "physical environment of hospital," which were statistically signi cant. "Patient satisfaction" was found to mediate the relationship between quality of healthcare perceived by the patient ("physician's practice service," "medical staff's kindness and consideration," and "physical environment of hospital") and intent to revisit.
The direct effect on "intent to revisit" was highest for "patient satisfaction" and was followed by "physician's practice service," "medical staff's kindness and consideration," "nurse's practice service," and "physical environment of hospital." The indirect effect on "patient satisfaction" through "intent to revisit" was highest for "medical staff's kindness and consideration," followed by "nurse's practice service," "physician's practice service," and "physical environment of hospital." The total effect was highest for "physician's practice service," followed by "medical staff's kindness and consideration," "nurse's practice service," and "physical environment of hospital."

Discussion
This study examined the effect of quality of healthcare perceived by patients using regional hub public hospitals on their patient satisfaction and intent to revisit the hospital. A research model was established through a theoretical literature review, and to test the model, 6,086 patients including 2,951 outpatients and 3,135 inpatients over 18 years of age who had an experience of using regional hub public hospitals were analyzed using the results of the "2018 Evaluation for Operation of Regional Hub Public Hospital." The summarized results are as follows: First, the variables that directly affected intent to revisit were, for the outpatient group, physician's practice service, physical environment of the hospital, and patient satisfaction, and for the inpatient group, physician's practice service, medical staff's kindness and consideration, and patient satisfaction. This is consistent with the results of Kang [16] regarding inpatients in public medical institutions. Kang [16] reported that medical professionalism, kindness of staff, interest in and service for patients, convenience of the process of being served in the hospital, and hospital facilities and environment had a positive (+) correlation with intent to revisit. These are consistent with the claims that a higher satisfaction with physician's practice service and environment of the hospital are likely to increase intent to revisit by Yoon [17] and that the medical staff's medical service and hospital facility in uenced intent to revisit by Han [18]. These results indicate the signi cance of the physician's treatment skills, which are the essence of medical institutions. The cooperation with private medical institutions is also an excellent way to develop the knowledge and skills of medical personnel working for regional hub public hospitals.
Second, all the variables for the inpatient and outpatient groups had a signi cant effect on patient satisfaction and the mediating effect on intent to revisit through patient satisfaction was also signi cant in all variables. This is consistent with one previous study that investigated the effect of quality of healthcare service on intent to revisit and the mediating effect of patient satisfaction in patients who use small and medium hospitals. Park [19] reported that patient satisfaction had a mediating effect on the relationship between the quality of healthcare service and intent to revisit. Amarantou et al [20] investigated the effect of quality of healthcare service on the intent to revisit through the mediating effect of patient satisfaction in emergency room patients in Greece and reported that patient satisfaction had a positive (+) signi cant mediating effect. These results suggest that it is necessary to develop various strategies to enhance the quality of medical care services and continuously increase patient satisfaction to improve patients' intent to revisit.
Results of the effect analysis indicated that the indirect effect is highest, in the outpatient group, for physician's practice service, followed by medical staff's kindness and consideration, and physical environment of hospital, and in the inpatient group, for medical staff's kindness and consideration, followed by nurse's practice service, physician's practice service, and physical environment of the hospital. The results showed that, among the factors of quality of healthcare, medical staff's kindness and consideration had the strongest effect both in the outpatient and inpatient groups. One previous study [19] that investigated the effect of quality of healthcare on intent to revisit through patient satisfaction had results consistent with those of this study, reporting that the indirect effect was highest in the empathy factor, which indicates consideration for customers, among the quality of medical services factors. Aliman and Mohamad [21] showed that, among the quality of medical service factors, not only the ability of the staff, but also the con dence representing goodwill, respectful attitude, and sincere interest in patients had the strongest effect on patient satisfaction and intent to revisit. The difference in the most important factor between outpatient and inpatient groups of this study is due to the practice process: Outpatients are likely to leave the hospital just after seeing the physician, so the practice of the physician is most important. However, unlike outpatients, inpatients are present in hospital for medical services. This allows them many opportunities to communicate with employees of the hospital. For the maintenance of customer, the medical service provider should ensure not only that quality healthcare service, which is the essence of healthcare, is provided but also that medical staff show kindness, sincerity, care, and respect for patients so that they are encouraged to revisit. For example, Hospital A ranked 1st in the patient experience evaluation conducted by the Health Insurance Review and Assessment Service, and the most frequently mentioned factor was the kindness of the staff toward patients. Hospital B, which ranked 2nd in the evaluation, implemented the so-called "Activity as Patient for Experience" in which employees experienced the patient's treatment process to nd a space for improvement to create a patient-oriented medical culture in their hospital. These examples demonstrate that the provision of a service that considers the patient's position in uences patient satisfaction. If regional hub public hospitals seek to provide quality healthcare to the public while maintaining and surviving in the current strong competition, the development of programs to educate medical staff as well as all staff dealing with patients to treat patients sincerely is needed. Regular management of patients through active training and monitoring by the quality assurance team is also necessary.
This study has several limitations. First, there is an insu cient understanding of the causal relationship between variables because this is a cross-sectional study using data from the "2018 Evaluation for Operation of Regional Hub Public Hospital." Thus, futures studies using longitudinal data are recommended to clarify the mechanism by which the quality of healthcare affects patient satisfaction and intent to revisit.
This study, nevertheless, contributed to this eld in that it investigated the management strategy to generate appropriate pro ts for regional hub public hospitals by analyzing the relationship among quality of healthcare, patient satisfaction, and intent to revisit, as previous studies have been conducted mainly targeting private hospitals, in outpatient and inpatient using regional hub public hospitals after controlling for gender, age, health status, and education level.

Conclusion
This study used a structural equation model to examine whether there is a relationship among the quality of healthcare service perceived by patients, patient satisfaction, and intent to revisit in outpatients and inpatients visiting regional hub public hospitals. This study aimed to provide fundamental data to improve patient satisfaction and service in regional medical centers and Red Cross hospitals.
The results indicated that, in the outpatient group, the better the physician's practice service, physical environment of the hospital, and patient satisfaction, the more likely there were to increase the patients' intent to revisit. The indirect effect on intent to revisit through patient satisfaction was highest for physician's practice service, followed by medical staff's kindness and consideration, and physical environment of the hospital. Moreover, in the inpatient group, better physician's practice service, medical staff's kindness and consideration, and patient satisfaction were likely to increase the patients' intent to revisit and the indirect effect on intent to revisit, through patient satisfaction was highest for medical staff's kindness and consideration and was followed by nurse's practice service, physician's practice service, and patient satisfaction.
Based on the results, we present the following suggestions. First, the environment of public hospitals should be improved to satisfy medical consumers to strengthen publicity through nancial consolidation. Second, the provision of active healthcare service through cultivating professional knowledge and acquiring technology in healthcare professionals should be attempted. Lastly, the medical service provider should not only ensure the provision of quality healthcare service, but also that medical staff show kindness, sincerity, care, and respect for patients so that they are encouraged to revisit.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.
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Funding
The author(s) received no speci c funding for this work.
Authors' contributions SL was responsible for study conception and design, analysis and interpretation of data, MK provided critical revision. All authors have read and approved the manuscript.