The consciousness of excellent quality service to improve effectiveness of TQM and kaizen-PDCA quality management

The competition era and patient demand that is constantly changing demands that every hospital needs to be aware of the importance of improving the quality of excellent service and has become a necessity. Hospitals that can create excellent service quality can improve patient satisfaction. Integrated implementation of TQM and Kaizen-PDCA is intended to create patient satisfaction through improved service quality. Awareness of improving the quality of excellent service is expected to mediate the effectiveness of the implementation of integrated quality management and kaizen-PDCA on patient satisfaction in Makassar type B hospitals. This study aims to analyze: (1) Integrated Quality Management, partially integrated Kaizen-PDCA influences the awareness of the importance of improving service quality and patient satisfaction, (2) Integrated Quality Management, integrated PDCA-Kaizen partially influences patient satisfaction through awareness of the importance of improving the quality of excellent service. This research was conducted at Type B hospitals in Makassar. Samples of 400 inpatients. Data were analyzed by SEM (Structural Equation Modeling) - AMOS 24 and SPSS-22. The results of this study indicate that Integrated Quality Management, PDCA Kaizen partially has a positive and significant effect on the urgency of excellent service quality and patient satisfaction, (2) Integrated Quality Management, PDCA-Kaizen partially has a positive and significant effect on patient satisfaction through the urgency of service quality prime.


Introduction
The spectrum of health services in Indonesia covers traditional, complementary to modern spectrums.states that quality is compatible with market needs.This means that the hospital must be able to understand what the patient needs.The home community is aware of the importance of quality to obtain benefits such as greater patient loyalty, greater market share, higher stock prices, higher selling prices, and greater productivity.The importance of increasing awareness of excellent service quality is the maximum effort that can be provided by hospital service personnel to improve patient satisfaction.Research from Atep proves that excellent service quality is optimal service that results in patient satisfaction.Several empirical studies have concluded that excellent service quality has a positive effect on patient satisfaction [1].
The services provided by Indonesian hospitals are still less than the services provided by overseas hospitals.Research from Ignatius and Lisa shows that many patients who are financially able to use overseas hospital services for treatment, such as Singapore and Malaysia.As for several factors that are the cause, such as the competence of medical personnel, and the quality of hospital services.To create excellent service quality, hospitals must be able to find out the needs and needs of patients [2].Proves that excellent service quality provides benefits, such as patients deciding to directly use the services offered, creating trust, patients remaining loyal use services, patients reuse services, and avoid the occurrence of demands or complaints that are not necessarily patient.
Patient satisfaction is a feeling of pleasure or disappointment from a patient that appears after comparing the performance (results) of the product that is thought of the expected performance.Kotler's opinion is in line with the theory of disconfirmed paradigms.This theory explains that satisfaction / Full-time dissatisfaction is determined by the patient's evaluation of the difference between initial expectations (or other comparative standards) and perceptions of actual product performance after service use.Patients feel satisfied when the actual product performance exceeds initial expectations and vice versa.Research from Jahng proves that patient satisfaction will provide hospital-specific benefits such as adhering to the range of doctors in treatment, shortening the healing period, and improving health in general [3].
The superior quality of primadi hospital services is manifested by providing quality services in an effective, efficient, safe, timely, and patient-oriented manner.The results of the study generally prove that there is a positive influence between the quality of excellent service to patient satisfaction.
Patient demand that is constantly changing causes hospitals to strive to maintain and improve the quality of excellent service through quality improvement.Quality improvement is based on the integration of conceptual TQMs and KaiCA-PDAs (Plan, Do, Check, Act).The effectiveness of implementing TQM and Kaizen-PDCA influences patient satisfaction improved service quality, improved performance and reduced operational costs.
Total Quality Management (TQM) is the satisfaction of patients, doctors, nurses, and suppliers (such as shareholders) and other interested groups, achieved by implementing effective planning, programs, policies and strategies (hard issues), and humans and all other assets (soft issue) efficiently and sustainably [4].
PDCA-Kaizen is a small continuous improvement and is a routine function in an organization.Kaizen implementation has a purpose, such as (a) making the organization learn better through small incremental changes / small change steps towards improvement known as Kaizen event.(b) associating with work culture to get improvements that never end both in quality and productivity efficiency; (c) eliminating hidden costs originating from 7 (seven) seven waste in the production process such as overproduction, waste of time, transportation waste, inventory waste, excess processing waste, waste movement, and production defects); (d) provide added value to production operations so as to improve the quality of products at the lowest cost; (e) shorten delivery times to customers, and make changes in a relatively short time and low cost.
Quality Prima Service is service to patients based on quality standards to meet the needs and desires of patients so that patients can obtain satisfaction which ultimately can increase their trust in the hospital.The success of prime services depends on speed, accuracy, friendliness, and comfort.Various specific benefits of excellent service, such as patients decide to directly use the services offered, create trust.Patients remain loyal to use services, patients reuse services, and avoid the occurrence of demands or complaints that are not necessarily patient.
Patient Satisfaction is feeling happy or disappointed with the patient resulting from comparing perceived service performance (or results) concerning expectations.Specific benefits of patient satisfaction include a positive association with patient loyalty, the potential to be a source of future income (especially through repeat purchases), reduce patient transaction costs in the future (especially patient service costs), reduce volatility and risk with predictions of future cash flows, increase price tolerance, gethok tular recommendations are positive, patients tend to be more receptive to product line extensions, brand extensions, and new add-on services offered by hospitals, as well as increased bargaining power relative to hospitals for supplier networks and business partners.1.Effect of TQM on awareness of its importance in enhancing quality service excellence TQM Philosophy is that every improvement in methods and work processes will continually be able to improve the quality of excellent service.Research from S.M. Irfan, proves that there is a positive and significant influence between TQM on service quality.Research from Faizal prove that the successful implementation of TQM can improve patient satisfaction, improve service quality, improve performance and reduce operational costs.Service Profit Chain Theory, confirms that patient satisfaction is seen as a function of the value created by patients through the quality of services provided by the hospital.This satisfaction is seen as contributing greatly to patient loyalty and can subsequently generate profits.

Effect of PDCA-Kaizen on awareness of the importance of improving service quality
Deming (Deming Cycle) or PDCA (Plan-Do-Check-Act) Cycle) explains that constant improvement and continuous service systems will improve the quality of excellent service and productivity, which in turn will constantly reduce costs.Research from Gordian proves that the implementation of Kaizen-PDCA can improve operational efficiency, primitive service quality and reduce operational costs.The theory of resource-based theory, explains that hospitals that produce high-quality service that is high are the result of the ability of hospitals to accumulate resources that have capabilities that are rare, valuable, and difficult to imitate.This theory implies that continuous improvement (Kaizen) can only succeed in improving the quality of excellent service when accompanied by good and appropriate resources.

Effects of TQM on patient satisfaction
States that patient satisfaction is the focus of TQM.To achieve patient satisfaction, continuous quality improvement and employee involvement are required in every process of the organization's activities.Without these two activities, the desire to give satisfaction to patients will be difficult to achieve.Prove that the level of satisfaction for doctors, nurses, and employees has increased significantly.Deming's Chain Reaction theory explains that every improvement in work methods and processes will continually provide a series of results such as improving human quality, process quality and environmental quality.It is impossible to produce quality services without going through human and quality processes.

Effects of kaizen-PDCA on patient satisfaction
TQM cannot be separated from continuous efforts to make improvements.Continuous improvement is based on the Kaizen concept, which is always looking for ways to improve operations.Empirical research has shown that effective Kaizen can reduce operational costs and improve patient satisfaction.Research from David, proves that the implementation of Kaizen-PDCA can improve patient satisfaction.1.5.Effect of awareness of the importance of quality improvement of excellent service on patient satisfaction Awareness of improving excellent service quality can increase patient loyalty, positive communication, and reduce complaints.Research from Hani proves that patient satisfaction is strongly influenced by responsiveness, followed by empathy, assurance, physical means.Disconfirmation paradigm theory, explains full-time satisfaction/dissatisfaction determined by patient evaluations of differences between initial expectations and perceptions of actual service performance after service use.If the perception of actual service performance exceeds expectations, the patient will feel satisfied.But if the perception of actual service performance is less than expected, the patient will feel dissatisfied.Patient dissatisfaction indicates a gap or problem with the quality of service.

Effect of TQM on patient satisfaction through awareness of the importance of improving quality
of service excellence Hospitals that implement TQM well can improve the quality of excellent service and have an impact on patient satisfaction.TQM philosophy is to improve patient satisfaction.Patient satisfaction is closely related to the quality of excellent service provided by the hospital.To improve excellent service quality, the implementation of TQM has a significant influence

Effect of kaizen-PDCA on patient satisfaction through service quality
The ever-changing demand for patients requires hospitals to improve the quality of excellent service.Excellent service quality can only be achieved if hospitals improve quality continuously.Kaizen-PDCA is a continuous improvement system that prioritizes on improving the quality of excellent service and impacting

Methods
The population in this study were all inpatients in the four type B hospitals (Stella Maris Hospital, Ibn Sina Hospital, Faizal Hospital, Labuang Baji Hospital) in the city of Makassar, which numbered 70,000 patients.The sampling technique used was purposive sampling with a minimum sample of 400 inpatients.The analysis method used Structural Equation Model (SEM) -Amos 22 and SPSS-22.

Result and discussion
The results of the hypothesis test prove that: (1) partially the effectiveness of the implementation of TQM, Kaizen-PDCA, influential positivity and significance for increasing awareness of excellent service quality, and Patient Satisfaction is a positive and significant effect (sig ≤α = 0.05).( 2) awareness of the increasing quality of prime service can mediate the influence between TQM, PDCA-Kaizen on patient satisfaction [5].

Conclusion
Integration of computer management and PDCA Kaizen partially has a positive and significant effect on patient satisfaction.The importance of improving the quality of prime services can mediate positive expectations and significantly influence the influence of computer management and PDCA on patient satisfaction.