The Effect of Service Quality on Patient Loyalty with Mediation of Patient Relationship Management and Moderation of Hospital Brand Image

The Effect of Service Quality on Patient Loyalty with Mediation of Patient Relationship Management and Moderation of Hospital Brand Image

Muneeba Razzaq, Sana Rasheed, Safa Khan, Dr Sheraz Ahmed

Riphah International University, Islamabad, Pakistan

DOI: https://dx.doi.org/10.47772/IJRISS.2024.8110068

Received: 30 October 2024; Accepted: 08 November 2024; Published: 03 December 2024

ABSTRACT

In today’s competitive healthcare business, the impact of a hospital’s service quality on a patient’s attitude and behavior toward the hospital has become a major concern. The goal of this research is to look into the link between the hospital’s brand image, service quality, patient relationship management, and loyalty. To test the association, survey data was obtained from private and government hospitals in Islamabad and Rawalpindi that were accredited by five standards of care. Sample size was 300. SPSS was used to analyze the data. The findings reveal that the hospital’s service quality has both direct and indirect effects on the patient’s loyalty. This indicates that the hospital’s service quality not only enhances patient loyalty directly, but also enhances patient relationship management through enhanced service perception, which in turn raises the patient’s intention to return. The hospital’s brand image functions as a moderator in increasing service quality and patient loyalty. Furthermore, the findings suggest that service quality has an impact on patient loyalty through a pathway that incorporates patient relationship management as a mediator. As a result, according to this study, hospital managers should aim to develop and maintain the image of good hospitals in order to increase service quality, patient relationship management, and loyalty. It’s also a good idea to look into some tactics for building and maintaining a positive self-esteem facility.

INTRODUCTION

Background

A hospital is a healthcare organization that assists patients by providing them Healthcare service with devoted doctors and nursing staff through medical equipment. With the advancement of technology and medical research, the private hospital industry is now more advanced and prolific than public hospitals. It is reflected in the majority of hospitals owning more futuristic medical technology, as well as the government’s initiative to open new hospitals. These situations push service providers (in this case, hospitals) to go to great lengths to maintain hospital loyalty. Superior businesses are those that keep their clients happy and enthralled. It is easier and more cost effective to maintain an existing relationship between service providers and consumers than it is to recruit new customers (Kotler & Keller, 2009).

In recognition of the agenda for enhancing health systems, the World Health Organization (WHO) developed a model for health systems that breaks down health systems into six components: information, medical products, vaccines and technologies, leadership/governance, health workforce, service delivery, and financing (WHO, 2007)

Effective, safe, high-quality individual and generic health interventions that are provided to individuals in need at the appropriate time and location with the least amount of resource waste are considered to be good service delivery. A health workforce that performs well is one that, given the resources and conditions at hand, works in a fair, efficient, and responsive manner to produce the greatest possible health results. An effective health information system makes sure that accurate and timely data on health determinants, health system performance, and health status are produced, analyzed, disseminated, and used. A healthy healthcare system guarantees that everyone has fair access to necessary pharmaceuticals, vaccines, and technologies that are of guaranteed efficacy, safety, quality, and affordability, and that are used in a way that is both economical and scientifically sound. In order to guarantee that people can get necessary services and are shielded from financial ruin or impoverishment brought on by having to pay for them, an effective health financing system must raise enough money for healthcare. Ensuring the existence of policy frameworks, effective supervision, coalition building, regulation, system design attention, and accountability are all components of leadership and governance.

Enhancing these six components of the health system and regulating their interconnections to produce more equitable and long-lasting improvements in health outcomes and services calls both political and technical know-how as well as action (WHO, 2007). In order to track program management of health system investments, evaluate health system performance, and analyze the outcomes of health reform investments, the WHO has bolstered its health system framework with a monitoring and evaluation framework (WHO, 2010)

Health-care organizations encounter unique issues all across the world. Because of the open-door policy in the medical service sector, a huge number of hospitals face tremendously competitive situations (Kim et al., 2008). The expanding number of elderly persons, along with a growing focus on health, has resulted in a dynamic increase in specific health wants and demands among the general population. In today’s medical service market, the buyer has an advantage over the seller (Lee et al., 2010). As a result, in the sphere of medical services, the necessity of customer-oriented marketing is now being emphasized more. Hospitals strive to create marketing tactics that enhance brand image among patients in order to satisfy them and gain their loyalty while also promoting performance.

Hospitals are medical service businesses founded on the trust principle; as a result, service quality, patient satisfaction, and patient loyalty determine their fate. Operational performance will determine service quality, and its success will be determined by aspects such as employees, system, technology, and customer interaction. (Kotler & Keller, 2009). In every marketing business, whether it is a manufacturer or a service provider, service quality significantly contributes to the establishment of distinguishing, positioning, and competitive strategy. There are two sorts of quality measurement perspectives: internal and external. The internal type denotes compliance with requirements, but the external type denotes an understanding of quality based on customer perception, expectation, satisfaction, behavior, and enjoyment (Sachdev & Verma,2004). Service quality is a fundamental approach for achieving success and long-term viability in a highly competitive corporate environment (Parasuraman, Zeithaml & Berry, 1988).

Improving service quality has been a major goal for businesses, particularly in the private sector. The fight to improve service quality, according to Sohal (1994), is the greatest problem facing service businesses. Studies on service quality have been conducted in the service industries, both public and commercial, ranging from conceptual investigations to empirical studiesIn the public sector, there is a significant gap between expectations and reality, and the aspects of anticipation and perception are rated differently (Toner & Antony, 2006).
Acceptability, assurance, tangibility and reliability, fairness, and responsiveness are the ratings on the dimension of anticipation. In reality, the dimension of certainty is ranked fourth, and acceptability is ranked fifth. According to Connely and Yoger (2001), has an impact on loyalty.

According to a study, the PRM process is ever evolving in the management of customer-company relationships so that customers can choose a continued relationship that is commercially beneficial for both parties or predict the contrary. Bergeron (2002) In PRM practices, the organization’s responsibility is to keep in touch with patients and supply them with important information. The existence of a link between service quality and PRM practices can be explained logically. If the service quality is higher (e.g., facility availability, birthday gifts for patients), good communication with patients will result. In the study, PRM practices were used as a mediation variable in the relationship between patient loyalty and service quality.
Patient Focus—considering patients’ feelings, protecting their privacy, and properly treating their information; Patient Relationship—maintaining and developing patient loyalty; and Share of Patient —pleasing patients directly by delivering something different than what they have previously purchased. Customers, on the other hand, benefit from the PRM strategy in terms of continuity—being associated with the same supplier/company; contact point—interacting with companies that provide consistent product and service quality; and efficiency. Personalization—maintaining positive relationships with companies that provide products and services (Zikmund , 2003)

Many research on the relationship between PRM and loyalty have been undertaken, with Agrawal (2003) indicating that PRM had a favorable and significant influence on patient loyalty. Ndubisi (2007); Haq, Ramay, Rehman, and Jam (2010); Tseng (2010); Reijonen and Laukkanen (2010) all found similar findings. CRM has a large and positive impact on patient loyalty. 2004 (GU Enzi & Pallone)

Another PRM study uncovered a conceptual model that links PRM (in the form of creative value) to patient loyalty. PRM was recognized as a separate business 25 years ago when it became a significant strategy for building customer loyalty by increasing patient adaption, evaluating patient feedback and criticism, responding and performing them fast. The male stud (Tseng, 2010)
In today’s competitive market, a company’s branding is a valuable intangible asset. Positive brands empower customers to better envision and comprehend products, minimize customers’ perceived risks in purchasing services (Kim et al., 2008a), and assist organizations in achieving sustained outstanding performance. In the world of marketing, brand image is particularly important.

Academics and practitioners are becoming more interested in studying the origins and outcomes of brand image. This development is fueled by the idea that a strong positive brand image can help a company obtain reputational value and a competitive advantage (Porter and Claycomb, 1997). A positive brand image improves a variety of outcomes, including customer satisfaction, service quality, and loyalty. (Bloemer et al., 1998; Da Silva and Alwi, 2008; Lai et al., 2009)

In general, brand image research focuses on corporate contexts such as manufacturing companies, service companies, and retail establishments (Bloemer and de Ruyter, 1998; Nguyen and LeBlanc, 1998; Lai et al., 2009).

Research Gap

Many studies were done on “the Impact of Service Quality on Patient Loyalty. Another study was performed by Vila and Unite Tania in 2020 in which same framework was studied that is between service quality, patient loyalty and patient satisfaction. Apart from these studies, many more were performed who works on the same framework. Despite the fact that hospital brand image is becoming a more essential issue in the competitive health-care business (Javalgi et al., 1992), there are few studies in this sector.

Furthermore, no research has looked into how the hospital’s brand image affects patients’ views and behaviors toward hospitals. As a result, it is vital to investigate the intricate interaction between hospital brand image and patient intentions. To begin, the research presents an integrated model that explains the link between hospital brand image, service quality, patient relationship management, and loyalty. Following that, the associations between these constructs inside the integrated model are thoroughly evaluated. Finally, the findings of this research have fresh marketing implications for hospitals looking to cultivate positive brand images. This study will be a new insight in this field and helps to make things more clear and specific. Apart from that no study has used the variables service quality, patient loyalty, patient relationship management and hospital brand image collectively. This study will present a new framework based on 4 variables at a time.

Research Questions

The specific study questions are as follows:

1. What effect does service quality have on patient loyalty & patient relationship management?
2. How does the image of a hospital affect service quality & patient loyalty?
3. Does Patient Relationship Management play as a mediator between Service Quality and Patient Loyalty?
4. Does the image of a hospital moderate the relationship between service quality and patient loyalty?

Significance of Study

A lot of studies are performed on this concept. Chen & Chen (2010) and Liu &Tsai (2010) performed a study a study in which they make the service quality as one of the most factors of the business management. A lot of other studies are performed by (Zeithaml, 1988; Biter & Hubert, 1994; Sureshcandar et al., 2002; Kotler and Keller, 2009; D’Astous and Gargouri, 2001; Flavian et al., 2004) and many other presents significant results on this field. But there are almost very few studies that use the exact set of variables as ours. Our study will be a significant addition into this line and will make the associations between the variables clearer. This will help to make things more understandable by using different variables and multiple analyses will make the results significant. Our study is significant contribution to service quality policy makers and will help the marketing and promotional staff to work on suggested points.

Research Objectives

The following are the study’s research goals:

1. Determine the effect of service quality on patient loyalty & PRM
2. To find out the Impact of Hospital Brand Image on Service Quality & Patient Loyalty
3. To determine the mediatory role impact of Patient Relationship Management on patient loyalty.
4. To determine the impact of the hospital’s brand image and service quality on patient loyalty.

Definitions of Study Variables

Service Quality

The customer’s overall impression or appraisal of the organization’s and its services’ relative deficiency or superiority is referred to as service quality (Zeithaml, 1988; Bitner & Hubbert, 1994).

Patient Relationship Management

Organizations can use patient relationship management (PRM) technologies to build and manage relationships with their patients.

Patient Loyalty

Patient loyalty is described as a patient’s trust in their doctor to act in his or her best interests and offer appropriate therapy and medical care (Anderson & Dedrick, 1990; Thom & Campbell, 1997).

Brand Image

“The set of beliefs, thoughts, and impressions that a person holds toward an object” (Kotler, 2001). The amount of people who have an opinion about a brand is usually proportional to how recently they have used it.

LITERATURE REVIEW

Service Quality

Service quality, which is one of the most important aspects of business management, has been extensively debated and highlighted in both academic and commercial circles (Chen and Chen, 2010; Liu and Tsai, 2010). The total verdict, impression, and evaluation of the customer regarding the relative superiority or inferiority of the organization and its services can be defined as service quality. (Zeithaml, 1988; Bitner & Hubbert, 1994). It can be quantified by comparing consumers’ expectations with their impressions of actual service performance (Parasuraman et al., 1985).

Satisfaction, happiness, and commitment are all based on quality and service. The ultimate goal and objective of the business is to ensure that satisfied and loyal consumers are ready and willing to do business with the company. When the major purpose and objective is to have satisfied and loyal clients, it is therefore necessary to provide high quality and the greatest of facilities (Richard, 2002).

Service is defined as an activity or performance that establishes customer advantage by making a change that the customer accepts and acknowledges (Piercy et al., 2002). Consumer service is the one rose that supports and braces a company’s primary product in order to attain and gain them (ZeithamI, 2000).

Sureshcandar et al. (2002) established and recognized five components of substantial service quality from the standpoint of the consumer, namely the core of the service or product, elements of the service mode, systematization of the service mode, (forms of service, and social responsibilities. When a significant relationship between distribution and loyalty exists, it may be claimed that distribution, as viewed by the consumer, will create a distinguishing point in the customer’s view by allowing consumers to receive products/services with ease and efficiency.

The customer’s message to the service provider is clear: be responsive, reassuring, compassionate, and, most importantly, dependable. Recognize and understand this is easier than completing it. Customers assess service quality by contrasting what they desire or expect with what they receive or perceive. Organizations must meet or exceed client expectations in order to develop a reputation for quality.

Parasuraman divides the SERVQUAL component of service quality into five categories:

a. Tangibles (physical evidence), which refers to a company’s ability to effectively communicate its existence to third parties. According to Berry and Clark (1991), a customer’s perception of quality is influenced by their physical appearance. Physical appearance can influence consumer happiness (Bitner, 1990)
b. Reliability: The ability of a corporation to perform promised services accurately, effectively, and dependably on schedule is referred to as reliability. Garvin (1987) discovered that while evaluating service quality, reliability is often overlooked. According to Parasuraman et al. (1988), reliability is the most significant trait that customers look for when evaluating service quality.
c. Responsiveness Despite its lack of dependability, Bahia and Nantel (2000) indicate in their research that SERVQUAL and all of its categories are well known and universally recognized as a measurement for perceived quality.
d. Assurance: Knowledge, politeness, and the ability of personnel to create client trust in the organization are all examples of assurance (guarantee and certainty). Employee behavior, such as politeness, trust, and understanding, were identified as critical factors of assurance. (Parasuraman et al., 1991).
e. Empathy: Empathy is defined as the act of giving customers honest, genuine, and personalized attention with the goal of understanding their requirements. In the ten basic characteristics of service quality evaluation, empathy can take the place of access, communication, and customer knowledge (Zeithaml, et al., 1988).

Technical and functional quality are two independent aspects of healthcare quality, according to Chakravarty (2011). Technical quality can be described as the precision with which medical diagnoses and treatments are performed, and it is widely understood by professionals but not by patients. Patients often see functional quality as the way in which services are delivered.
Admission, nursing care, physician care, staff care, food, and lodging are exceptional service aspects that promote patient happiness and loyalty (Otani, 2009)

Chaker (2005) compared the quality of service provided by private and state hospitals. They claimed that empathy, tangibles, reliability, administrative response, and assistance are all characteristics of service quality.

Baker and Taylor (1997) proposed that the quality of healthcare services has an impact on future purchase targets due to patient satisfaction.

The SERVQUAL measure was changed by Licata et al. (2003) to include the following 13 attributes: facilities, reliability, reputation, and attitude toward patients, peer recommendation, indigent care, billing, equipment, expertise, diagnostic service, staff training, and admission scheduling.

Svensson (2001) evaluated a number of three qualities of service measures produced by Parasuraman et al. (1988) and Dabholkar et al. (1996), which were produced by Parasuraman et al. (1988) and Dabholkar et al. (1996). As a result, these measurements lack generality and consistency over time. The study indicates that the direction of change in perception should be measured, complimentary features should be measured, and the degree of perception of the phenomenon should be examined in the context of specific experiences by merging the overall trend dimension into a number of measurements.

Within legal firms, hair stylists, film processors, and retail establishments, investigated the cause of service problems from service providers based on service intangibility (Bebko, 2000). Customers anticipate more from intangible services than from services with more physical attributes, according to research. According to research, when customers have problems with services, the gap between their expectations and perceptions is not as large as it is when they do not have problems. Furthermore, the difference between consumer expectations and perception is not substantially higher when consumers encounter problems with intangible services than when consumers face problems with tangible services.

To define service quality, Lehtinen and Lehtinen (1991) suggest a five-dimensional framework: Quality of interaction, which is the quality of interaction between the receiver and the supplier at the time the service is delivered; quality of enterprise, which is “formed in the history of the connection between the service process. Output quality, which is the customer’s assessment of the results of the service interaction process; and process quality, which is the customer’s qualitative assessment of their experience in the service process.

The customer’s view of the quality of service is heavily influenced by human performance. Human performance is directly responsible for three of the five dimensions: responsiveness, certainty, and empathy. Furthermore, the person’s performance is usually a big factor in reliability. Obviously, if you want to understand and avoid service quality issues, you must compete with the rivals
The customer’s expectations for a specific service impact their evaluation of that service’s quality. The perceived quality of service is harmed when there is a disconnect between the customer’s expectations and management’s comprehension of those expectations. One of the quality gaps is management’s failure to effectively recognize consumer wants.

We now turn our attention to various therapies after reviewing some of the causes of poor service quality. Quality of Service is a puzzle with a lot of components that must be properly put together. Only by a systematic, step-by-step process can service be improved; boost employees’ capacity and motivation to deliver services by developing an organization that supports quality services in each area.

Defining the organization’s service standards based on customer expectations is the first step in any quality improvement endeavor. Service standards assist in defining the function of work and communicating the organization’s priorities. They also serve as a benchmark against which performance can be measured. It is not necessary for service organizations to set a significant number of standards. It’s easier to manage some of the criteria connected to the most critical customer expectations—for example, transaction accuracy, permitted waiting time, and suitable customer service. Setting standards entails articulating client expectations so that service staff are completely aware of them. This is significant because quality improvement necessitates the one providing the service taking responsibility for it (Berry, L, Parasuraman. A & Zeithaml,1988)

Managers, as well as those who interact with customers and provide internal support services, should be the focus of quality improvement activities. Maintaining good quality over time is one of the most difficult quality-of-service challenges. The Operations Unit Manager is critical to meeting this challenge. The manager is in the ideal position for quality control in the work unit since he or she sets the tone. In service businesses, however, persons with technical skills are more likely to be promoted to management positions than persons with interpersonal abilities. Many firms may greatly enhance service quality by evaluating operations managers’ dedication to service and personnel skills, as well as retraining (or replacing) those who do not pass. Moreover, any measures made to improve the organization’s overall quality of service, such as training, performance monitoring, and incentives, must include managers. (Berry, L, Parasuraman. A & Zeithaml, 1988)

The quality of Service depends on a long-term view. Human attitudes, habits, knowledge, and skills cannot be changed quickly. It’s better to conceive in terms of organizational evolution rather than revolution. To overcome many of the challenges that impede service excellence, businesses require leaders who can envision and establish a service-oriented culture. Service quality is more than a collection of tasks; in the end, it is mostly a mindset. Only leaders who are focused with quality of service will be able to persevere through difficulties, short-term financial difficulties, and setbacks and meet consumer expectations. (Berry, L, Parasuraman. A & Zeithaml, 1988)

Patient Relationship Management (PRM)

PRM is a customer relationship management (CRM) approach to patient care that is defined as a business strategy that employs information technology to create companies that are competent, trustworthy, and integrated with patients on their side, allowing all processes and interactions with patients to help maintain and improve profitable relationships (Zikmund, 2003). It evolves into an integrated sale, marketing, and repair strategy (Kalakota and Robinson, 2001). It is a dynamic method for managing customer-business relationships so that they can choose between maintaining an economically mutually beneficial partnership or breaking the relationship for corporate benefit (Bergeron, 2002).

PRM, according to Turban (2004), is a long-term service approach to customers that can bring value to both the customer and the organization. According to Temporal and Trott (2001), PRM is a partnership with each customer to create a win-win situation by increasing the value of the customer’s life every day in order to keep them loyal. It stores customer information and records all interactions between customers and a firm, as well as creating a customer profile for company employees who need to know about the customer (Laudon and Traver, 2002).

Customer Relationship Management (CRM) is a key method for managing relationships between businesses and their clients. It is no less critical in the healthcare setting. Because patients are the most important clients of hospitals and other healthcare facilities, the phrase “patient relationship management” is applied to their systems (Kohli, 2001). The focus of a PRM-enabled healthcare organization is on determining and addressing patient requirements (Siau, 2003)

PRM entails keeping track of patient data ranging from diet and exercise to past diagnoses, family history, and allergy information, all of which can be updated or edited by the patient, empowering him or her to provide and seek information (Siau, 2003). Health care practitioners will be able to transmit e-information to patients about newly published health care research that may be relevant to the patient, or offer customized suggestions that fit the patient profile, thanks to the storage of all of this data.

Healthcare workers, namely nurses and doctors, as well as patients, are the major users of a PRM system. PRM systems, according to healthcare professionals, should be tightly connected with existing hospital information systems (HIS) and electronic health records (EHR), so that their deployment has minimal influence on existing workflow. Because of the potential for privacy issues, patients must expressly register to utilize a system like this. It is important to either construct a patient-specific web site or integrate an existing portal for that purpose.

The services of PRM includes Alert service, waiting time display, Clinical data entry, Cancel appointments, Send information to population, and Application development frame work. A PRM system must be connected with the hospital’s various information systems in order to be effective. The HIS, the electronic health record (EHR), and the laboratory information system (LIS) are all evaluated for this purpose.

The use of a PRM system is a useful tool for making patient follow-up easier. They should cut spending on visits, exams, and treatments in which the patient fails to show up. The hospital’s debts could potentially be decreased by reminding patients of their obligations to pay. In some circumstances (e.g., follow-up of children with type I diabetes), automatic follow-up of the patient can be used to improve the interaction between the patient and the health professional, decreasing medical or nursing workload.

Patient behavior, according to Kotler and Keller (2009), is a process of decision-making and individual acts that are physically involved in evaluating, procuring, and spending or being unable to spend goods and services. Patient behavior can be defined as a process that includes things that impact patients before, during, and after the purchase process. It also includes barter, which fully emphasizes the consumption process and includes things that impact patients before, during, and after the purchase process. As a result, patient behavior can be characterized as direct individual activities to obtain and use cost-effective medications and services, involving an earlier decision-making process and prior determination.

According to the American Marketing Association, patient behavior is dynamic, meaning there is interaction between affection and cognition, behavior, environmental events, and barter engagement. (Olson, 2000)

CRM encompasses four distinct behavioral characteristics (Sin et al., 2005; Yim et al., 2005). The core customer focus, CRM organization, knowledge management, and technology-based CRM are the behavioral characteristics. It’s vital to remember that all of these elements must function together in a methodical manner in order for the organization’s performance to improve. (Sin et al. Yim et al., 2005; Yim et al., 2006., 2005). A survey on the influence of CRM dimensions on Malaysian contact centres by Abdullateefet al. (2010) is a good example in this regard. Customer orientation, he says, is a more comprehensive CRM factor than customer focus.

CRM, according to Kumar, V. (2010), is the strategic process of identifying and shaping the consumers that the company can most successfully service, as well as the organization’s contact with those consumers. Our goal is to maximize our customer’s company’s current and future value. The following are the important elements of this definition:

Strategic Process: CRM activities begin and are managed from the top of the organization, according to the strategic process. CRM is not the domain of a single department; it need contributions and reinforcements from all levels of the organization. CRM is also a continuous process that cannot be treated like any other software implementation job. It must be viewed as a continuous endeavor aimed at making the organization more customer-centric.

1. Prioritization: When a company’s resource allocation is based on a customer’s economic value, it makes sense for it to priorities its most profitable or potentially profitable clients. This is not to say that particular clients should not be served, but rather to acknowledge that the company’s products and the segment’s desires, behaviors, and traits are compatible.
2. Interaction: This implies that the customer-firm connection takes the shape of an interactive discussion. Information and goods are transferred, and the exchange evolves as a result of previous transaction.
3. Client: A customer can be an individual account, one or more market sectors, or the entire market, depending on the industry and firm. Customers also include middlemen such as distributors, merchants, and other service providers.
4. Customer’s current and future value: This indicates that the company is shifting from profiting from a single transaction to profiting from a series of interactions. As a result, businesses began to focus on maximizing customer equity, or the value of all client relationships. Traditional metrics like market share are being phased out in favour of newer metrics like customer lifetime value (CLV).

Customer relationship management is a customer-centric business model that must be created around customers across the firm. This is a continuous activity that necessitates a customer-centric redesign of essential business processes as well as customer input. Customers are asked about the challenges they face from the Seybold Group at the start of the process (Seybold, 1998; Seybold et al., 2001). The purpose of a product-centric approach is to identify clients for the product via a large-scale marketing campaign. The purpose of a customer-centric approach is to develop products and services that suit the needs of customers.

The customer-centric model aims to boost revenue, build customer loyalty, lower sales and service expenses, and streamline processes. Customer relationship optimization necessitates a thorough understanding of all customers, both lucrative and non-profit, as well as the organization of corporate operations to serve consumers uniquely based on their requirements and values (Renner, 2000). Al-Mashari and Zairi (1999) present a holistic assessment of the success and failure variables in the paradigm of business process transformation. Change management, managerial support, organizational structure, project management, and information technology were all given special attention.

More patients engaging in treatment has better outcomes in the health-care industry, and major healthcare companies are actively finding strategic strategies to promote this process. Unlike fee-based services, attracting patients will be critical to improving provider performance, which will necessitate increased patient numbers, shorter stay times, and larger profit-making improvements in surgical rates. The US Department of Health and Human Services has set a goal for 90 percent of traditional health insurance payments to be value-linked by 2018. This is an unusual action. (Ahearne et al., 2005)

In the health-care industry, CRM translates to PRM. As a result, in order to retain patient happiness and loyalty, healthcare providers must employ effective marketing strategies and quality assurance processes. For the following reasons, this is not a simple task:

* Limited hospital marketing capacity * Customer sensitivity * Difficulty delivering tailored care to each patient * Difficulty keeping patients for preventative treatment * Difficulty advertising new facilities and services

Since PRM was introduced at WHO, it has resulted in increased information system compliance, decision-making transparency, and the development of collective intelligence. (Yousefi & kargari, 2004)

Patients can benefit from the PRM application since it allows hospitals to better understand their needs and, ideally, improve communication through the follow-up system. It is critical for clinicians to comprehend the treatment’s impact. Doctors can have a better understanding of how their treatments and operations function by letting them know how satisfied their patients are. As a result, improving patient connections and increasing patient loyalty benefits both healthcare providers and patients. (Mohiuddin, 2009). Patients can now quickly get their treatment instructions via the internet. When hospitals deliver real-time information to their present and potential patients, they will be able to stay in touch with them and compete for customers with other healthcare companies. To support the shift in attention to patients, hospital management plans should consider comprehensive and efficient hospital information systems. Hospitals may be able to function more customer-centric than before thanks to the PRM concept. (Walker et al., 2018)

The following are key features of hospital PRM:

1. Gather information about the patient’s personal information, his or her frequency of visits, the doctor to whom he or she recommends, the patient’s admission, medical history, discharge, attendants, and doctor information, among other things. Create and manage a database or master file that contains information from the entire company.
2. Analyze data to identify prospective lucrative consumers, create the greatest marketing possibilities for them, and choose the best way to engage with them in order to achieve the defined objectives.
3. Create marketing initiatives that convert potential customers into lucrative clients.
4. Keep track of the initiatives’ effectiveness and return on investment (Rafique et al., 2016)

PRM is a vision attained by technology, not a technology; technology allows for greater coherence across different components of the health-care system, resulting in improved clinical outcomes and patient satisfaction.” 2015 (Green & Johnson).

PRM can be used to:

1. Aid in the prevention of other diseases. Doctors can more quickly spot the link between current symptoms and potential health concerns when they have a 360-degree perspective of the patient.
2. Enhance the quality and consistency of care. To ensure that important security procedures are followed and that firms comply with privacy and other regulatory policies, automated processes can be built.
3. Improve the efficiency of routine procedures such as admission, referral, and discharge. Improvements can be made by analyzing the performance of normal activities, removing superfluous steps and increasing patient satisfaction.
4. Eliminate wasted time accessing information. By electronically storing indexed documents, such as treatment plans, symptoms and diagnostic relationships, and reference articles, can reduce the time spent searching to provide the information needed for quality care (Vardaska, 2011)

Patient Loyalty

Patient loyalty is described as a patient’s trust in their doctor to act in his or her best interests and offer appropriate therapy and medical care (Anderson & Dedrick, 1990; Thom & Campbell, 1997). In a marketing context, Dick and Basu (1994) defined customer loyalty as a response that is highly related to a vow or promise to uphold commitment on the underlying a relationship continuity, and is typically reflected in continuous repurchase from an equivalent service provider, on a dedication basis and pragmatic limit. Repurchases from loyal customers are backed up by positive feedback.

Definitions by Griffin (2005) said that customer loyalty is a behavior that can be defined as the purchase of nonrandom purchase as is clear after time after time by the decision of the specific unit. According to Lovelock (2005), the loyalty of the patient is the readiness of customers to keep buying from the company for the long haul and recommending this product to friends, including preference, intention, and will in the future while Mowen and Minor (1998) says that customers have a positive conditions have positive feelings about it, both committed to the brand into the future, and have the right to buy in the future. Singh and Sirdeshmukh (2002) said that client loyalty is conceptualized as intention of to maintain the link by providing a service with the service provider and to be ration of the contract made with certainty. Priyanto (1998) said that the factors affect to any goods or services in, among others, is the value (price and quality). The image (from the personality of the personnel or the reputation of the brand), the comfort and the facilities to access the product, customer satisfaction. According to Aaker (1997) in Riyadi (1999), influence factors loyal customers, the level of dissatisfaction, behavior, commitment, product help, the trust and remove the cost

The significant link between employee satisfaction and patient perceptions of service quality can be measured by the likelihood of returning and recommending the hospital to others. Employee unhappiness can have a detrimental influence on service quality, a bad impact on patient loyalty, and, as a result, a bad influence on hospital revenues (Atkins et al., 1996). It motivates them to show their commitment to the company. Employee loyalty will then lead to increased productivity. Employee productivity fosters the creation of external service value, which in turn influences external patient happiness. One of the criteria that determines patient loyalty is patient satisfaction. (Kotler and Keller, 2009).

Griffin (2005) considers patient loyalty to be a more dependable predictor of sales and financing expansion than patient happiness. Many businesses rely on customer pleasure as a guarantee of future success, only to be disillusioned when they discover that their customers are happy enough to buy competitor’s products without hesitation.

According to Kotler and Keller (2009), loyal patients are extremely valuable to a company, and competitors typically find it difficult to snare them. They can also be firm marketers, which means they can offer recommendations and generate a significant amount of earnings to the company because they influence patient purchase patterns and provide free recommendations to others.
The concept of loyalty refers to a positive attitude, behavior those results in repurchasing, and a long-term commitment from the buyer (Gremler and Brown, 1996; Oliver, 1999; Wong and Sohal, 2003; Zeithaml et al., 1996) towards a selected product, service or business. Through this sense of loyalty, the consumer continues to buy follow-up needs from the same brand and endorse the brand to other consumers. In this context, loyalty may be a concept which incorporates not only behavioral reactions but also attitudes also (Kim et al., 2007), therefore, loyalty can be measured by two approaches: behavioral and attitudinal (Chahal and Kumari, 2011; Curasi and Kennedy, 2002; Morgan and Hunt, 1994; Roberge et al., 2001). Behavioral loyalty refers to repurchase behavior, attitude loyalty refers to the sense of commitment to the brand or business that guides the behavior (Kurtuldu et al., 2008; Zhou et al., 2017). Also, attitudinal loyalty refers to the buyer ’s emotional loyalty towards the brand in order that albeit the consumer doesn’t purchase it, he or she may recommend the brand to other consumers (Barksdale et al., 1997). Furthermore, it demonstrates positive reactions related to the positive word of mouth (Gee et al., 2008; Khan and Fasih, 2014) and this is often thanks to positive emotions that are felt towards that brand. Consumer loyalty to a healthcare provider is defined as patient loyalty (Sumaedi et al., 2015).

According to Lombardi (2012), “loyal patients are the simplest sort of patients” because if a patient is proud of the service, he or she will refer it to friends, family and co-workers. In a competitive environment, patient loyalty is critical for hospitals that don’t want to lose their current clients. Sustainable business success highly depends on consumers who purchase back a product or service. To provide that, businesses should be ready to make customers loyal since keeping current customers is a smaller amount costly (Lin and Wang, 2006) as against gaining new customers. In this regard, loyalty may be a pivotal factor that indicates whether a business maintains its presence or not (Pişgin and Ateşoğlu, 2015). Zhou et al. (2017) argue that long-term commitment to worry and compliance with medical advice is critical in improving healthcare services and patient outcomes. Thus, for the advantage of each side, patient loyalty must be managed by healthcare providers. The factors that affect patient loyalty must be understood, in order to manage effectively. In literature, although some results are contradictory, much inquiry has been conducted to work out these predictors. The terms that are addressed include “satisfaction”, “service quality”, “perceived value”, “brand image”, “trust”, and “commitment.” (Zhou et al., 2017). This study aims to look at the basic mechanisms between a number of these predictors (trust, satisfaction, perceived image, and strength of hospital-patient communication with social media) and patient loyalty as the dependent variable.

Loyalty is defined as the continued use of a product or service based on a positive attitude toward that product or service. The distinction between loyalty and frequent use pertains to the rationale behind a product or service selection. Loyal buyers are more invested in the relationship, whereas habitual consumers are unconcerned about regular behavior (Knox, 1998). Customer loyalty, according to Dick and Basu (1994), is a link between a person’s attitude toward entities (brands, services, businesses, and suppliers) and their patronizing behavior. Customer loyalty has three elements, according to Gremler and Brown: behavioral loyalty, attitude loyalty, and cognitive loyalty. The behavior of consumers associated with certain brands over time is referred as behavioral loyalty (e.g. repeated purchases) (Gremler & Brown, 1996).

Customers become loyal to a product or service when they are satisfied with it. Customers that are loyal to the brand continue to buy its items on a regular basis. They also give the company good marks and positive feedback. They also spread positive word about the service and the company that provided it. (Kumar, & Advani, 2005). According to Iddrisu (2011), satisfied consumers are more likely to promote the service to their friends and family members. Client loyalty, according to Iddrisu (2011) and Teich (1997), is achieved when a company consistently fulfils and surpasses customer expectations. According to Iddrisu (2011), client loyalty may be achieved by delivering a high-quality product as well as coupons, free incentives, extended warranties, and low interest rates. To make their customers feel satisfied and joyful, the corporation should provide these incentives. Customers will build a sense of loyalty as a result of these feelings, and they will continue to buy from you.

Customer loyalty (e.g., intention to buy, readiness to spread a positive word) was discovered to be a function of customer pleasure, which was discovered to be a result of cognitive comparison between expectations before to consumption and actual experience (Fornel et al., 1999). What can shape the behavior of the patient’s purpose, according to Aliman & Mohamad (2013), is eventually promote patient loyalty. In their study, Hu et al (2010) discovered that customer satisfaction has a positive and substantial link with customer loyalty. According to Wu (2011), client loyalty might be an endogenous variable caused by a combination of satisfaction, making customer loyalty a function of satisfaction. If there is a positive relationship between customer satisfaction and loyalty, then high satisfaction will promote customer loyalty.

Hospital Brand Image

The brand could be a valuable intangible that is tough to mimic and can help you achieve long-term superior performance (Roberts and Dowling, 2002). Brand image can be a combination of perceived quality and esteem (Yagci et al., 2009). In other terms, a brand image can be defined as a recollection of a brand that reflects a customer’s entire impression. A positive brand image is frequently regarded as critical to an organization’s ability to maintain its market position.

Knap (2001) a brand is defined as the internalization of a number of impressions as accepted by the customer which involves a special position in their memory about the function of their emotional feel. According to Staton, (1996) a brand is defined as a name, idioms, symbols, design specified or a combination of the elements mentioned this, formulated to identify the goods or services provided by the seller. Kotler, (2000) says the brand is a commitment from the seller consistently delivers the features, benefits and services specific to the buyer, is not only a symbol of distinguished similar to the company’s competitors particular.

In the context of health care, Kotler and Clarke (1987) stated that hospital brand image is the sum of a patient’s beliefs, thoughts, and impressions about a hospital. A hospital’s brand image is relative to the brand images of competing hospitals; it is not absolute. Patients frequently build a brand image of a hospital based on their personal checkups and treatments (Kim et al., 2008a). Furthermore, the image of a hospital has a strategic purpose. The brand image of a hospital is frequently used to assist it strengthen its competitive position through smart marketing operations (Javalgi et al., 1992). As a result, a positive hospital brand image aids in the development of patient intentions for choosing a hospital.

The perception of a receiver backed by the consideration that it is on the company’s identity and reflexes interpretation of the various attributes of firms from many sources is referred to as brand image. People are concerned about the organization because of the brand’s multifaceted interpretation (D’Astous and Gargouri, 2001). According to Flavian et al. (2004), a company’s image can be judged by access to services, services offered, human interaction, and security reputation. They also defined the firm image as “what the firm sends to its receivers about itself and how these projections are received.”

A positive brand image is a valuable asset for most businesses, since it influences customer perceptions of communication and operations of organizations that value their customers. According to Grönoos (2000), the image serves two purposes: The corporate image must speak to a variety of expectations, and so the company’s image may be a function of both outstanding service and a wide range of client expectations. According to Kotler (2003), a firm’s image is a collection of impressions, beliefs, and attitudes about the organization that exist in the minds of customers. Furthermore, according to Kotler and Keller (2006), the service industry has generated a number of powerful brands through time. One of the unique aspects of the service is that it is intangible, therefore the quality fluctuates depending on who is providing the service. As a result, branding is critical for service organizations to demonstrate the value of intangible offerings. The brand name sign becomes more essential as the service gets more definite in form.

Service Quality and Patient Loyalty

Customer loyalty is discussed in terms of the quality of relationship services obtained. Customer loyalty can be gained through high-quality service. Furthermore, consumer loyalty is the company’s foundation. The business learned that client retention was more profitable than acquiring new clients. This leads to the conclusion that a loyal client benefits the organization by reducing marketing costs for finding new customers. As a result, improving the product or service’s quality of service is a crucial part of client loyalty. Customers can only be loyal to a firm if they appreciate the items or receive excellent service. The most important thing to be able to be useful according to the needs of consumers is not only the quality of the product or service, but also the quality of the product or service. The greatest things that you can comprehend and meet the wants and wants of consumers should be presented in the quality of service. If the quality of service provided does not fulfil the demands and desires of customers, they will gain no benefit or may even be disappointed after utilizing the product/service. As a result of the losses, customers seek out products and services that satisfy their needs. Customers will not be loyal because of the poor quality of service; it might be argued.

Customer retention and loyalty are aided by excellent service quality (Potluri and Zeleke, 2009). In the case of healthcare services, Boshoff and Gray show that service quality has a positive effect on loyalty, as evaluated by buying intention, in Wu’s (2011) study. According to Parasuraman et al. (1988), a company that provides good service quality might improve customer loyalty. It means that the quality of service has an impact on patient loyalty. At Midwest Hospital, Atkins et al. (1996) discovered a substantial link between hospital nurse quality of service and patient loyalty. According to Cronin et al. (2000) and Guenzi and Pelloni (2004), a hotel’s service quality will improve the amount of tourist loyalty.

According to Kang and James (2004), corporate quality refers to a company’s overall perception of service quality to present and potential customers, as well as the general public. Furthermore, Al-Rousan and Badaruddin (2010) discovered that service quality has an impact on customer loyalty.

According to Hamidiyah (2016), there is a link between patient satisfaction with service quality and patient loyalty. According to Belaid et al. (2015), service quality has a favorable and considerable impact on patient loyalty. In his study, Al-Abri and Al-Balushi (2014) found that the quality of service has a substantial impact on patient satisfaction and loyalty. In his study, Siska (2016) found that the dimensions of service quality are generated by tangible, dependable, responsive, reassuring, stressed, and trusting impacts, which greatly satisfy patients and make them loyal.

Good service quality will contribute to positive word of mouth by telling good service to close friends, family, and acquaintances, affecting patient loyalty. The study’s findings on service quality have a beneficial impact on customer loyalty. (Parasuraman et al., 1988).

Customer loyalty, satisfaction, retention, and long-term relationships can all be improved by providing high-quality service. Profitability, performance, market share, and customer turnover all improve as a result of this (Boshoff & Tait, 1996)

On the other hand, good service quality can meet consumer expectations for a product/service when the product/service is used to suit the wants and wishes of the client. The consumer will feel at ease utilizing the product, allowing the product/service to meet the client’s needs. Customers that are happy with their product or service purchases show repeated or ongoing loyalty, which we call customer loyalty. To recognize the connection, we must first comprehend the function of a service. Every soul and every employee of the firm that provides such services should be responsible for improving services or services. Aykac et al. (2009) shown that the quality of service has an impact on customer loyalty at Marmara University Hospital in prior investigations. A study reveals the impact of patient loyalty on the quality of service provided by private hospitals, explaining the findings that loyalty may be explained by service quality (Arabic, et al., 2012). Similarly, Kesuma et alfindings,.’s (2013) The study’s findings revealed that there is a link between quality of service and patient loyalty, with customers feeling satisfied and loyal when the quality of treatment at the hospital matches or surpasses their expectations.

A hypothesis can be formulated as follows based on details of theory and finding:

H1: Patient loyalty is influenced by service quality in a positive and significant way.

Service quality and PRM

PRM is an interaction process between patient and service providers in order to attract, maintain and retaining the patients to use the organization’s service. PRM implementation seeks to keep patients for the reason of loyalty, which is valuable for the company. The installation will not be successful if the company’s service is of poor quality. It means that good service quality makes PRM implementation easier. If the company’s service quality is good, PRM implementation can be improved or strengthened.

Customer relationship management has grown in importance in recent years, owing to the fact that it not only gives an organization a competitive edge by creating long-term relationships with customers, but it has also become a requirement for the existence of the company.

In marketing, service quality is viewed as a critical aspect in assisting a firm in achieving its objectives, as evidenced by the literature (Izogo & Ogba, 2015). The customer’s evaluation and satisfaction with the services provided by the company is used to determine service quality. As a result, any service-related organization’s performance is determined by the quality of service and consumer satisfaction with the services offered (Makanyeza, & Chikazhe, 2017).

In all of the company’s activities, the consumer’s perceived happiness will eventually give onto a value offered by the consumer. The products/services that should be promised are how they imagine in their minds in order to receive a good review from the consumer. This is because customer happiness is directly proportional to the quality of the product or service given. Customers should feel pleased after using the goods or using the services supplied, so the level of service supplied should reflect that. The consumer will not hesitate to consume or repeat the product/service if the service quality is satisfactory.

Consumers are loyal to previously used products/services and show satisfaction with the products/services after utilizing them. This suggests that the consumer had a benefit or good result as a result of using the product/service, or that the product/service is of good quality. (Umie, & Syah, 2017)

The quality of service offered is inextricably linked to patient relationship management. The service quality must be able to reach a high standard, particularly in the service that allows the production of well-trained personnel to assist clients. Human resource behavior in the delivery of services is a critical component of service quality and customer satisfaction. As a result, the priority of the regulatory strategy is geared toward the interests of consumers, with an emphasis on service component quality. In the service sector, attention to the wants and aspirations of customers should be an inherent aspect of service excellence. This will cause a feeling of happiness, which may lead to satisfaction. Patient relationship management is a component of consumer comparison results based on the performance of the product/service intended to be used. Companies will constantly be mindful of the relevance of customer factors in this era of globalization. As a result, determining the level of customer satisfaction is critical, even if it is not as simple as determining the consumer’s weight or height. Achieving high levels of customer satisfaction through patient relationship management provides a number of benefits for companies.

Client satisfaction and quality of service are two phrases that can be used interchangeably, and quality of service ensures customer contentment or discontent.

The total experience of the organization’s service environment is related to the customer’s evaluation and measurement of service quality. When employees treat customers with respect, listen to complaints intently, and respond effectively and quickly to resolve customer complaints, success in providing high-quality services will be possible. When an organization understands all of these factors and considers their implementation, the quality of service will be improved, which will not only satisfy customers, but also develop strong relationship (Chase, 2004)
However, it was also researched that the quality of service at Marmara University Hospital has an impact on patient relationship management (Aykac et al., 2009). Patients are content with the services offered, according to Markovic et al. (2014), implying that quality of service is a measure of patient relationship management. Furthermore, in his research, Arsanam and Yousapronpaiboon (2014), as well as Pouragha and Zare (2016), point to an impact between quality of service and patient relationship management. As can be seen from several previous studies, quality of service is seen as an important strategy for satisfying customers and building patient relationship management strategies

A hypothesis can be made based on the above details and findings:

H2: Service quality influences patient relationship management (PRM) in a favorable and meaningful way

PRM and Patient loyalty

While two components of human resources and the service delivery process can directly influence patient loyalty, three aspects, including organizational indicators, information technology, and knowledge management, are regarded to be elements that indirectly influence patient loyalty to the ward (Hajikhani, 2015)

Considering the lack of chance to ask personal questions, limited time spent with physician, and physician behavior as the primary reasons for patient discontent with hospitals, a significant association was identified between the PRM and loyalty (Ayimbillah Taiga et al., 2012). Another study discovered a strong positive association between the score of patient loyalty and the factor of interactive quality (the quality of staff-patient contact) (Arab et al., 2012)

Customer relationship management also entails automating and improving customer-centric sales, marketing, and service activities. It not only automates these operations, but also ensures that front-office applications improve client pleasure, resulting in higher customer loyalty. (Kumar, 2010). Loyalty programs have long been used by businesses to determine the current and future value of their clients. A loyalty program is a type of marketing that rewards customers for making recurring purchases. Consumers that enroll in loyalty programs choose to concentrate their purchases on a few brands, giving up the freedom of choice they enjoyed previously. To focus their purchases on the firm, they collect assets (e.g. “points”) that may be exchanged for products and services that are normally connected with the focal company. All successful loyalty programs share a common purpose and emphasize a key component of customer management: selling to existing customers is less expensive than finding new ones.

The basic purpose of relationship marketing, according to Sanchez (2003), is to establish relationships with clients that lead to long-term, profitable growth, rather than simply make sales. Sales are the first step in converting buyers into long-term clients. Customers that are loyal to a product are delighted to assist the company in encouraging others to try or possibly purchase the product. Brand loyalty is an asset (Sanchez, 2003). A brand is little more than a trademark—an owned, identifiable symbol with limited value—without client loyalty. The brand becomes more than just a trademark when customers are loyal to it.

Patients who trust the clinic/hospital are always welcome to create a long-term therapeutic relationship with them. Patient satisfaction is positively impacted by good patient relationship management by doctors, nurses, and other clinic/hospital personnel. Treatment experience, sentiments of delight or disappointment (in the context of expectations), and if the facility will be recommended to others are all factors that influence a patient’s satisfaction with the hospital/services (Salgaonkar, 2006).

Customers are satisfied when they have positive thoughts about the service or product in question. Meeting or exceeding their wishes, demands, and expectations generates such great sensations. In other words, such pleasant sensations stem from a mismatch between their expectations and their impressions after obtaining or using the service or product. This discrepancy will influence one’s purchase decision (Wiele, Boselie, &Hesselink, 2002; Akbar, &Parvez, 2009).

Customer relationship management, according to Bhattacharya (2011), is a strategy to cut expenses while improving company performance and quality, resulting in profitability through customer loyalty (Rahimi, & Kozak, 2017).

CRM entails automating and improving customer-centric sales, marketing, and service activities. It not only automates these processes, but it also ensures that front-office apps boost customer satisfaction, resulting in improved customer loyalty (Kumar, 2010)

Patient relationship management and patient loyalty are well predicted by a nice medical environment, good communication, privacy and security protection. Patient relationship management aids in the development of patient loyalty and has a direct link to it (Fatima, Malik, & Shabbir, 2018). Improving patient loyalty has the ability to improve patient health outcomes by ensuring continuity of service, successfully reducing patient conversion behavior, and improving patient compliance. Increased patient loyalty can assist medical institutions develop a positive image and accomplish the effect of word-of-mouth communication (Rundle, & Russell, 2010). Hu et al. (2011) studied patient relationship management and patient loyalty in Taiwanese hospitals and discovered that patient relationship management had a significant impact on patient loyalty. Srivastava (2015) demonstrates that patient relationship management and consumer loyalty are linked. The impact of consumer happiness on consumer loyalty is influenced by the consumer’s life experience and cognitive processes. Mendoza (2014) found a link between patient relationship management and patient loyalty at CP Reyes Hospital in a later study. Patients at CP Reyes Hospital were quite delighted with the quality of care they received, according to his research.

Thus, hypothesis can be formulated as:

H3: Patient relationship management (PRM) positively and significantly affects patient loyalty

Mediating role of Patient Relationship Management (PRM)

PRM theory demonstrates that PRM implementation strives to care for and retain consumers in order to increase customer loyalty, which is profitable for the company. (Bergeron, 2002; Zikmund, 2003; Anderson et al., 2004; Turban, 2004; and Buttle, 2004) The implementation will not be successful until the corporate’s Service Quality is incorporated. It means that good service quality makes PRM implementation easier. If the company’s service quality is good, PRM implementation can be improved or strengthened.

Patients’ loyalty will be influenced by the quality of service provided to their closest friends, family members, and acquaintances, resulting in favorable word of mouth. Customer loyalty has a favorable impact on service quality (Parasuraman et al., 1988); Ketchand, 1998; Cronin & Taylor, 1992; Akbar & Parvez, 2009). Offered Service Quality will be able to strengthen/improve PRM implementation, whereas Sigala (2006) found that service quality has a favorable impact on PRM when studying hotel guests’ perceptions. The relation between Service Quality and Customer Loyalty can occur as a result of PRM. The impact of PRM on customer loyalty has a favorable effect on consumer loyalty (Agrawal, 2003). Ndubisi (2007), Tseng (2010), Reijonen and Laukkanen (2010) all corroborate this conclusion.

Customer relationship management and service quality are inextricably linked. They also believe that improving service quality through better service processes, service design processes, service productivity, and corporate culture will help customers stick around longer. (Mudie & Cottam, 2010)

A preposition can be written as follows:

H4: Patient Relationship Management (PRM) helps to mediate the influence of service quality on patient loyalty.

Moderating role Hospital Brand Image

A receiver’s view of a brand is based on their interpretation of the company’s identity and reflection of the company’s numerous features from numerous sources. People are concerned about the organization because of a complex interpretation of the brand image (D’astous & Gargouri, 2001; Flavian et al., 2004).

A powerful marketing program to the product, which is distinctive and has features that distinguish it from other items, can help to build a positive brand image. A powerful brand image for consumers can be created by combining aspects that support each other. According to Kotler (2003), different buyers may have various reactions to a company’s image or brand. Furthermore, according to Kotler and Keller (2006), the brand image is a collection of beliefs about the brand. The creation of the impression of being one of the basic characteristics of the marketing orientation that is through giving more attention as well as the creation of a strong brand is one of the basic characteristics of the marketing orientation that is through giving more attention as well as the creation of a strong brand is one of the basic characteristics of the marketing orientation that is through giving more (Fournier, 1998). Making it the brand of a product has the effect of creating an image of the product in the minds of consumers, as well as the underlying incentives for customers to choose a product. (Aaker, 1996)

Kumar and Thota (2014) investigated the impact of image quality health care on hospital image and found that the quality of services has a significant beneficial impact on the hospital’s image. The study’s findings also show that the hospital’s image has a favorable and significant impact on client satisfaction. In other words, improving service quality will boost the hospital’s image in the eyes of patients. Customer satisfaction will also rise as a result of this (Pai & Chary, 2013). Similarly, the satisfaction of patients with health services (Chaabouni & Abednnadher, 2014) and pharmacy services is determined by brand image research is conducted by (Srivastava & Kumar, 2014)

Brand image has been shown in several studies to have a direct and/or indirect positive impact on loyalty and behavioral intent. According to Merrilees and Fry (2002), brand image has a direct impact on loyalty. Loyalty, on the other hand, is indirectly affected by Brand Image through customer happiness, according to Davies and Chun (2002). Furthermore, Brand Image can affect Loyalty both directly and indirectly. Brand image is found to be a powerful predictor of client loyalty.

The image of the brand has become a special consideration for the customers to choose the items-service (Mowen & Minor, 1998), including service in a school (Li and Hung, 2008) and Hospital (Wu, 2011). This study further confirmed by Sirapracha & Toquer (2012), as well as by Sonmez (2014). From that research, the hypothesis might be made that the image of the brand it also will increase the loyalty of patients in the hospital.

The perception of a company’s brand is a significant influence in determining how good a service is (Bitner, 1991). There is sufficient evidence that image can have a substantial impact on a customer’s evaluative judgement, such as their sense of quality (Darden and Schwinghammer, 1985; Andreassen and Lindestad, 1998). Furthermore, Bloemer et al. (1998) looked at issues with the bank’s image and found that the bank’s positive brand image enhanced the perceived quality of service greatly. In other words, brand image is an important factor in determining service quality. A positive hospital brand image is likely to improve the quality of services provided to patients in the healthcare industry.

According to Andreassen and Lindestad (1998), visuals have a filtering effect on consumer satisfaction. In a similar vein, Davis et al. (2003) claim that brand image is linked to consumer satisfaction. The importance of brand image in ensuring consumer pleasure has long been recognized. As a result, hospitals with a favorable brand image tend to have higher patient satisfaction.
As an example, a preposition can be written as follows:

H5: The impact of service quality on patient loyalty is moderated by the hospital’s brand image.

Conceptual Framework:

Figure 1: Research Model

RESEARCH METHODOLOGY

Design of Research

Study Type

With the aim of investigating the causative relationship between elements including overall service quality, patient relationship management, hospital brand image, and patient loyalty, the study was categorized as a causality study based on the features of the problem.

Horizontal Time

The information is cross-sectional in nature and will be collected over the course of the research.

Analytical Unit

Patients in private and government hospitals in Islamabad/Rawalpindi serve as the research thesis’s unit of analysis.

Population and Sampling

Population of study

Patients in private and government hospitals in Rawalpindi/Islamabad who met five standards (Medical Care, Emergency Care, Administration Service and Management, Nursing Care, and Medical Record Service) were included in the study.

Sample Size

Convenient sample size was 300 patients from different hospitals.

Sampling approach

The sampling technique utilized in this study is Judgmental/ Purposive Sampling since the population is made up of patients from private and government institutions that have been accredited by five standards of care (Medical Care, Emergency Care, Administration Service and Management, Nursing Care, and Medical Record Service)

Scales & Measures

The scales of measurement will be use Likert scale 1=strongly disagree, 2= disagree, 3=neutral, 4= agree, 5=strongly agree and data was analyzed through SPSS.

Service Quality

In this study Service quality is the only independent variable. Health service quality provided by the hospital will be assessed on the basis of the parameters of the SERVQUAL method-based questionnaire. The parameters of SERVQUAL questionnaire namely reliability, assurance, tangibles, empathy, responsiveness. Questionnaire adopted was developed by Parasuraman (1988) and includes five sub-measures with three items each. There are total fifteen questions to assess service quality

Sample questions to measure the Assurance were 1. Special attention is given to emergency patients 2. Accuracy lies in Lab reports. 3. Doctor care their patients. For measuring Empathy 4. Doctors have genuine concerns about their patients 5. Staff and nurses care the patient.6. Doctors/staff observe the promised time. To measure Reliability 7. Patients are observed according to appointment 8. There is on time delivery of reports and services 9. Good Feedback mechanism is present. Another measure is Responsiveness 10. Doctors/staff efficiently respond to the patients 11. Doctors / staff are willing to help the patients 12. Hygienic conditions at hospital are satisfactory. Tangibility is measured by 13. Cleanliness in wards/rooms is proper 14. There is healthy environment at hospital 15. Waiting facility is available for attendants and patients

Patient loyalty

Patient Loyalty is used as dependent variable in the study. Three questions adopted from Zeithaml et al. (1996) study to measure the loyalty of patients which are: 1. This hospital is good 2. I will recommend this hospital to others 3. I will revisit the hospital to reuse the services

Patient relationship management

Patient relationship management (PRM) is used as mediator variable. Four questions adopted from study of Yaghoubi. M and Rahmati Najarkolaei. F (2014). Questions used to measure include: 1. Complaints are more than services provided 2. I am satisfied with the hospital 3. There is proper patient complaints management in the hospital 4. Patient satisfaction is top most priority of the hospital

Hospital brand image

Hospital brand image is used as moderator. First question adopted from the study Chitty et al. (2007) and remaining questions from study of Kayaman and Arsali (2007). Questions are 1. This hospital has good reputation 2. Hospital provides excellent facilities 3. Hospital has comfortable environment 4. I trust hospital facilities and services 5. Advance technologies are available in the hospital

Tool for Data analysis

The SPSS software is used to examine the data. The Preacher and Hayez approach is used for mediation analysis. To obtain the results, an overall analysis such as regression, correlation, reliability, and validity, as well as mediation moderation, is performed.

Variables in Control

During regression analysis, demographic factors were controlled using a one-way Anova.

Procedure to analyze data

First, the data is examined for missing values. After confirming that there are no missing values in the data, the data is assessed for outlier analysis. Second, a reliability analysis was performed to ensure that the scales were reliable. Finally, a frequency distribution study was performed, which included a review of the demographic information. To get a thorough picture of the results, descriptive statistics, correlation, and regression analysis
were used.

RESULTS & ANALYSIS

The outcomes of the data collection are explained in this chapter. The data is analyzed using SPSS software. The demographic summary, reliability analysis, correlation analysis, and regression analysis are all included in the analysis. To check the moderation analysis, stepwise regression is employed, and the preacher and haze approach is employed for mediation.

Socio Demographic Characteristics

This research looked at four different demographics. In the sections that follow, the summary of each demographic variable is presented in detail. They were also taken into account in regression analysis.

From a total sample size of 300, 54.7% of the participants were male and 45.3% were female, according to the analysis. This outcome is consistent with what was observed during the data gathering phase. The male population makes up the majority of the sample.

Responder’s Education

According to the target audience’s qualification distribution, 1.3% were matriculated, 29.0 % completed their inter, 48% had a bachelor’s degree, 20.7% had a master’s degree, and just 1% had a PhD.

Responder’s Age

In the current survey, 20.0% of the targeted audience were under the age of 25years or below, 36.7% of the audience were lies in 26-35 years of age, 26.0% were under 36-45 years and 17.3% of 46 years and above.

Table 4: Category of Visited Hospital

In current study, data collected from patients who visited either public or private sector hospital. Out of which 51.3% visited public sector while 48.7% visited Private sector hospital.

Reliability Analysis

The variables instrument reliability present in the model are included in the reliability analysis results. Patient relationship management shows .993 Cronbach alpha value, on the Service Quality Scale. 996, Patient Loyalty is presented with .974 Cronbach alpha reliability, and Hospital Brand Image has.994 Cronbach alpha reliability.

Table 5: Reliability Analysis

Analyzing Correlation

Correlation analysis is used to determine whether the variables are statistically significantly connected. The results are listed in the table below.

Table 6: Correlation table

The association between variables evaluated in this study, such as Service Quality (SQ), Patient Relationship Management (PRM), Patient Loyalty (PL), and Hospital Brand Image (HBI), is shown in the table above (HBI). Service Quality (.992), Patient Relationship Management (.995), and Patient Loyalty (.988) are all strongly positively connected with hospital brand image. Patient Loyalty has a.994** correlation with Service Quality, and a.993** correlation with Patient Relationship Management. At.996**, Patient Relationship Management is substantially linked with Service Quality. At the 0.01 level, all variables are positively associated with one another in the given model.

Analysis of Regression

Regression analysis is used to determine the relationship between the proposed model and the data. The regression analysis findings are presented in the following tables.

Table 7: Regression Results for Service Quality and Patient Loyalty

N=300, **p<0.01

The regression findings for the independent variable, Service Quality, and the dependent variable, Patient Loyalty, are shown in the table above. The results were obtained using linear regression. According to regression study, a one-unit increase in Service Quality will result in .994-unit increase in patient loyalty. Because the value of p is.01, the association between variables is statistically significant positive. The hypothesis is accepted based on the regression analysis results.

Table 8: Mediation regression analysis

Notes: Regression coefficients that are not standardised are presented. The sample size for the bootstrap is 1000.

The regression analysis findings utilising the Preacher and Hayes approach are shown in the table above. The direct influence of Service Quality (IV) on Patient Relationship Management is tested by following step-by-step mediation in the first phase (Mediator). At a beta value of 1.058, the results show a significant connection with a p.000. The impact of Patient relationship management (M) on the dependent variable patient loyalty is examined in the second stage, which reveals a significant association with a beta value of.823 at p.020. The influence of Service Quality (IV) on patient loyalty (DV) is examined in the third stage, with a beta value of 1.018 at p.000. The influence of Service Quality is still considerable with a p value of.000 in the final phase by controlling mediator findings.

The indirect effect is 0.6227, which ranges from.3094 to 1.0447, and both the LLCI and the ULCI have a positive sign, indicating that the results are significant. Patient Relationship Management strongly mediates the relationship between Service Quality and Patient Loyalty, according to this finding.

Moderated Regression Analysis

Table 9: Conditional Direct effect

To check the effect of hospital brand image as a moderator b/w service quality and patient loyalty, HAYES (2013) PROCESS regression was run. Model#5 was used to check the relationship of variables. Findings of the analysis show statistically significant results for the conditional direct effect and indirect effect through mediator.

In first step the conditional direct effect of brand image of hospital (HBI) on patient loyalty is 0.2407 with lower limit 0.1712 and upper limit 0.3243. The effect is said to be significant as charges of both LLCI and ULCI are alike i.e. positive. In next step by increasing the value of moderator the effect is also increased from 0.2407 to 0.5425 with ULCI and LLCI having positive values. In last step by increasing the value of moderator the effect is further increased. The results are said to be significant because the value of effect lie between the LLCI and ULCI and secondly the charges of both LLCI and ULCI are alike.

The findings support the hypothesis that hospital brand image moderates the influence of service quality on patient loyalty, and they support the hypothesis that hospital brand image moderates the influence of service quality on patient loyalty. It has been proven that the image of a hospital increases the link between service quality and patient loyalty.

Acceptance/ Rejection of Hypothesis

Table 10: Hypothesis summary

Accepted.

DISCUSSION & CONCLUSION

Discussion

Although there have been numerous researches using various constructs on Service Quality, Patient Relationship Management, Patient Loyalty, and Hospital Brand Image in the historical literature. However, with the mediating role of patient relationship management and the moderating role of Hospital Brand Image, there is relatively little emphasis dedicated to patient loyalty enhancement due to service quality. Patients who visited a public or private hospital accredited with five standards of care, including Medical Care, Emergency Care, Administration Service and Management, Nursing Care, and Medical Record Service, are being studied for the suggested hypothesized model.

With the mediating role of patient relationship management (PRM) and the moderating role of hospital brand image (HBI), the current study investigates the impact of service quality (SQ) on patient loyalty (PL) among hospitalized patients the information was gathered from patients and caregivers who came to the hospital. The statistical analysis was performed on the acquired data using SPSS, and the results are intriguing and will be detailed in the next part.

Hypothesis-1 (H1)

The correlation and regression results show the direct effect of service quality on patient loyalty. And the results prove that Patient loyalty is influenced by service quality in a positive and significant way (H1).

This study provides an opportunity to consider whether the quality of a patient’s perception has an impact on their loyalty to the hospital. Our findings show that patients ‘ experiences associated with hospital services have a significant impact on outcome variables, such as whether they are willing to return to the same hospital and use or suggest their services to others.
The findings of this study revealed a willingness to spread favorable word of mouth about hospitals, suggest them to others, and return to the same one.

The Hospital is the industry of social service-orientation. Service quality has an important role to increase the loyalty of their patients. Because hospitals in this day face intense competition, they should always seek to improve the quality of their services in order to promote patient loyalty and, as a result, raise earnings. Although the hospital is the social organization, the advantage is definitely needed for the survival of its business and the provision of the latest medical equipment.

Consistent with previous studies, the service dimension also has a clear impact on patient loyalty. (Dagger & Johnson, 2007; Kessler & Mylod, 2011). The process of care is considered to be a decisive factor in forming a patient’s perception of the quality of service. Patients often expect their hospitals to provide timely, convenient, effective and professional services (Choi et.al, 2005). Therefore, hospitals should design an efficient scheduling system and are committed to providing impeccable and punctual service.

Based on Parasuraman et al. (1988), prior researchers, these findings empirically verified the concept of customer loyalty. The fact is that the quality of service has a direct impact on client loyalty. This means that in other businesses, there is a link between service quality and client loyalty.

Cronin et al., 2000), which performs research on the quality of service linked with loyalty, found that the findings were consistent with earlier research. They are aware of the quality of direct services and have a big impact on customer loyalty. Cronin et alfindings.’s (2000) back up Atkins et al (1996).’s study, which found that quality service hospital nurses have a high association with patient loyalty in the Midwest Hospital. In the telecoms industry, Akbar and Parvez (2009) investigated whether a company’s quality service record had a major impact on customer loyalty.
According to the current findings, the interpersonal-dimension has a considerable impact on patient loyalty, which is consistent with study (Bosh off and Gray, 2004). Previous literature points to the importance and positive impact of the interpersonal dimension of quality of service on patient loyalty (Dagger & Johnson, 2007; Kennedy, 2008). The results of a study in Greece showed that the compassion of staff and doctors towards mothers in the delivery room had a strong and significant impact on their willingness to recommend hospitals to others (Chaniotakis, 2009). Lis et al. (2011) found that as individuals caring for patients and helping them understand their condition had an impact on their willingness to recommend a medical center to others. Therefore, the doctor / person must inform the patient of their illness and condition, answer their questions, understand and pay attention to their emotional and social needs, and provide it to them when needed.

Hypothesis-2 (H2)

Regression result shows service quality positively and significantly affects patient relationship management (H2). Results above revealed positive correlation between patient relationship management (patient attraction, patient value, patient retention, and patient knowledge) and services quality of hospital services.

Quality of services shown to improve PRM system including complaint management, patient satisfaction and patient priority. As better services deal patient queries more efficiently. Concern of employees towards patient care ultimately affects positively and significantly patient relationship management

Patients are more satisfied when they believe their health care providers care about them and devote extra attention to them, according to one study. Patient satisfaction is also influenced by the physical facilities, equipment, and appearance of doctors and other employees. Patients will be happier with health care if providers are willing to support them and provide timely treatment, according to the Institute. This discovery is in line with earlier research (Remez, 2012; Mostafa, 2005)

Surprisingly, studies conducted in small groups and individual practice clinics have found that the impact of doctors’ knowledge, courtesy, and ability to convey trust and confidence (the assurance dimension), as well as the ability to reliably and accurately deliver committed services (the reliability dimension), on patient relationship management. While assurance and reliability have a smaller influence than compassion and physical features, this does not mean they are unimportant or should be overlooked when it comes to increasing the quality of medical services (Lin, Xirasagar & Laditka, 2004). It is only suggested that more level of patient satisfaction is be achieved by focusing on empathy and tangible aspects in the environment of government hospitals.

Customer relationship management is important because it is an indicator of quality of service. If the customer is not satisfied, it may be because their needs have not been met for some time. Customer service support is often the voice and face of a business when a customer interacts with a business that they expect to get a quality product or service. Therefore, it is important for customer service support to make a good impression and remain calm and professional even when dealing with difficult or unreasonable customers. Customer relationship management can be achieved by clearly defining customer service policies. In the long run, a well-defined customer service policy will save the company a lot of time and effort.

Hypothesis-3 (H3)

As per regression result, it is proved that patient relationship management is positively associated with patient loyalty. The findings suggest that patient relationship management influences patients’ inclination to return to the same hospital and reuse services, to have a favorable image of the hospital, and to refer the hospital to others.

Rao et al. (2006) found that patient relationship management is influenced by access to healthcare services, the hospital environment, and the supply of information to patients in their study. By using the PRM system, the collective intelligence of hospital units is likely to improve to a large extent. For hospitals, this means that doctors will be able to better their work by developing a personal understanding of their patients and coworkers. In case of patients, it means that it is possible to express how the treatment will operate on them, which, ideally, will lead to better care in the long run.

Previous research has shown that patients who are loyal to the hospital have a positive view of the facility, which is the most effective strategy to maintain existing patients and attract new patients (Bush,2004; Rahayu,2017). Patient relationship management enhances patient satisfaction and the higher the patient satisfaction, the longer the patient loyalty (Cardozo, 1965). The degree to which patients are unaffected by external conditions and marketing initiatives, are satisfied with hospital services, and are prepared to spend in
the future is referred to as patient loyalty.

Hospital inpatients have a high level of overall happiness, and there is a link between PRM and loyalty. Hospitals can improve the image of medical personnel, improve the quality of medical service, increase inpatient satisfaction, and foster inpatient loyalty (Wang, Li, Zhao, & Yin, 2017)

PRM is a significant indicator of organizational performance metrics, as satisfied patients eventually become loyal (Moreira, & Silva, 2015). Patient relationship management has a beneficial impact on patient loyalty to the medical profession, according to a quantitative research of 195 patients at six public and private hospitals in Bangladesh (Hossain, Yahya, & Khan, 2019).
Patients are attracted to clinics and institutions, which nurture and create relationships with them. Commitment, trust, and communication can all be used to assess the clinic/relationship hospitals with the patient. This relationship is linked to loyalty, as evidenced by a strong positive opinion about the institution, a willingness to defend it, and frequent patronage. (Rostami, Ahmadian, Jahani, & Niknafs, 2018).

Hypothesis-4 (H4)

The preacher and Hayes technique was used to assess the mediation of patient relationship management between service quality and patient loyalty (H4) in regression analysis. Patient connection management strongly mediates the association between service quality and patient loyalty, according to the regression analysis, implying that patient relationship management is an essential predictor of patient loyalty.

Increase the quality of service denotes the confidence of the patient to the hospital and healthcare workers is increasing this is due to all the dimensions of quality as a form of quality of service.
According to a study, service quality has a favorable and considerable impact on customer loyalty with patient satisfaction as a mediation on an inpatient in a Hospital Jati Husada Karanganyar. Also stated it is not much different from that service quality has an impact on customer loyalty indirectly through customer satisfaction (Randa, Yulianti, 2019) The higher the quality service will be the higher the level of patient relationship management, and patient relationship management will create a loyal customer (As’ad, 2013; Randa, 2014)
Patient relationship management can be characterized as hospital professionals who work with care and take initiative to act swiftly and properly to meet the demands of patients. This will provide patients a positive impression of the hospital and allow them to assess the quality of service, which will lead to patient retention. As a result, service quality should begin with the customer’s needs and finish with the customer’s perspective (Kotler, 2010). Furthermore, Lewis and Booms (2007) propose that quality of service can be measured by meeting customer expectations as a measure of the extent to which a given level of service can meet customer expectations.

Patient relationship management can be achieved if the accuracy and speed of the service supplied (responsiveness) exceeds the patient’s expectations. Patient relationship management denotes that patients have experienced the benefits or positive outcomes of these services. This demonstrates how the level of service offered can have an impact on the patient’s feelings since it can make the patient feel as if he is cared for, neglected, and is intended to create a sense of safety, comfort, and satisfaction. On the other hand, if medical or non-medical employees perform services at a slow pace, lack initiative, and the work assigned is inappropriate or unresponsive, discontent might result. Patient discontent arises when the needs of the patient’s wishes are not met by the patient’s expected appearance, resulting in unhappiness. Furthermore, the findings of this study support many other studies’ conclusions that there is strong loyalty to service quality. (Aykac et al., 2009; Markovic et al., 2014; Arsanam & Yousapronpaiboon, 2014; Pouragha & Zare, 2016)

Low quality of care, on the other hand, might cause patients to become unsatisfied as a result of bad patient relationship management, leading to patients switching to other hospitals and abandoning their allegiance. The findings of this study corroborate prior research by Mendoza (2014) and Srivastava (2015), which found that the impact of service quality on loyalty is mediated through patient relationship management. Based on the foregoing study, it is clear that improving service quality leads to patient relationship management, which in turn leads to increased patient loyalty.

Based on these findings, it can be concluded that the study can give empirical proof that the PRM is a variable intervention that serves to mediate the ideal relationship between service quality and customer loyalty. Furthermore, decision makers are concerned about boosting patient loyalty in the hospital in order to consistently increase patient satisfaction because it has a beneficial impact on promoting patient fidelity.

Furthermore, the findings of this study complement those of Caruana (2000), Cronin et al. (2000), Guenzi and Pelloni (2004), and Kerti Yasa (2011), who investigated how service quality influences customer loyalty via customer satisfaction. The findings on the relationship between service quality and client loyalty are expanded not only through consumer satisfaction, but also through CRM adoption. This revealed that CRM can boost customer satisfaction and has a favorable impact on the link between service quality and customer loyalty.
Based on the theoretical underpinning and actual realities, it is vital for hospital management to improve the quality of service and boost the implementation of the PRM in order to boost patient loyalty.

Hypothesis-5 (H5)

The impact of service quality on patient loyalty is moderated by hospital brand image, according to regression results (H5). The latest findings are in line with earlier research findings (Andreassen, & Lindestad, 1998; Wu, 2011).

The impact of hospital brand image on revisiting intentions demonstrates not only that image is important in determining service quality, patient happiness, and loyalty, but also that hospital brand image has a direct impact on revisiting intentions (Wu, 2011). The perception of a hospital’s brand is seen to be a strong predictor of patient loyalty. Clearly, the image of a hospital is important in terms of boosting service quality, patient satisfaction, and patient loyalty.

A positive hospital brand image will increase patient service quality at first. Then, as service quality improves, patient happiness rises, resulting in increased patient loyalty. Bloemer et al. (1998) discovered the mediating influence of service quality and satisfaction in the relationship between brand image and loyalty, and this result is consistent with their findings. Brand image influences satisfaction through service quality, and service quality influences loyalty through satisfaction. These findings are also in line with previous research that has shown that brand image has a direct impact on loyalty. (Merrilees & Fry, 2002).

The hospital’s image is the customer’s impression of the hospital. When customers have a good impression of a hospital, their satisfaction with the services provided by the hospital increases. This result supports the results of Lai et al., (2009); Hu & Huang (2011); Hidajahningtyas et al., (2013); and Juhana et al.,, (2015) Indicates that the company’s image has a positive influence on customer satisfaction.

Another aspect that influences patient loyalty is hospital familiarity, which is gained through referrals from doctors, family members, friends, and other patients, as well as media advertisements. Patients who were familiar with the hospital through their families had more loyalty than those who were recommended to the hospital by their doctors, according to the findings.

The influence of quality of service on patient loyalty is moderated by hospital’s brand image. This is because if the patient believes that the hospital has a good image, then the patient will be loyal to the hospital. Companies with a good image in the minds of customers will attract customers to use the same service provided by the same company, make a re-purchase, and recommend the service to others. This conclusion backs up Wu (2011) and Chung et al., (2015), who discovered that a company’s image had a favorable impact on customer loyalty.
In Kenya, Tarus and Rabach (2013) investigated corporate image as a regulatory variable that improves the association between service value, service quality, customer loyalty, and social stress variables. The findings demonstrate that the influence of the link between these variables is strengthened by corporate image.

Conclusion

With the mediating role of patient relationship management and the moderating role of hospital brand image, the current study examines the effects of service quality on patient loyalty among patients who visited the hospital. Quality of service is a multidimensional construct with several variables that reflect it. This is proven in a secondary confirmation analysis of quality of service variables, where tangible, reliability, responsiveness, empathy, and assurance structure are all essential components. This means that the following five elements of service excellence are reflected: tangible, dependable, responsive, stressed, and guaranteed. The highest physical and empathetic dimensions are embodied in the highest level of service quality.

The following conclusions can be drawn based on the phrasing of the problem, objectives, theoretical foundation, assumptions, and test results:

1. Patient relationship management is influenced by service quality in a favorable and important way. This means that improved service quality will be complemented by improved patient relationship management and a higher percentage of satisfied customers.
2. Patient relationship management affects patient loyalty in a favorable and meaningful way. This indicates that higher levels of patient pleasure and relationship will be matched by greater levels of patient loyalty.
3. Customer service quality has a positive and significant impact on patient loyalty, implying that improved customer service quality would be followed by increased patient loyalty.
4. The impact of Service Quality on patient loyalty is mediated through patient relationship management. As a result of this finding, patient relationship management can be used to explain why service quality affects patient loyalty. Patient relationship management will improve as service quality improves, and patient loyalty will increase as patient relationship management improves.
5. The impact of hospital quality of service on patient loyalty is moderated by hospital brand image. High image is supposed to influence the customer’s opinion of the company’s product or service, and is measured by the hospital’s reputation and standing. The image of a hospital strengthens the service quality connection with patient loyalty

Implications

This study examine the model combines the brand image of the hospital, quality of service, relationship management of the patient, and loyalty. In this study, five research hypotheses were shown to be valid. The findings of this study can assist hospital managers in better understanding the inter-connection between the hospital’s image, quality of care, patient relationship management, and re-visitations, as well as a mechanism to promote patient fidelity. Furthermore, the findings support the study of hospital management and related issues in general. The following are some of the conclusions taken from the findings.

Firstly, quality of service, act as the primary replacement in the integrated model. Service quality can directly affect the re-visitations through the relationship management of the patient. In this scenario, the service quality is a very effective vehicle for improving patient relationship management, which enhances patient loyalty. Hospital manager should plan and implement a strategy to ensure a patient-oriented medical services and expect this strategy will lead to the higher management of the patient relationship and loyalty. Strategy for providing services Patient management is critical to providing high-quality medical care, and it should be done in a multi-faceted manner that includes assurance, empathy, tangibility, reliability, and cooperation.
It is critical to assure the patient that they will receive the desired amount and quality of service at the time they were admitted to the hospital. To acquire the trust of hospital patients, all medical professionals should demonstrate professionalism, technical competence, success, and respect. In order to address the issue of empathy, medical personnel must emphasize soft performance abilities such as offering personalized attention, understanding of the patient’s requirements, and addressing concerns, among others. Being prompt and attentive to the patient’s request, as well as communicating with them honestly, is a key component in the delivery of medical services. In terms of dependability, medical staff must put forth effort in providing accurate and dependable medical services, such as registration, therapy, post-treatment care, and patient follow-up. In terms of tangibles, hospitals should make an effort to provide and maintain a clean environment.

Hospital management is required to increase service quality in real-world areas, particularly in terms of facilities and employee performance. In terms of who can be trusted, the hospital’s administration is expected to maintain commitments that have been made previously, and staff are expected to handle problems as soon as possible. On the part of the Hospital Management, it is anticipated to improve the speed with which the staff provides service and the taste of the Patient Assistance when necessary. The finest of the hospital’s management is intended to boost patients’ sense of security and confidence in the treatment they are receiving. In terms of empathy, the hospital’s management is supposed to apologies promptly when a patient complains and to increase the patient’s understanding and needs.

Finally, the hospital’s image serves as a moderator in the integrated model. The hospital’s brand image not only encourages patient loyalty, but also increases customer satisfaction through perceived increased service quality, which leads to the patient’s intention to return. In a competitive health market, hospitals should concentrate their marketing efforts on successful brand management. The hospital manager, in particular, should devote more time and effort to enhancing the facility’s favorable image. Managers must completely comprehend the need of developing a favorable brand image for the hospital in order to improve perceived service quality and patient happiness, which in turn generates patient loyalty.

Limitations:

Each study has its own set of constraints and requires more resources in other areas. Other researchers will need to address some of the limitations of the current study in the future.

1. For starters, the hospital offers a wide range of medical treatments.
2. Because this study was conducted in a private and government hospital in Rawalpindi and Islamabad that was accredited by five standards of care, the findings may not be applicable in other settings.
3. Second, several key factors that may influence patient loyalty are not taken into account in the existing paradigm, such as trust, image, strategy, customer value, and product superiority.

Directions for Future Research:

1. Future study is expected to broaden the object’s scope.
2. Future researchers will be expected to obtain data from larger samples.
3. The number of study variables utilized to forecast patient relationship management is projected to grow in the future.
4. In the future, an integrated model can be repeated in many types of hospitals or other settings to ensure that the candidates are qualified. In addition, because there are few studies that use hospital brand image as a variable, the extra construction can be included in the model to determine their link with the hospital’s brand image.

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APPENDIX 1: QUESTIONAIRE

Dear Respondent!

I am a student of Riphah International University (RIU) Islamabad and doing this survey as I am working on my thesis entitled “Impact of Service Quality on Patient Loyalty with Mediating Role of Patient Relationship Management and Moderating role of Hospital Brand Image”.

These questions require answers based on your experiences while visiting any health care facility either government or private Hospital. Your answers will be kept strictly confidential and will be used only for research purpose. Your identity will be not disclosed on this document so kindly give an honest opinion to make this research unbiased.

You are requested to take 10 minutes out of your busy schedule to fill this questionnaire. Although you are not bound to answer these questions and at any point in time, you can quit answering but still I will be privileged by your opinion in this research work. If you need findings of this research, please order a copy at muneebarazzaq6699@gmail.com. Once again thanks for your precious time and cooperation Regards, Muneeba Razzaq

Research Scholar

Please tick the appropriate answer

SECTION-1

DEMOGRAPHICS