Factors affect to relationship marketing for creating customer loyalty in hospital services business

91
ASEAN Marketing Journal • Vol. X • No. 2 • 2018 • 91-108
ABSTRACT
Manuscript type: Research paper.
Research Aims: The purpose of this paper is to understand and answer problems from the
variables of service quality (interaction quality, physical environment quality, & outcome
quality), customer trust, customer value, and customer loyalty to hospital consumer that has
applied JCI standard accreditations through green hospital concept.
Design/methodology/approach: The study uses a descriptive research design, with 209 valid
respondents. SPSS is used to pretest the variables that well construct variables, and SEM to
analyze significant construct variables and influence the construct variables.
Research Findings: There study findings are: 1) interaction quality, physical environment
quality, and outcome quality positively influences customer trust; 2) customer trust positively
influences customer value; 3) customer value positively influences customer loyalty; 4) customer
trust negatively influences customer loyalty; and 5) the mediating effect of customer value
positively influences customer trust and customer loyalty in high to a great extent, so it can have
a full mediating effect.
Originality/value: The study is one of the few empirical investigations into service quality
based on customer trust, customer value, and customer loyalty in the healthcare industry that
implements the green hospital concept, builds long-term relationships between customers and
medical staff, and the healthcare is doing the examining the mediating effects of customer value
on customer trust and customer loyalty.
Practitioner/Policy Implications: This study can explain customer trust, customer value,
customer loyalty based on hospital services quality through relationship marketing. Hospital
has been applied JCI standard accreditation through green hospital build long-term relationship
for their customer and good businesses for its hospital.
Research limitation/Implications: The research results indicate that service quality is the basic
step in increasing customer trust, customer value and customer loyalty in hospital management.
The findings of the study will help hospital management to 1) build relationships between medical
staff and their customers, and create customer loyalty in long-term relationships, 2) to develop
and implement the green hospital concept based on Joint Commission International standards
within a green marketing framework.
Keywords: Service Quality, Customer Trust, Customer Value, Customer Loyalty, Relationship
Marketing, Green Marketing, JCI accreditation.
FACTORS AFFECTING RELATIONSHIP MARKETING IN CREATING
CUSTOMER LOYALTY IN THE HOSPITAL SERVICES BUSINESS
Iqbal Afifi1
Master Management of Marketing, University of Indonesia
Jakarta, Indonesia
iqbalafifimmui@gmail.com
Ahdia Amini2
Master Management of Marketing, University of Indonesia
Jakarta, Indonesia
ahdiaamini.mmui@gmail.com

92 Iqbal Afifi et al. / ASEAN Marketing Journal © December (2018) Vol. X No. 2
INTRODUCTION
Today, the healthcare industry, especially
hospital businesses, is growing significantly
in Indonesia. The industry is improving in
six areas: Indonesian people’s expectations
for a healthy life; rival hospital business;
hospital accreditation standards; relationship
marketing between hospital management
with their customers, and hospital standards
for global accreditation (Anna, 2012; BMI
Research & Healthcare, 2016; Depkes Editor,
2012; JCI, 2017; Nielsen, 2017; Siloam
Hospital Editor, 2017).
Nowadays, Indonesian people needs problem
solving for diseases, which has been
happening through promotive and preventive
action. These actions are executed to make
people understand the importance of a healthy
life and their needs to protect their health,
because maintaining health is more difficult
than curing diseases (Noviana, 2013).
Nowadays, Indonesian people needs become
hospital business trend to increase their
quality of service following the growth of the
hospital business in Indonesia and globally.
Hospital businesses in Indonesia and globally
have applied JCI standard accreditation to
hospital management, which shows their
service quality in creating customer loyalty
in long-term relationships. The Indonesian
government has planned to apply the green
hospital concept by 2020 for all hospitals in
the country.
It is hoped that have national standard
accreditation will improve their service
quality to JCI (Joint Commission
International) accreditation with the applied
green hospital concept (Depkes Editor,
2012). The Indonesian government has been
collaborating with the JCI organization in 26
hospitals, and the Global Green Healthy and
Hospital, with three hospitals being members
since 2008, both government hospitals and
private hospitals. JCI accreditation can be
adopted to national standard accreditation
and has been applied since 2011 (Green
Hospital Editor, 2015; JCI, 2017). The goal
is to improve hospital service quality, and run
green campaigns for each hospital activity.
Dr. Lia G. Partakusuma from Fatmawati
hospital and Perhimpunan Rumah Sakit
Indonesia (PERSI) at the Green ICT
Conference explained the criteria for green
hospitals cited based on JCI Accreditation
2008 to develop hospital accreditation in
Indonesia (Marketeers Editor, 2011c). The
green hospital concept is part of green
marketing development, whose purpose is to
reduce the environmental effect of goods and
services delivered by companies throughout
their organizations (Marketeers Editor,
2011b). Five hospitals in Indonesia have
applied the green hospital concept: Ciputra
hospital, Persahabatan hospital, Prof. Dr.
Soerojo hospital, Umum Pekerja hospital,
and Siloam hospital (Adhi, 2010; Alexander,
2015; Asril, 2014; Chandra, 2011; Kompas
Editor, 2008).
The results from the study by Lien, Chen and
Wang (2014) show that service quality in
hospitals in Taiwan can influence the level of
trustbetweenpatientsanddoctorsandnurses.In
Indonesia, the Bandung government arranged
a competition to celebrate the 204th Bandung
anniversary, with appreciation of public
facilities which provide services to people,
with categories such as good services, clean,
comfortable, and facilities. Four hospitals won
the competition: Hasan Sadikin hospital (1st),
Santosa hospital (2nd), Rajawali hospital (3rd),
and Al Islam hospital (4th) (Kuswandi, 2014).
Indonesian people value hospital services that
delivered to consumer, clean, comfortable, and
their facilities.
However, the green hospital concept that has
been applied by hospitals in Indonesia does
not fulfil Indonesian needs, with high prices
of medical services, information technology
problems,Indonesianpeople’strustofmedical
treatment in foreign countries, and abuse
of green building certification (Adhi, 2010;
Djumena, 2012; Latief, 2013; Marketeers
Editor, 2011a). Based on these four problems
in relation to the green hospital concept in

93
Iqbal Afifi et al. / ASEAN Marketing Journal © December (2018) Vol. X No. 2
Indonesia, marketers intend to investigate and
solve the problems and implement the results
in line with Indonesian needs and the hospital
business.
In this research, the service quality variable
is used to examine and solve the problems of
the price of medical services, information
technology, Indonesian people’s lack of belief
inmedicalservices,andabuseofgreenbuilding
certification. The customer trust variable is
used to examine and solve the problem of
the price of medical services, Indonesian
people’s lack of belief in medical services,
and abuse of green hospital certification. The
customer value variable is used to examine
and solve the problem of Indonesian people’s
lack of belief in medical services, the price of
medical services, and abuse of green hospital
certification. The customer loyalty variable
is used to examine and solve the problem
of abuse of green hospital certification, and
Indonesian people’s trust in the relationship
marketing concept for medical treatment in
the hospital business.
The focus of this research is on solving four
problems related to the green hospital concept
in Indonesia. The research objective is the
consumer, who knows that hospitals have
applied JCI standard accreditation through
their medical services facilities. The detailed
formulation of the research is as follows:
1. Does service quality based on interaction
quality influence customer trust?
2. Does service quality based on physical
environment quality influence customer
trust?
3. Does service quality based on outcome
quality influence customer trust?
4. Does customer trust influence customer
value?
5. Does customer value influence customer
loyalty?
6. Does customer trust influence customer
loyalty?
7. Does customer trust influence the
mediating effect of the relationship
between customer trust and customer
loyalty?
LITERATURE REVIEW
Green Marketing
The growth of the population and
industrialization have put pressure on the
environment,infrastructure,andtheavailability
of resources to increase need of consumer
findingenvironmentally(Khandelwal&Yadav,
2012). The green marketing concept has been
developed since 1980-1990 through papers in
the marketing journal Journal of Marketing
Management (Peattie & Crane, 2005).
According to Polonsky (1994), green
marketing is consistent from all activities
that design services and facilities to satisfy
human needs and wants without impacting
on their environment. According to the
American Marketing Association (AMA),
green marketing (based on social marketing
definition) is the development and marketing
of products designed to reduce the negative
physical impact on the environment or to
improve its quality (American Marketing
Association Editor, 2017a).
Marketers and consumers are increased their
sensed to fulfil their needs for environmental
of goods and services (Peattie, 2011).
Green Hospitals
The green hospital concept has been
developed in the United States by the U.S.
Green Building Council (USGBC), with
standard application of Leadership in
Energy Environmental Design (LEED) in the
construction of buildings (Alexander, 2013).
The concept in Indonesia has been developed
by the Green Building Council Indonesia
through green building standard criteria, such
as reducing pollution, energy usage, and put
on proper environmental to consumer (Latief,
2013). The development of Joint Commission
International (JCI) accreditation builds on
the objective of the green hospital concept
to increase the service quality of hospitals
and the green concern applied by hospitals
(Marketeers Editor, 2011c).

Green hospitals have become one of the
means to fulfil the medical treatment industry,
appropriate to people’s needs. People’s needs
with regard to the medical industry include
satisfaction with the service, security, comfort,
and the guarantee that customers will not suffer
a negative impact from the service activities.
PERSI respect connection with the problem
is related to service quality, patient safety,
and environment problems. PERSI attention
and commitment towards the environmental
problems in hospital have included the
development of the Green Hospital committee
since 2009 (Pdpersi Editor, 2011b).
Depkes (2012) explains that a green hospital
is one with green insight and is responsible
for the service needs of hospital customers,
including a comfortable and safe hospital
environment. A green hospital is structured
with facilities such as recycling, reuse of
materials, reduction in waste, and production
of clean water (Pdpersi Editor, 2011a).
StandardassemblingconceptofJCIaccreditation
through the green hospital concept with its goals
of patient safety, quality of care, improvement
in quality, and reduction of patient risk (Green
Hospital Editor, 2015; JCI, 2017).
Relationship Marketing
According to Gronroos & Annika (2002),
relationship marketing fosters the relationship
between the company and consumers in
small scope of environment to create stable
customer loyalty, provide profit for each other,
and a long-term relationship. According to
the American Marketing Association Editor
(2017b), relationship marketing is marketing
with awareness of developing long-term
control or trust related to customers,
distributors, suppliers, or other partners in the
marketing environment.
Service Quality
Service quality is the evaluation by consumers
of overall long-time service and rating of
the performance of the service provider
(Hoffman & Bateson, 2001). Since 1985-
1988, Parasuraman et al. have developed a
measurement of service quality called the
SERVQUAL model, with five dimensions:
reliability, dependability, interaction
capability, assurance and empathy. The
SERVQUAL model rates service quality
in order to differentiate between consumer
expectations and perceptions (Parasuraman et
al., 1985; Parasuraman et al., 1988).
According to Brady & Cronin (2001), the
service quality model has been developed based
on three main dimensions: interaction quality,
physical environment quality, and outcome
quality. The Brady & Cronin model bases the
evaluationofservicequalitybasedonthreemain
dimensions. Interaction quality is a functional
quality which indicates the interaction between
employee and consumer. Physical environment
quality is the influence from the surrounding
environment that showed toward service to
consumer. Outcome quality is technical quality
related to facilities that consumers receive for
evaluation after services have been delivered
(Lien et al., 2014; Wu et al., 2016).
A previous study found that interaction
quality and outcome quality positively
influence trust, but that physical environment
quality non-significantly and negatively
influences patient trust in 15 general
hospital in Taiwan (Lien et al., 2014). In the
green hotel business in Taiwan, interaction
quality, physical environment quality, access
quality, and administration quality positively
influence green experiential quality, but
outcome quality negatively influences green
experiential quality (Wu et al., 2016). Based
on previous studies, this study argues that in
the healthcare industry and services business,
service quality will positively affect customer
trust in hospital business services. It is
therefore hypothesized that:
H1: Interaction quality positively influences
customer trust.
H2: Physical environment quality positively
influences customer trust.
H3: Outcome quality influences customer
trust.

95
Customer Trust
Consumer trust is the expectation of
consumers that service providers will be
reliable and trustworthy when delivering
their promises (Sirdeshmukh et al., 2002).
According to Chen et al. (2015), green trust is
the willingness to depend on a product, service
or brand based on the belief in or expectation
of its credibility, benefit and skill, including
its level of being environmental friendly.
Aprevious study found that trust in an original
hospital positively influenced trust in allied
hospitalsin15generalhospitalinTaiwan(Lien
et al., 2014). In the retail services business
in the USA, FLE (Frontline Employee) trust
positively influences value (Sirdeshmukh et
al., 2002). In the electronic product business
in Taiwan, perceived green value positively
influences green trust (Chen, 2013). Based
customer trust will positively affect their
trust in hospital business services. The study
therefore hypotheses that:
H4: Customer trust positively influences
customer value.
Customer Value
Value is the consumer perception of profit
minus costs to maintain a relational bond with
service providers (Parasuraman et al, 1988).
According to Woo and Kim (2015), customer
value is the difference between the total profit
and total sacrifice perceived by consumers
when they buy goods or services.
According to Sweeney & Soutar (2001),
there are three dimensions of value
consumption: emotional value, functional
value and social value. Emotional value
is the feel/preference stage in customer
experience, or the anticipation experience
when customers consume a company’s
goods or services. Functional value is the
value connected with practical gain or user
technical obtained from goods or services.
Social value is need gives from product
skills to improve the individual social
concept (Sweeney & Soutar, 2001).
A previous study found that value positively
influencedloyaltyintheretailbusinessinUnited
States of America the USA (Sirdeshmukh et
in Taiwan, perceived green value positively
influences green loyalty (Chen, 2013). Based
customer value will positively affect customer
loyalty in hospital business services. It is
therefore hypothesized that:
H5: Customer value positively influences
customer loyalty.
In this study, customer value is predicted to
influence the mediating effect of customer
trust on the customer loyalty relationship.
Perceived value for consumers is an important
factor that influences purchase intention,
satisfaction, and loyalty to specific service
providers (Brady & Robertson, 1999; Cronin,
Brady & Hult, 2000)
A previous study found that value positively
mediating effect of trust with loyalty
relationship as partial mediating effect in the
retail business in the USA (Sirdeshmukh et
in Taiwan, green trust positively mediating
effect of green perceived value with green
loyalty relationship as partial mediating effect
(Chen, 2013). Based on previous studies, this
study argues that in the healthcare industry
and services business, customer value will
positively mediating effect between customer
trustwithcustomerloyaltyinhospitalbusiness
services. The study hypothesizes that:
H7: Customer value positively influences
mediating effect of the relationship
between customer trust and customer
loyalty.
Customer Loyalty
Loyalty is the commitment level to repurchase
goods or services consistently in the future
(Oliver, 1999). Consumer loyalty has been

96
Figure 1. Research model
indicated by the intention to display different
behavior with motivation signs to develop
relations with local companies, including
allocation of their profit for specific provider
services, positive word-of-mouth, and
repurchases of services (Zeithaml et al., 1996).
Greenloyaltyistheintentionleveltorepurchase
influenced by a strong environmental attitude
and sustained commitment to objectives such
as goods, services, companies, brands, and
groups(Chen, 2013).
In this study, customer trust is shown to
influence customer loyalty. A previous study
has found that trust positively influences
loyalty in the retail business in the USA
(Sirdeshmukh et al., 2002). In the hospitality
industry in Spain, green trust positively
influences green loyalty (Martínez, 2015).
In the electronic product business in Taiwan,
green trust also positively influences green
loyalty (Chen, 2013). Based on previous
studies, this study argues that in the healthcare
industry and services business, customer
trust will positively affect customer loyalty
in hospital business services. It is therefore
hypothesized that:
H6: Customer trust positively influences
customer loyalty.
RESEARCH METHOD
Research Framework
The study uses descriptive research to explain
the hypotheses. The research framework
consists of three dimensions of service quality
(interaction quality, physical environment
quality, and outcome quality), customer
trust, customer value, and customer loyalty.
The mediating effects of customer value
on customer trust and customer loyalty are
investigated. The conceptual framework is
shown in Figure 1.
Research Sample
The research is empirically based on primary
data collected from all types of hospitals
located in Indonesia. The survey was
conductedfromOctober27,2017toNovember
19, 2017. A background explanation of
JCI standard accreditation is given within
the online questionnaires to ensure that the
respondents understand the content and
answer the questions correctly. The samples
werecollectedbythejudgmentalsamplingand
snowball sampling techniques, through which
the participating respondents were asked to
recruit more potential participants from within
their networks. The participants could answer
the survey questions based on their experience
of hospital services in Indonesian hospitals.
The samples were collected through an online
survey using Google forms, which needed a
minimum of 200 responses to run the SEM
(Structural Equation Model) method, based
on Malhotra (2010). This research obtained
a total of 352 samples (211 responses were
samples which are 209 valid samples and 2
invalid samples, while 141 responses were
not used as samples because not meet the
requirement). The respondents that knew
about standard accreditation for hospitals
based on JCI, as well as service quality, and

97
Table 1. Demographic Profile of Samples
Variable N (%) Variable N (%)
Hospital with JCI accreditation
Yes
No
211
141
60
40
Payment
Private/family
Company
Assurance
BPJS
Other payment type
79
29
34
64
3
38
14
16
31
1
Type of hospital visited
Government
Private
62
147
30
70
Gender
Male
Female
73
136
35
65
Purpose of hospital visit
Medical examination
As patient
As patient’s family
Visitor to patient
Patient references from other
hospitals
Surgery
Other purpose
58
44
63
34
3
3
4
28
21
30
16
2
1
2
Age
< 21 years
21 – 25 years
26 – 30 years
31 – 35 years
> 35 years
28
88
49
15
29
13
42
24
7
14
Frequency of hospital use a year
1 time
2 – 3 times
3 – 4 times
4 – 5 times
> 5 times
64
82
25
6
32
31
39
12
3
15
Occupation
Student
College university
Employee
Entrepreneur
Housewife
10
83
76
16
24
5
40
36
8
11
Medical facilities
Policlinic
Medical checkup
Pharmacy
Emergency
Endoscopy
Physiotherapy
Radiology
Hemodialysis
Laboratory
Rehabilitation medic
Other facilities
94
45
2
18
6
6
1
1
6
13
17
45
22
1
9
3
3
0.5
0.5
3
6
8
Average annual expenditure
(rupiahs)
≤ 1.000.000
1.000.000 – 3.000.000
3.000.000 – 5.000.000
6.000.000 – 8.000.000
8.000.000 – 10.000.000
> 10.000.000
37
81
51
19
5
16
18
39
24
9
2
8

Note: N = Total Respondents, % = Data Percentages

had experience of using hospital service
facilities were considered able to participate
in the study.
The participants could choose government
hospitals or private hospitals that had JCI
standard accreditation as their preferred
choice for medical treatment in Indonesia.
The patient category was hospital customers
who had used and were familiar with
hospitals which had applied JCI accreditation
standards. The non-patient category was
hospital customers who had received
recommendations from customers who had
been patients in the hospital, such as patient
references from other hospitals, medical
examinations, families of patient, surgery,
visitors to patient, and others.
The research object was government and
private hospitals which had applied the
green hospital concept through international
standards based on JCI accreditation.
Survey Instrument
This research used Google forms to ensure
respondents answered all the questions
correctly, and in an easy way using their
mobile phones and notebooks. An online
questionnaire was developed and adapted
from previous marketing studies; it was then
sharedtosocialmediasuchasWhatsapp,Line,
and Facebook. The questionnaire was pre-
tested on 35 respondents who had experience
of hospital services in Indonesian hospitals.
The feedback from the respondents showed
that the instructions and questions needed
to be modified to ensure the respondents
understood correctly. The questionnaire was
tested with the SPSS program by validity
analysis and reliability analysis to ensure that
the operational variables were well developed.
After development was complete, the survey
could start to obtain the primary data using the
online questionnaire. A total of 26 operational
variable items were investigated by a six-
point Likert scale. ranging from “1 = strongly
disagree” to “6 = strongly agree”.
RESULTS AND DISCUSSION
Demographic Profile of the Samples
Table 1 shows the respondent data, such
as hospital with JCI accreditation; type of
hospital visited; purpose of hospital visit;
frequency of hospital use; medical facilities;
payment; gender; age; occupation; and
average annual expenditure.
The data show that 60% of respondents knew
about hospitals with JCI accreditation, and
that 70% chose private hospitals. The biggest
purpose of respondents to JCI hospital
standard were family of patient (30%),
chosen medical facilities were policlinics
(45%), frequency of hospital use 2-3 times
a year, and their chosen payment for all
type of hospital was private (38%). 65% of
respondents were female, who were familiar
with hospitals with JCI accreditation, aged
21-25 years old (42%), their occupation was
college university (40%), and their average
expenditure was 3 to 5 million rupiahs (24%)
based on Table 1.
Structural Model
The data in Table 2 show that the t-values for
each variable are significant (> 1.96; SEM
standard) and no question needs to be deleted
for model fit. The SFL value for each variable
is valid (> 0.50 / > 0.70; SEM standard) for
model fit. The CR value and VE value for each
variable do not need model re-specification as
they pass the validity test (CR ≥ 0.70; SEM
standard), and reliability test (VE ≥ 0.50;
SEM standard).
Model Fit Test
The data in Table 3 show that the overall fit
test results of the research model have three
categories of model fit: poor fit, marginal fit
and good fit. In poor fit, there are two GOFI
measurements in the category, the p-value
and AGFI. In marginal fit, there is one GOFI
measurement in the category, GFI, while in
good fit there are 10 GOFI measurements

99
Table 2. Structural Model Test Result for Study
Construct Variable Measurement Indicator t-value SLF
Interaction quality:
CR = 0.90; VE =
0.70
1. Staff in this hospital are polite from time to time 14.81 0.85
2. Staff performance in this hospital displays appropriate
services
16.58 0.91
3. As generally deliver medical services, hospital staff show
good response to customer needs
15.56 0.87
4. The hospital tries to implement environmentally friendly
services
10.97 0.69
Physical
environment quality:
CR = 0.94; VE =
0.79
1. I believe the physical environment and hospital buildings
have been maintained to neat and clean standards
16.91 0.91
2. The facilities owned by the hospital are kept clean and
comfortable
17.32 0.92
3. In general, the hospital environment makes me feel
comfortable
15.57 0.87
4. I am impressed by the environmental quality around the
hospital
15.25 0.86
Outcome quality:
CR = 0.89; VE =
0.68
1. The medical services provided by medical staff have restored
my health
15.78 0.89
2. My condition has improved after receiving medical treatment
at this hospital
16.75 0.92
3. The hospital makes their customer needs a top priority 11.13 0.70
4. I always have a better experience when treated at this
hospital
12.72 0.77
Customer trust:
CR = 0.91; VE =
0.73
1. My opinion is that this hospital gives professional services
and is reliable
16.94 0.92
2. My opinion is that these hospital services are dependable and
meet required standards
16.08 0.89
3. My opinion is that medical staff at this hospital met my
expectations in delivering the best services for my condition
15.29 0.86
4. My opinion is that this hospital has maintained its service
commitment
12.11 0.74
Customer value:
CR = 0.88; VE =
0.60
1. I consider that the medical cost at this hospital are appropriate
for its services
11.37 0.71
2. I consider that the time spent at the hospital using its service
facilities was appropriate
12.42 0.76
3. I consider that medical staff’s efforts at the hospital were
appropriate for their services
14.46 0.84
4. I consider that the hospital services were a good experience 14.66 0.85
5. My opinion is that this hospital has benefited me with its
services
11.32 0.71
Customer loyalty:
CR = 0.85; VE =
0.55
1. I always use this hospital’s medical services 8.05 0.55
2. My opinion is that the costs for this hospital’s service facilities
meet my expenditure level
9.85 0.64
3. I prefer to choose this hospital’s medical services rather than
those of another because of its service commitment
12.92 0.79
4. I will recommend this hospital to my friends, family, and
partner
14.59 0.86
5. I will use this hospital again as its medical services are
appropriate for my needs
13.45 0.81


100
Table 3. Model Fit Test for Study
Figure 2. Study Model Structure
Note: *estimates (β), **t-value > 1.96
Model Fit
Measure
Model Fit
Criterion
Index
Value
Model
Statement
Model Fit
Measure
Model Fit
Criterion
Index
Value
Model
Statement
Absolute Fit Indices Incremental Fit Indices
χ
2
/df (χ
2
=
191,41, df =
115)
Less value 1.66 Good fit NNFI ≥ 0.90 0.99 Good fit
p-value > 0.05 0.001 Poor fit NFI ≥ 0.90 0.98 Good fit
NCP (42,23 –
118,48)
Between
interval
76.41 Good fit AGFI ≥ 0.90 0.76 Poor fit
GFI > 0.90 0.82 Marginal fit RFI ≥ 0.90 0.98 Good fit
Standardized
RMR
≤ 0.05 0.050 Good fit IFI ≥ 0.90 0.99 Good fit
RMSEA ≤ 0.08 0.057 Good fit CFI ≥ 0.90 0.99 Good fit
ECVI
(saturated
model = 147)
Less than
saturated
model
1.29 Good fit

category, namely statistic chi-square, NCP,
standardized RMR, RMSEA, ECVI, NNFI,
NFI, RFI, IFI, and CFI.
Based on the results from the combination of
GOFI measurements and model fit category, the
overall model fit test is generally a good model.
As shown in Figure 2, the structural model
results mean that six hypotheses are accepted,
and one is rejected based on t-value and
estimate (β) measurement. The accepted
hypotheses are H1, H2, H3, H4, H5, and H7,
while the rejected hypothesis is H6.
Variable interaction quality is significant and
positively influences customer trust (β = 0.88;
t-value = 10.01), so H1 is confirmed. With
this variable, the most significant influence
indicator is the polite attitude of hospital staff.
This is supported by the study results of Wu et
al. (2016), who showed that good interaction
with hotel staff in a green hotel in Taiwan
was the most important indicator of a quality
environmentally friendly experience. This
result supports H1, with a positive influence
on the 1st
research hypotheses.
The physical environment quality variable
is significant and positively influences
customer trust (β = 0.75; t-value = 7.57), so
H2 is confirmed. With this variable, the most
significant influence indicator is a comfort-
inducing environment. This is also supported

101
by the study results from Wu et al (2016), who
showed that the best physical environment
hotel facilities in a green hotel in Taiwan was
the biggest influence indicator for a quality
environmentally friendly experience. This
result supports H2, with a positive influence
on the 2nd
The outcome quality variable is significant and
positively influences customer trust (β = 0.92;
t-value = 10.08), so H3 is confirmed. With
this variable, the most important influence
indicator is the quality of the experience of
medical treatment in the hospital. This is
supported by the study results from Lien et.
al. (2014), who showed that medical services
which restored patients’ condition in Taiwan
hospitals was the most influential indicator
of customer trust. This result supports H3,
with a positive influence on the 3rd
research
hypotheses.
The customer trust variable is significant
and positively influences customer value (β
= 0.92; t-value = 6.32), so H4 is confirmed.
With this variable, the most significant
influence indicator is professional services
and reliability. The results from Chen et al.
(2015) show product that environmental
friendly dependable to green product in
Taiwan become the biggest indicator of green
perceived quality. Chen et al.’s (2015) results
support H4, with a positive influence on the
4th
The customer value variable is significant and
positively influences customer loyalty (β =
1.14; t-value = 4.12), so H5 is confirmed. With
this variable, the most influential indicator is
that hospital services give a good experience.
The study results from Chen (2013) show
product that environmental friendly produces
profits for electronic product companies in
Taiwan, being the biggest indicator of green
loyalty. Chen’s (2013) results supported H5,
with a positive influence on the 5th
research
hypotheses.
The customer trust variable is non-significant
and negatively influences customer loyalty
(β = - 0.32; t-value = -1.42), so H6 is not
confirmed. This hypothesis shows that
customers do not trust hospitals which
have applied JCI accreditation standards
through the green hospital concept if they
are not comparable with their hospital
values (indicators within the customer value
variable, such as medical costs, time medical
services, staff efforts, customer experience,
and customer benefits). Respondent had
low trust because their trust did not meet
their expectations. The consequence is
that customers do not trust hospitals which
simply claim to follow the green hospital
concept and claim JCI accreditation standards
without meeting these, including people’s
expectations of medical services in Indonesia.
This is supported by the results of a study
by Kalafatis et al. (1999), who showed that
companies which claimed to be green, and
exaggerated the value of their green products
were not trusted by customers.
In this study, the relationship between
customer trust and customer loyalty needs
mediation from customer satisfaction to build
a significant and positive influence on H6.
The results from a study by Hur et al. (2015),
show that satisfaction is significant and
positively influences loyalty in the hybrid car
industry in the USA. Customer satisfaction
is an important criterion for customer loyalty
(Gronroos & Annika, 2002).
The customer value variable is significant and
positively influences the mediating effect of
the relationship between customer trust and
customer loyalty (β = 0.92 and 1.14; t-value
= 6.32 and 4.12), so H7 is confirmed. With
this variable, there are two main influencing
indicators, the quality of the experience when
receiving medical treatment in the hospital,
and hospital services which give a good
experience. This is supported by results from
Sirdeshmukh et al. (2002), who show that
value positively influences trust with loyalty
through partial mediation.
Customer benefit including patient and non-
patient use of hospitals with JCI standards,

102
Table 4. Direct, Indirect and Total Effect of Customer Value
Direct Effect 0
Indirect Effect
Degree of CT ! CV ! CL
0.92 x 1.14 = 1.0488
Total Indirect Effect 1.0488
Total Effect 1.0488

includes the interaction quality of medical
staff which gives the perception of experience
and safety, fast health process restored, trust
in medical staff quality, guarantees of non-
standard medical services, and guarantees from
the danger of hospital waste, so the relationship
between customers and the hospital becomes a
good bonding long-term one.
Mediating Effect of Customer Value
Finally, the mediating effect measurement of
customer value between customer trust and
customer loyalty based on Table 4. In Table 4,
the direct effect of customer trust on customer
loyalty is – 0.30, so it can be 0.
The indirect effect of customer trust and
customer loyalty on customer value is 1.0488,
so customer value has a full mediating effect.
The customer value variable becomes a
complete connection between the customer
trust variable and customer loyalty, but
customer trust cannot directly influence
customer loyalty (Hair et al., 2010). As a
result, H7 is confirmed.
RESULT AND CONCLUSION
The results from the research mean that six
hypotheses are accepted as research models,
and one hypothesis is rejected. High cost
problem can be explained by the fact that
hospital staff give better service experience,
including medical services, facility services,
and building relationships with customers
for long-term benefit. The information
technology problem can be explained such as
build better facilities for medical services and
medical facilities. Indonesian people’s lack of
trust can give solution by the fact that hospital
staff give the best service quality, give better
medical information, show better standard
medical treatment, and build relationships
for better competitive advantage. The green
hospital concept explained services standard
such as best medical services, guarantee
medical standards, safe medical equipment,
and building a green environment for better
relationships in the long term.
Customer trust directly to problem of
loyalty cannot be explained by H6 because
medical experience is not comparable with
the hospital value indicator, based on non-
standard medical services, safety, waste
danger, hospitals just claiming they follow JCI
and green hospital standards, so customers’
expectations were not met, including those of
medical experience and facilities.
Customer trust toward mediating customer
value can build customer loyalty by research
hypothesis (H7) such as best experience when
medical treatment in the hospital, and hospital
services giving good experience. Overall, the
indicator on H7 can build good loyalty to their
customer trust using relationship marketing
for the best experience of medical treatment
and good experience of medical services.
Limitations of the Study
This study has a limited research area,
focussing on patients and non-patients, and
not yet covered all respondents in Indonesia,
so the results are less comprehensive for
hospital business. The study covered a limited
number of respondents who were familiar with
hospitals with JCI standard accreditation. The
respondent still general customer so it must be

103
REFERENCES
Adhi, R. K. (2010). Siloam Hospital Menangkan Penghargaan Global - Kompas.com. Retrieved
October 11, 2017, from http://properti. kompas.com/read/2010/10/29/11182292/siloam.
hospital.menangkan.penghargaan.global.
Alexander, H. B. (2013). Sertifikasi Gedung Hijau Ramah Lingkungan Dipertanyakan!
- Kompas.com. Retrieved October 15, 2017, from http://properti.kompas.com/
read/2013/08/06/1331447/Sertifikasi.Gedung.Hijau.Ramah.Lingkungan.Dipertanyakan
Alexander,H.B.(2015).CiputraMitraHospitalSiapLayaniPublikBanjarmasinFebruari2016-Kompas.
com.RetrievedOctober11,2017,fromhttp://properti.kompas.com/read/2015/04/20/213923321/
Ciputra.Mitra.Hospital.Siap.Layani.Publik.Banjarmasin.Februari.2016
American Marketing Association Editor. (2017a). Dictionary. Retrieved October 15, 2017, from
https://www.ama.org/resources/Pages/Dictionary.aspx?dLetter=G
American Marketing Association Editor. (2017b). Dictionary. Retrieved October 18, 2017, from
https://www.ama.org/resources/Pages/Dictionary.aspx?dLetter=R
Anna, L. K. (2012). Akreditasi RS untuk Tingkatkan Mutu, Bukan Tarif - Kompas.com.
Retrieved October 11, 2017, from http://bola.kompas. com/read/2012/03/06/06551580/
Akreditasi.RS.untuk.Tingkatkan.Mutu.Bukan.Tarif
patient that used and knew hospital with JCI
standard. This study has limited to collaborate
with hospital management and customers and
employs limited variables, such as service
quality, trust, value, and loyalty.
Suggestions for further study
This study result can explain Indonesian
people not trust, so hospital management can
build relationships with their customers and
medical staff using relationship marketing, JCI
accreditation and the green hospital concept.
Further research could focus more on prime
hospital customers who have used and are
JCI standard accreditation as familiar with
hospitals that have applied JCI standard
accreditation as patients. Researchers can
collaborate with hospital management and
customers to build more personal experience
so that customers can make direct suggestions.
Other research could involve other variables
as factors which influence the relationship
between customer trust and customer loyalty
through the mediating variable of customer
satisfaction.
Managerial Implications
This study can give hospital managerial
implications such as it can be applied the green
hospital concept in all hospitals in Indonesia
in collaboration with B3 waste developers,
including government and private firms, so
that they can prevent the danger of hospital
waste contamination in the environment,
based on the results of physical environment
quality (H2), customer trust (H4), customer
value (H5), & customer loyalty (H7).
Green marketing strategies through green
hospitals can be improved by improvement
in interaction quality (H1) and outcome
quality (H3) with hospital customers, so
these hospitals have different competitive
advantages (H4, H5) compared to other
hospitals through relationship marketing (H7)
programmes and become good relationship at
long-term benefit.

Asril, S. (2014). Presiden SBY Resmikan RS Umum Pekerja di Kawasan Berikat - Kompas.com.
Retrieved October 11, 2017, from http://tekno.kompas.com/read/2014/04/08/1314314/
presiden.sby.resmikan.rs.umum.pekerja.di.kawasan.berikat
BMI Research, & Healthcare. (2016). Indonesia Pharmaceuticals & Healthcare Report - Q4
2016. Indionesia Pharmaceuticals & Healthcare Report, 1–91. Retrieved from http://
search.proquest.com/ docview/1829810005?accountid=11077%5Cnhttp://sfxit.ugent.be/
ugent?url_ver=Z39.88-2004&rft_val_fmt= info:ofi/fmt:kev:mtx:book&genre=report&sid
=ProQ:ABI%2FINFORM+Trade+%26+Industry&atitle=&title=Colombia+Pharmaceutic
als+%26+Healthc
Brady, M. K., & Cronin, J. J. (2001). Some new thoughts on conceptualizing perceived
service quality: a hierarchical approach. Journal of Marketing, 65(3), 34–49. https://doi.
org/10.1509/jmkg.65.3.34.18334
Brady, M. K., & Robertson, C. J. (1999). An exploratory study of service value in the USA and
Ecuador. International Journal of Service Industry Management, 10(5), 469–486. https://
doi.org/10.1108/09564 239910289003
Chandra, A. (2011). 5 RS Terbaik dalam Pencegahan dan Pengendalian Infeksi - Kompas.com.
RetrievedOctober11,2017,fromhttp://lifestyle.kompas.com/read/2011/12/12/16573852/5.
RS.Terbaik.dalam.Pencegahan.dan.Pengendalian.Infeksi
Chen, Y. (2013). Towards Green Loyalty: Driving from Green Perceived Value, Green
Satisfaction, and Green Trust, 308(November 2010), 294–308.
Chen, Y., Lin, C., & Weng, C. (2015). The Influence of Environmental Friendliness on Green
Trust: The Mediation Effects of Green Satisfaction and Green Perceived Quality, (1),
10135–10152. https://doi.org/10.3390/su70810135
Cronin, J. J., Brady, M. K., & Hult, G. T. M. (2000). Assessing the effects of quality, value, and
customer satisfaction on consumer behavioral intentions in service environments. Journal
of Retailing, 76(2), 193–218. https://doi.org/10.1016/S0022-4359 (00)00028-2
DepkesEditor.(2012).MenerapkanGreenHospitaldiRumahSakit–RSUDUndata.RetrievedOctober
16, 2017, from http://www.rsundata.com /2012/10/menerapkan-green-hospital -di-rumah-sakit/
Djumena, E. (2012). Industri Rumah Sakit Harus Berbenah! - Kompas.com. Retrieved October
11, 2017, from http://lifestyle.kompas.com/read/2012/07/20/14131214/Industri.Rumah.
Sakit.Harus.Berbenah
Green Hospital Editor. (2015). Members | Global Green and Healthy Hospitals. Retrieved
November 17, 2017, from https://www.greenhospitals.net/members/?lang=en
Gronroos & Annika. (2002). The value concept and relationship marketing. European Journal
of Marketing (Vol. 30). https://doi.org/10.1108/03090 569610106626
Hair, Joseph F., et al. (2010). Multivariate Data Analysis: A Global Perspective. New Jersey:
Pearson Education, Inc.

105
Hoffman, K. D., & Bateson, J. (2001). Essentials of Services Marketing: concepts, strategies &
cases. South-Western Pub.
Hur, W., Yoo, J., & Hur, J. (2015). Exploring the Relationship Between Green Consumption
Value , Satisfaction , and Loyalty to Hybrid Car in Elderly Consumers, 25(4), 398–408.
https://doi.org/10.1002 /hfm
JCI. (2017). JCI-Accredited Organizations | Joint Commission International. Retrieved
November 17, 2017, from https://www.jointcommissioninternational.org/about-jci/jci-
accredited-organizations/?c=Indonesia
Kalafatis, S. P., Pollard, M., East, R., & Tsogas, M. H. (1999). Green marketing and Ajzen’s
theory of planned behaviour: a cross-market examination. Journal of Consumer Marketing,
16(5), 441–460. https://doi.org/10.1108/07363769910289550
Khandelwal, U., & Yadav, S. K. (2012). Green Marketing and Sustainable Development :
Marketing Professionals Attitude Towards Green Marketing.
Kompas Editor. (2008). Green Hospital, Rumah Sakit Berwawasan Lingkungan - Kompas.com.
Retrieved October 11, 2017, from http://nasional.kompas.com/read/2008/11/04/19231788/
green.hospital.rumah.sakit.berwawasan.lingkungan
Kuswandi,R.(2014).Ini4FasilitasPublikyangDianggapTerbaikdiKotaBandung-Kompas.com.
Retrieved October 18, 2017, from http://regional.kompas.com/read/2014/09/29/23001961/
Ini.4.Fasilitas.Publik.yang.Dianggap.Terbaik.di.Kota.Bandung
Latief. (2013). Mengapa Tidak Meniru Singapura atau Malaysia? - Kompas.com. Retrieved
October 11, 2017, from http://properti.kompas .com/read/2013/03/28/17281723/mengapa.
tidak.meniru.singapura.atau.malaysia
Lien, C., Chen, Y., & Wang, C. (2014). Trust transfer and the effect of service quality on trust
in the healthcare industry, 24(4), 399–416. https:// doi.org/10.1108/MSQ-11-2013-0255
Malhotra, N. K. (2010). Marketing Research, 6th Ed. New Jersey: Prentice Hall.
Marketeers Editor. (2011a). 90 Persen Rumah Sakit di Indonesia Punya Kendala IT. Retrieved
October 11, 2017, from http://marketeers.com/90-persen-rumah-sakit-di-indonesia-punya-
kendala-it/
Marketeers Editor. (2011b). Green Financing in Indonesia. Retrieved October 11, 2017, from
http://marketeers.com/green-financing-in-indonesia/
Marketeers Editor. (2011c). Membangun Green Hospital dan e-Health. Retrieved October 15,
2017, from http://marketeers.com/membangun-green-hospital-dan-e-health/
Martínez, P. (2015). Customer loyalty : exploring its antecedents from a green marketing
perspective. https://doi.org/10.1108/IJCHM-03-2014-0115
Nielsen. (2017). Indonesia Market - Waiting For The Wave, 83(January), 396–405.

Noviana, M. (2013). Jaminan Kesehatan (kuratif) Tak Mendidik atau Mendidik Rakyat ? oleh
Mita Noviana - Kompasiana.com. Retrieved December 25, 2017, from https://www.
kompasiana.com/mitanoviana/jaminan-kesehatan-kuratif-tak-mendidik-atau-mendidik-
rakyat 552a80a9f17e61b516d623bc
Oliver, R. (1999). Whence Consumer Loyalty? The Journal of Marketing, 63(Journal Article),
33–44. https://doi.org/10.2307/1252099
Parasuraman, A., Zeithaml, A. V., & Berry, L. L. (1988). SERVQUAL: A multiple-item scale
for measuring consumer perceptions of service quality. Journal of Retailing, Volume 64(1),
12–40.
Parasuraman, a, Zeithaml, V. a, Berry, L. L., & Parasuraman. (1985). A conceptual model of
service quality and its implications for future research. Journal of Marketing, 49(1979),
41–50. https://doi.org /10.2307/1251430
Pdpersi Editor. (2011a). Green Hospital/ Green Building Concept And Carbon Footprint Komite
Green Hospital PERSI. Retrieved October 16, 2017, from http://www.pdpersi.co.id/con
tent/news.php?mid=5&catid=4&nid=24
Pdpersi Editor. (2011b). Komite Green Hospital. Retrieved October 16, 2017, from http://www.
pd persi.co.id/content/news.php?mid=5&catid=8&nid=605
Peattie, K. (2011). Towards sustainability: achieving marketing transformation - a retrospective
comment. Social Business, 1(1), 85–104. https://doi.org/10.1362/204440811X570581
Peattie, K., & Crane, A. (2005). Green marketing: legend, myth, farce or prophesy?
Qualitative Market Research: An International Journal, 8(4), 357–370. https://doi.org/
10.1108/13522750510619733
Polonsky, M. J. (1994). An introduction to green marketing. Electronic Green Journal, 1(2),
1091. https://doi.org /10.1016/j.neuron.2011.12.010
Siloam hospital Editor. (2017). Siloam Hospitals | Cara Rumah Sakit Ini Menghibur Pasien
Saat Paskah - Rumah Sakit Siloam Hospitals. Retrieved October 18, 2017, from https://
www.siloamhospitals.com/whats-new/read/cara-rumah-sakit-ini-menghibur-pasien-saat-
paskah.html
Sirdeshmukh, D., Singh, J., & Sabol, B. (2002). Consumer Trust, Value, and Loyalty in
Relational Exchanges. Journal of Marketing, 66(1), 15–37. https://doi.org/10.1509/
jmkg.66.1.15.18449
Sweeney, J., & Soutar, G. (2001). Consumer perceived value: the development of a multiple item
scale.JournalofRetailing,77(2),203–220.https://doi.org/10.1016/S0022-4359(01)00041-
0
Woo, J., & Kim,Y. (2015). The role of consumer values and socio-demographics in green product
satisfaction: the case of hybrid cars 1, 2, 2014, 406–427. https://doi.org /10.2466/01.
PR0.117c19z1

107
Wu, H.-C., Ai, C.-H., & Cheng, C.-C. (2016). Synthesizing the effects of green experiential
quality, green equity, green image and green experiential satisfaction on green switching
intention. International Journal of Contemporary Hospitality Management, 28(9), 2080–
2107. https://doi.org/10.1108/IJCHM-03-2015-0163
Zeithaml, V. A., Berry, L. L., & Parasuraman, A. (1996). The Behavioral Consequences of
Service Quality. Journal of Marketing, 60(2), 31. https://doi.org/10.2307/1251929
APPENDIX
Questioner
Screening question
1. What your perception about hospital that used/visited already applied good standard hospital
services? Yes/No
2. What did you always use hospital that own national standard accreditation with some type?
Government (go on questioner no. 3) / Private (go on questioner no. 4)
3. If you used government hospital, please choose one hospital! Persahabatan; Umum Pekerja;
Dr. Sardjito; Jantung Harapan Kita; Fatmawati; and other hospital, explain one hospital
4. If you used private hospital, please choose one hospital! Ciputra; Hermina; Saint Carolus:
Siloam Asri: Medistra: and other hospital, explain one hospital
5. Did you visit that hospital for some period for the last 3 – 6 months? Yes/No
6. What did your purpose visit to its hospital? Medical examination; patient; as patient’s family;
visitor to patient; patient references from other hospitals; surgery; and other purpose
7. How many frequencies did you visit to its hospital each year? 1 time; 2 – 3 times; 3 – 4 times;
4 – 5 times; > 5 times
8. Which medical facilities did you visit? Policlinic; Medical checkup; Pharmacy; Emergency;
Endoscopy; Physiotherapy; Radiology; Hemodialysis; Laboratory; Rehabilitation medic;
and other facilities
9. Which payment types you choose in hospital? Private/family; Company; Assurance; BPJS;
and other payment type
Part 1
Interaction quality variables questioner based on Table 2
Part 2
Physical environment quality variables questioner based on Table 2
Part 3
Outcome quality variables questioner based on Table 2
Part 4
Customer trust variables questioner based on Table 2
Part 5
Customer value variables questioner based on Table 2
Part 6
Customer loyalty variables questioner based on Table 2

Profile of samples
1. Gender: Male/Female
2. Age: < 21; 21 – 25: 26 – 30; 31 – 35; >35
3. Occupation: Student; College university; Employee; Entrepreneur; Housewife
4. Average annual expenditure (rupiahs): ≤ 1.000.000; 1.000.000 – 3.000.000; 3.000.000 –
5.000.000; 6.000.000 – 8.000.000; 8.000.000 – 10.000.000; > 10.000.000

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