The effect of perceived service fairness toward relationship quality and switching intention (a case study of patient from X generation and Y generation in a hospital)

This research was conducted with the hypothesis of the influence of perceived service fairness (which consists of price fairness, procedural fairness, interactional fairness and outcome fairness) variables on relationship quality (consisting of trust and commitment variables) and switching intention and their differences in generation X and Y. Survey was conducted to find out the factors that affect the switching intention patient behaviour and it is found that the physician factor is the dominant factor. The study was conducted at one of the hospitals in Central Jakarta which using 524 respondents, who were included in the criteria of 600 target respondents, of which 40% generation X and 60% generation Y, the study is using qualitative and quantitative research, and the type of research is exploratory research. This study is using PLS-SEM analysis method. It obtained results, which are far different from the existing reference, where the hypothesis of perceived fairness and service relationship qualilty with switching intention are all rejected. The differences between generation X and Y, A relationship of trust with switching intention in, it is found that price fairness is related to commitment in generation X, vice versa in Y generation. It concluded that in some input for hospital management and provides thoughts on the need for other studies in hospitals that have different characteristics from the study sites as the need for deeper research related to physician factors.


Introduction
The private health services, especially hospitals, has a quite large conribution on it obligation to fullfill health services needed. From the total of hospital in Jakarta, private hospital own 63% while government hospital only own 27% (Kementrian Kesehatan RI, 2019). It is known that private hospital occur a massive development where 2014, the development of private hospital has reach 34,12% while general hospital only 4,18% (Bisnis.com, 2016). Based on its owner, the development of private hospital non-profit has more aggressive growth around 17,3% (Tristiantoro, 2018). This situation automatically creates stiff and dynamic competition. The phenomenon of large investors in hospital business development has been spread in various cities and provinces such as Mitra keluarga, Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 4 Siloam, Eka, Awal Bros and others. This situation, adds more dynamic level of hospital competition which can affect the business continuity of various existed hospitals, included other hospitals that not have a proper adequate networks and funds.
This research was conducted in a medium-sized hospital in Jakarta which has started the business since 1960 and still growing until now. As a hospital that has been established for a long time, this hospital has been experienced success and became well-known hospital.
By the development of hospital, where a well-known bank become the owner majority share, therefore there is a plan on working purposes and plan to increase hospital business by optimalize consument potential of people who often come to hospital. Hospital Management understand that the high competition influenced by higher standard of medical facilities (clinic or hospital), the increase of service demand, the change of people life style, the development of medical support facilities, the change of knowledge and medical technology, there are digital technology and other, it is possible for consument or patient to choose several places to get any treatment and easy to choose their switching intention from a facility to other facility.
Various private medical facility has been established for a long time, now experienced a phenomenon called as product/service life cycle, where their growth period has been passed and they are now faced the condition of Maturity or Decline. Based on the analysis of annual report 2015-2018, it can be concluded that the trend of outpatient is relative flat. Referred to that conclusion, based on the study of hospital, it is known that for the last few years, much of hospital is under maturity status and directed to the phase of decline. This situation has experienced by several private medical facility such as clinic and hospital which has been established for a long time. Basically, Hospital management has aware on the importance of renewal, therefore, management started to make an effort on improvement and renewal including to create a division called Business Development which has an obligation to did every analytic effort, evaluation and looking for opportunities on improvement and other development option.
The issue related to switching customer has been an important issue nowadays, more developed business strategies, and more strict competition in every kind of business. (Ranaweera & Prabhu, 2003) defined the switching customer as a decision of customer to stop purchasing a kind of product. In the midst of intense competition on hospital business, the intention to switch (intention to seek treatment) at different hospital also included as important issue on hospital business competition. Therefore, the competition between private hospitals become really competitive to certain that patient will continue to come and trust the Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 5 service of a hospital (Meisenher, 1997). This case requires hospitals to develop various strategies Switching intention behavior is different from generation to next generation. (Rahman, 2016) stated that the X generation has lower intention level of brand switching of 33,00 (of 100,00) compare to Y generation which has higher intention of 54,83. The difference of consumer behavior of every generation including Baby boomer, X generation and Y generation has been analyzed, who concluded that difference generation affect different behavior including the aspect related to loyality. (Nindyati, 2017) indicated that compared to X generation, Y generation consider as more brave to take any decision and leave their comfort zone and move to other workplace. And the opposite, 60% of X generation stated that they have never moved a job. Generally, it can be said that there are different behavior including switching intention, from X generation to Y generation.
Relationship quality can influence switching intention. Relationship qualitycan be explained as perception of consumer and the assessment of how people relation to fulfill the expectation, prediction, purposes and customer desire (Kim & Cha, 2002). The high level of quality relation is related to high trust and commitment level. Therefore, improve a trust and Ever since the latest few years, referred to several data source and received feedback, hospital management has been conclude a movement of patients during their treatment to other hospital. By the establishment of the Business Development Division, it was decided to conduct a study/survey to analyze the factors that influence the switching intention of patients in hospitals. (Bansal & Taylor, 1999) has analyzed the relation between service quality and satisfaction on switching intention of Bank business. Thus, (Han, Kim, & Kim, 2011) Research, Society and Development, v. 9, n.8, e482986265, 2020(CC BY 4.0) | ISSN 2525 6 analyzed the relation between service performance and customer satisfaction toward switching intention of hotel business. Furthermore, (Nikbin, Marimuthu, & Hyun, 2016) analyzed the influence of perceived service fairness of relationship quality and switching intention toward Restaurant business. There is a lot of analysis that used customer satisfaction as variable, therefore, researcher tried to refer the analysis of Nibkin and other to examine the recent factors such as perceived service fairness and relationship quality, and also has more sub-variables, and it expected to gain more information to make a new idea for hospitals. (Nikbin et al., 2016), Concluded that switching intention can be influenced by perceived service fairness (which consist of price fairness, procedural fairness, interactional fairness and outcome fairness) and relationship quality (which consist of trust and commitment). By the increasement of service demand, the increase of private hospital competition, and the polarization of generational groups in society, especially X and Y generation which have different characteristics, the hospital also needs to analyze the differences factors of X and Y generation above.

Theoretical Concept
This reseach refers to the study of the effect of perceived service fairness on relationship quality and switching intention which has been done by (Nikbin et al., 2016) on restaurant service industry. The conceptual framework and the results of the study considered as quite relevant with the hospital's health services industry. On it effort to anticipate the development of consumer behavior, in order to manage business competition, including analyzing the differences of X and Y generation.
Service can be defined as the interaction between seller and buyer to get what they want or meet their needs where the results can provide additional intangible value (Zeithaml, Berry, & Parasuraman, 1996). To provide a service, referred to the theory of fairness, consumer motivated by their comparation of inputs ratio they received and others (Adams, 1965). Service fairness becomes very important because it really determines how the organization able to own their unique strategy compared to other organizations, because consumer will draw conclusions from his perception whether they will accepts fair and satisfying behavior or not. On the other hand, consumer sacrifice in consuming a product or service should also be an important factor that must be considered as a price to be paid (price fairness) and the time to be spent (procedural fairness). From consumer benefit perspective, a literature of fairness states that fair behavior by service companies may be important not only Research, Society and Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 for instrumental reasons (outcome fairness), but also for relational reasons (interactional fairness) (Namasivayam, 2004). Fairness/Pricing fairness is an important factor of business. If the company raises the price unilaterally when demand level is high, thus consumers will consider it as unfair (Herrmann, Xia, Kent, & Huber, 2007). If this happens, consumers will not pay the offered product or service because it consider as unfair (Kalapurakal, Dickson, & Urbany, 1991). Procedural fairness refers to the perceived fairness of procedures which the organization makes decisions (Tyler, 1998). Fair procedures means that the procedures not taking any sides with an individual or group (Leventhal, Meyer, Nerenz, & Rachman, 1980). Procedure fairness can be defined as a time accuracy and efficiency of service system and it must be adjusted to consumer sacrifice, the sacrifice is not always related to material but also the time delay of a service (Namkung, Jang, Almanza, & Ismail, 2009).
According to Munchinsky (Febriani, R. dan Nurtjahjanti, 2006), procedure fairness is a measure of fair that used to achieve certain outcomes or targets While Interactional fairness quality treatment, whereas procedural justice is a process used to obtain the outcome of a decision. According to (Tyler, 1989(Tyler, , 1998 inside (Yuwono, 2005), there are three important things that should be considered in the process of discussing interactional justice, such as Appreciation, Neutrality and Trust. Airness outcomes have a close relation to the evaluation of results which carried out by consumers. (Adams, 1965) stated that the achieved outcome is a reflection of social relationships that experienced because of consequences of an incident and every transaction activity that occurs; consumer will measure the received results, whether the results are related to what as expected. In business, the best product or service results are the most important things to convey to consumers (Grönroos, 2007). Thus, consider the sacrifice and benefits of customers; this study uses a model of the four factors of perceived service fairness such as: price fairness, procedural fairness, outcome fairness and interactional justice.
Relationship quality can be defined as a producent perception of how good their effort to fulfill the expectation, prediction, purposes and consumer desires (Gyau & Spiller, 2008), and can be considered as the right indicator for a success relationship (Hennig-Thurau & Hansen, 2000). Several studies indicated that the quality of relationships consists of Research, Society and Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 8 dimensions of trust and commitment from consumers (Kandampully, Zhang, & Bilgihan, 2015;Pan, Sheng, & Xie, 2012;Yoo & Bai, 2013). Trust and commitment mentioned above consider as factors that influence the relationship between seller and buyer. Trust can be interpreted as a person's willingness to be vulnerable toward the actions of others based on the expectation of others will take certain actions that important to the trust subject, regardless the ability of observe or control the other side (Mayer, Davis, & Schoorman, 1995). Trust is a reflection of hopes, assumptions or individual beliefs regarding the possibility that someone's actions in the future will obtain an advantages, good, and will not damage their interests. Trust can be the main requirement for companies to continue their relationships and enhance cooperation with suppliers (Morgan & Hunt, 1994). Commitments have to obtain special attention of transaction activity in organization, and can cause a decrease in customer omzet (Porter, Steers, Mowday, & Boulian, 1974), or higher motivation of consumer (Farrell & Rusbult, 1981). Commitment also leads onto greater social relations and can lead to lower opportunistic tendencies (Gundlach, Achrol, & Mentzer, 1995). Relationship where there is mutual trust exists among all sides will produce enough value for both sides to be ready to maintain their commitment (Dwyer, Schurr, & Oh, 1987).
Switching intention can be interpreted as an individual or consumer desire to make a move from a product or service from one product to another ( Several research regarding the difference of behavior between each generation has been done such as X generation that consider their quality and brand of product, while Y generation expecting a lower price from product rather than it qualities. By considering the development of generation in society, which have different characteristics, especially the current society dominated by the X generation (1960-1980) and Y generation (1980-2000). Therefore, it is estimated that there are differences behavior related to the variables of this study. For certain reason, this research also analyzes the difference of the influence of perceived service fairness on relationship quality and switching intention, between X and Y generation, as in the Figure 1: Source: Own study. Research, Society and Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 It is Referred to the hypothesis explanation and the analyisis of X and Y generation differences, therefore, the conceptual framework explained.

Research methodology
This research used descriptive quantitative approach by questionnaire to test the hypothesis.This research has been done in hospital in central Jakarta, it has been operated more than 50 years and have an official access of this research. The sample of this analysis is an outpatient that has been there more than 1 and aged according the the age range of X and Y generation.
In this study the independent variable consist of Perceive service fairness within 4 elements (variables) such as Price fairness, Procedural fairness, Interactional fairness, Outcome fairness. While Switching intention as dependent variable. There are mediating variable consist of Relationship quality within 2 elements (variables) such as Trust and Commitment. Questionnaire to test the hypothesis was made referred to previous questionnaire, which consist of 22 questions, 12 question for perceived service fairness, 7 questions for relationship quality and 3 questions for switching intention. From 12 questions for perceived service fairness, 2 of them are for sub-variable price fairness, 4 for procedural fairness, 4 for interaction fairness and 2 for outcome fairness. From 7 questions for relationship quality variable, 3 are for commitment variable and 4 for the trust variable.
Questionnaire used in this study is structured questionnaire, a questionnaire with predetermined questions and using Likert method on a scale of 1 to 5.
The sampling method used in this study is random sampling with simple random sampling method. The sample taking period planned until the number of respondents meets the requirements as a sample reaches appropriate number. Sample taking started from November 20 th 2019. It was done during doctor opening hour from morning to night. Everyday, questionnaire result will be verified and screen to determine which questionnaire consist as complete and meet the criteria (in order to fit the category of X and Y group) and the patient filled the questionnaire when they have their second time or more to come in hospital (in order to make their previous experience as reference, especially when they fill the questionnaire).
The method used for data analysis is structural equation modeling (SEM) because the purposes is from data to theory, the amount of sample is limited and did not meet various parametric assumption, therefore it used PLS-SEM as data analysis method inside hypothesis Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 test.Furthermore, PLS-SEM also use for validity and reliability test. By considering the ability to obtain the sample in order to fulfill the complete amount of sample referred to the amount of used variable, therefore this analysis used minimum 600 samples that consider as meet every requirement (one or more general requirements for PLS-SEM sample).
For some reason or another, an additional sample or questionnaire can be taken to obtain the additional necessary information. Questionnaire material will be adjusted based on the description of problem or the obtained findings.In-depth survey by questionnaire will be conducted on the same respondents as the research survey, randomly and in a certain time with a sample amount of approximately 20-30.

Discussion
From 600 questionnaires that have been received, those that fit the criteria (was born during 1960 -2000 and has their 2nd visit or more) consist of 524 people, where the number of respondents is 40% from X generation and 60% from Y generation. And it dominated by female respondents (74%). Most of respondents have married (87%). Most number of visits was (62%) above 5 times. Most of them obtain an income above 10 million rupiahs (64%), has an academic level of undergraduate degree or higher (65%), general employees (68%), domiciled around Jabodetabek (82%). Referred to the data above, it can be said that most of respondents describe as middle class citizen.
Based on the data, all items from each variable meet the factor loading requirements of more than 0.6, therefore all items question in questionnaire declared as valid and can be used for further analysis. Based on the results of discriminant validity test, the value of AVE square root in each variable is higher than the construct correlation, thus all variables tested consider as valid. Furthermore, based on the reliability test, it is obtained that all items have composite reliable more than 0.7, thus, all items declared as reliable as explained in the Figure   2: Research, Society and Development, v. 9, n.8, e482986265, 2020 (CC BY 4. Authors: Please, it is a good rule in high-level texts, that: after inserting Figure 2, it becomes interesting that you write a paragraph in which they say what is important for the reader to observe in it. The magazine is multidisciplinary and we have readers from several different areas that often do not have "your expertise" in capturing the details that they often think they are transmitting. Do that, thank you.

Construction of Hypothesis Test Result
Referred to the results above, it can be concluded that Hypothesis 1, the existence of positive relationship between perceived service fairness and relationship quality, partially rejected. Where hypothesis 1a is rejected, hypothesis 1b is accepted, hypothesis 1c is accepted, hypothesis 1d is rejected, hypothesis 1e is rejected, hypothesis 1f is accepted, hypothesis 1g is accepted and hypothesis 1h is accepted. These results indicate that price fairness does not affect trust and commitment, outcome fairness does not affect trust. Thus, it can be concluded that the applied price fairness did not affect the reputation of hospital and loyalty of patients in hospital, and the final results of service did not affect the reputation of Development, v. 9, n.8, e482986265, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.6265 13 hospital. This can be explained related to hospital payment system which dominated by the payment system using health insurance, which is known that most of respondents (68%) are employees of companies, that use health insurance. Related to the ineffectiveness of outcome fairness on trust can be explained because the final results of medical services cannot always be assessed mathematically and hospitals have been long established and filled by senior doctors who has reputation as teaching staff. This result is different from the finding of (Nikbin et al., 2016) who analyse restaurant service, Nibkin analysis conclude that outcome fairness has no influence on both variables trust and commitment. The results of this hypothesis test also indicated the importance of procedural fairness and interactional fairness factors because it affects both trust and commitment, which means for procedural fairness (for example jadeal doctors etc.) and the interactional fairness (length of time of consultation etc.) still not gain any satisfaction from respondents, therefore hospitals need to make various efforts to maintain and improve procedural and interactional aspects.
Moreover, it can be concluded that Hypothesis 2 are proved to be true that there is negative relation between relationship quality and switching intention, whether hypothesis 2a totally rejected. It is known that a significant influence of trust has been received by previous studies (Morgan & Hunt, 1994).And the significant impact of commitment in determining the intention to move. (Bansal & Taylor, 1999).
The last one, conclusion of Hypothesis 3, related to the existence of negative relationship between perceived service fairness and switching intention. This hypothesis result has different result with other analysis; include the analysis of Nibkin, et al. (Nikbin et al., 2016) concluded that all sub-variables of perceived service fairness were significantly negatively related to switching intention. These results provide an unusual description, referred to previous studies. However, these results can also be new finding that good services provided by hospitals may not be thefactor that affects patients' intention to move to other medical facility. (Han et al., 2011) analysed the relation between service performance and customer satisfaction and switching intention.
The conclusion of rejecting H2 and H3 hypotheses was an unexpected result; therefore, in-depth survey was conducted to find out factors that influence the intention of patient to move, about 20 respondents, choosen randomly, produceda findings as the Table 1 below:  of digital marketing concepts that help hospitals to obtain more shopisticated interaction through website platform, IG, Facebook, and optimize the process and quality of hospital interactions with patients needs to be optimally implemented in order to make more efficient and effective services.
Regarding the absence of relationship between perceived service fairness and relationship quality with switching intention, it should be considered to improve the independence through feedback, expand material information both through customer service / beter systems, hospital conventional media and digital media that can be considered to increase this level of commitment by implementing a customer enggagement program, customer loyalty and others.
Related to the conclusion of analysis hypothesis difference between X generation and Y generation, X generation accept the relation between price fairness and commitment (while Y generation did not accept anything). Furthermore, it means that X generation calculating the price fairness within their commitment toward hospital. If it decided that the service price will increase. Hospital management needs to make notification plan as early as possible to avoid negative impacts on X generation, which consist of a group within the age range of 40 to 60 yearls old, and most of them are not health insurance user. Moreover, Y generation indicated that there is a relation between trust and switching intention, which indicated that Y generation did not really care on hospital credibility and reputation.
Therefore, it needs to consider making further communication on the issues related to hospital credibility. Such as information about history of hospital, reputation of medical staff and achievement of latest treatment measures through recent suggestions, including the use of digital marketing platforms such as websites, IG, Facebook, and Youtube.
For further researchers, the researcher suggests that the results of this study are largely different from the results of other research studies, especially on the results of hypothesis testing that produce no relationship, both for perceived servicer fairness and relationship quality with switching intention. These results are far from the researchers' predictions.
Furthermore, additional results are also obtained through a simple deepening survey that shows the doctor factor as the dominant factor influencing the intention to move patients.
(Authors, please write a final paragraph in which you tell readers the suggestion or suggestions for future researches. This way of writing enriches and enhances your article.