Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction

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The direct impact of leadership and governance on patient experience and retention remains underexplored, despite the increasing recognition of their role in determining care delivery. This investigation investigates the connections between healthcare organizations’ corporate governance, service quality, patient satisfaction, and loyalty, as well as entrepreneurial leadership. Methods Data were obtained from 384 executive patients in hospitals throughout Indonesia using structural equation modeling (SEM). Results The findings indicate that corporate governance and service quality are considerably improved by entrepreneurial leadership, while patient satisfaction and loyalty are positively impacted by corporate governance. Nevertheless, patient satisfaction was found to be moderately influenced by service quality, while patient loyalty was significantly influenced. As a result, patient satisfaction was demonstrated to be a critical factor in the development of patient loyalty. These results emphasize the importance of high service quality, effective governance, and entrepreneurial leadership in promoting patient satisfaction and loyalty. Conclusions The research offers valuable insights for healthcare managers and policymakers who are interested in enhancing organizational performance and improving patient retention. This research theoretically enhances comprehension of the impact of leadership and governance frameworks on patient retention and service quality. In practical terms, it provides valuable recommendations for hospital administrators and policymakers to improve patient satisfaction and loyalty by implementing effective leadership, robust governance, and continuous service improvement. 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F1000Research 2025, 14 :1040 ( https://doi.org/10.12688/f1000research.166837.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] Iing Ichsan Hanafi https://orcid.org/0009-0006-3219-6978 1 , Taher Alhabsji 1 , Kadarisman Hidayat 1 , Ari Darmawan 1 Iing Ichsan Hanafi https://orcid.org/0009-0006-3219-6978 1 , Taher Alhabsji 1 , Kadarisman Hidayat 1 , Ari Darmawan 1 PUBLISHED 03 Oct 2025 Author details Author details 1 Business Administration, Universitas Brawijaya, Malang, East Java, 65145, Indonesia Iing Ichsan Hanafi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Taher Alhabsji Roles: Conceptualization, Methodology, Supervision, Validation Kadarisman Hidayat Roles: Conceptualization, Methodology, Supervision, Validation Ari Darmawan Roles: Conceptualization, Methodology, Validation, Visualization OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Health Services gateway. Abstract Background It is imperative to deliver exceptional services in order to improve patient contentment and cultivate enduring loyalty in the healthcare sector, which is becoming more competitive. The direct impact of leadership and governance on patient experience and retention remains underexplored, despite the increasing recognition of their role in determining care delivery. This investigation investigates the connections between healthcare organizations’ corporate governance, service quality, patient satisfaction, and loyalty, as well as entrepreneurial leadership. Methods Data were obtained from 384 executive patients in hospitals throughout Indonesia using structural equation modeling (SEM). Results The findings indicate that corporate governance and service quality are considerably improved by entrepreneurial leadership, while patient satisfaction and loyalty are positively impacted by corporate governance. Nevertheless, patient satisfaction was found to be moderately influenced by service quality, while patient loyalty was significantly influenced. As a result, patient satisfaction was demonstrated to be a critical factor in the development of patient loyalty. These results emphasize the importance of high service quality, effective governance, and entrepreneurial leadership in promoting patient satisfaction and loyalty. Conclusions The research offers valuable insights for healthcare managers and policymakers who are interested in enhancing organizational performance and improving patient retention. This research theoretically enhances comprehension of the impact of leadership and governance frameworks on patient retention and service quality. In practical terms, it provides valuable recommendations for hospital administrators and policymakers to improve patient satisfaction and loyalty by implementing effective leadership, robust governance, and continuous service improvement. READ ALL READ LESS Keywords entrepreneurial leadership, corporate governance, service quality, patient satisfaction, sustainable patient loyalty, healthcare management Corresponding Author(s) Iing Ichsan Hanafi ( [email protected] ) Close Corresponding author: Iing Ichsan Hanafi Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Hanafi II et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Hanafi II, Alhabsji T, Hidayat K and Darmawan A. Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.12688/f1000research.166837.1 ) First published: 03 Oct 2025, 14 :1040 ( https://doi.org/10.12688/f1000research.166837.1 ) Latest published: 14 Nov 2025, 14 :1040 ( https://doi.org/10.12688/f1000research.166837.2 )  There is a newer version of this article available. Suppress this message for one day. 1. Introduction The loyalty of patients is becoming an increasingly important factor in determining an organization’s ability to grow and develop over the long term in the healthcare industry. The ability to retain patients not only ensures a steady revenue stream but also contributes to a healthcare organization’s resilience in the face of fluctuating market conditions and changing healthcare demands ( Senyapar, 2024 ; Zhang et al., 2018 ). However, achieving and maintaining patient loyalty requires much more than just providing medical care. It necessitates a holistic understanding of the factors that influence patients’ decision to remain with a healthcare provider over time, which are influenced by their experiences, perceptions, and emotional connections formed within the healthcare setting ( Chunmei & Zhang, 2018 ). As such, loyalty in healthcare is becoming increasingly recognized as a multifaceted construct that extends beyond transactional exchanges between patients and providers. It is deeply interwoven with factors such as service quality, patient satisfaction, and the broader ethical dimensions of care delivery ( Monferrer et al., 2019 ; Nguyen et al., 2021 ; Singh & Dixit, 2020 ). This understanding has led to a shift in focus, from merely delivering care to cultivating lasting, meaningful relationships with patients. Healthcare providers must be perceived as competent, trustworthy, and adaptable to the changing needs and expectations of patients. This is especially crucial in the context of the increasing prevalence of digital health instruments that increase patient empowerment and their participation in healthcare decision-making ( Clark et al., 2006 ). In spite of these developments, numerous healthcare organizations in Indonesia encounter difficulties in maintaining patient loyalty. This is frequently the result of inconsistent service quality, inadequate governance structures, and the inability to adjust to new technological trends ( Hsieh & Lin, 2022 ). The decline in executive patients, who contribute significantly to the revenue from outpatient and inpatient services, has become a pressing issue for many hospitals in Indonesia. Data from 2020 to 2023 show an average annual decrease of 15% in the percentage of executive patients in Figure 1 , which directly impacts the hospitals’ financial stability and operational efficiency. This trend raises important questions about the underlying causes of the decline and the strategic efforts required to address the situation. One major factor contributing to this decline is the growing patient expectation for service quality, largely driven by digital health tools and better access to information. As healthcare professionals strive to satisfy these heightened expectations, patients are more inclined to transfer doctors if their needs are not addressed ( Berry, 2019 ). Issues such as communication gaps, long waiting times, and limited accessibility to healthcare services further contribute to patient dissatisfaction, weakening patient trust and engagement over time ( Batbaatar et al., 2017 ; Siddique et al., 2024 ). Patients now have more options than they ever have before, which means that healthcare institutions are having to contend with fierce competition ( Berry, 2019 ). To remain competitive and continue to provide value, it is crucial for healthcare organizations to leverage strategies that ensure the loyalty of their patients ( Rivers & Glover, 2008 ; Senyapar, 2024 ). In addition to being more likely to use the facility again in the future, loyal patients are also more inclined to refer others to it, acting as representatives of the company’s reputation and core principles ( George & Sahadevan, 2019 ; Poku et al., 2017 ). This aspect of patient loyalty, particularly in an environment where patient choice is at an all-time high, underscores its importance as a strategic asset for healthcare institutions. While traditional approaches focus on quality of care and patient treatment outcomes, patient loyalty encompasses much more. It depends on elements that are thought to be essential to establishing and preserving long-term relationships with patients, such as emotional fulfillment, the patient experience, and the provision of individualized care ( Iversen et al., 2025 ; Li et al., 2024 ). It is crucial to have a thorough awareness of the elements that promote patient loyalty within this framework. An organization in the healthcare industry that is able to successfully negotiate these difficulties is in a position to maximize its competitive advantage and maintain its current level of performance. The understanding that leadership has a significant impact on healthcare results is at the heart of our investigation on patient loyalty ( Cummings et al., 2008 ; Patri & Suresh, 2018 ; Strömgren et al., 2017 ). Specifically, in the healthcare industry, patient loyalty is mostly dependent on innovation, adaptability, and patient-centered approaches, all of which are fostered by entrepreneurial leadership ( Sayyed et al., 2025 ). Entrepreneurial leadership, distinct from traditional management models, is characterized by a forward-thinking, proactive approach to leadership, emphasizing innovation, risk-taking, and the ability to address challenges in novel ways ( Awad et al., 2024 ; Borde et al., 2022 ). This leadership style enables healthcare organizations to adapt to shifting demands, technological advancements, and evolving patient expectations in ways that enhance patient satisfaction and, by extension, loyalty ( Adiguzel, 2025 ; Raderstorf, 2024 ). Entrepreneurial leaders are adept at recognizing opportunities for improvement and driving change within organizations ( Koryak et al., 2015 ; Wu et al., 2025 ). The entire patient experience and patient outcomes can be directly impacted by the implementation of novel technologies, the introduction of new models of care, or the improvement of operational efficiency. Entrepreneurial leaders’ ability to establish a culture of continuous improvement and foster an environment that encourages risk-taking and problem-solving is crucial for adapting to the rapidly evolving healthcare landscape ( Mehmood et al., 2021 ; Wu et al., 2025 ). For instance, by leveraging the latest medical technologies and adopting patient-centric strategies, entrepreneurial leaders can improve the quality of care and make patients feel valued, ultimately reinforcing their loyalty to the institution. This approach contrasts with traditional models of leadership that may prioritize administrative efficiency or hierarchical decision-making. Entrepreneurial leadership places greater emphasis on empowering employees, fostering innovation, and encouraging collaboration at all levels of the organization ( Mehmood et al., 2021 ; Newman et al., 2018 ). This empowerment is crucial in ensuring that the staff feels motivated to contribute to improving the patient experience, whether through direct care or support roles. Corporate governance is also very important in the healthcare business since it helps entrepreneurial executives carry out their plans. Effective corporate governance practices help ensure that healthcare organizations operate transparently and ethically, which, in turn, enhances patient trust and satisfaction ( Sayyed et al., 2025 ). Corporate governance frameworks define the processes, structures, and policies that guide the organization’s operations, providing oversight and accountability for decisions that affect patient care ( Barbazza & Tello, 2014 ). Maintaining good governance standards allows healthcare businesses to manage risks, assure regulatory compliance, and develop an ethical decision-making culture, all of which contribute to patient trust. As patient loyalty is closely tied to perceptions of trust, effective corporate governance becomes a fundamental mechanism for securing patient confidence and long-term loyalty. Service quality is another fundamental determinant of patient loyalty, refers to the overall effectiveness of healthcare services in meeting or exceeding patients’ expectations ( Chehayeb, 2023 ). The quality of service is strongly linked to patient satisfaction and is a fundamental component in fostering patient loyalty ( Alodhialah et al., 2024 ; Coutinho et al., 2019 ; Divya et al., 2025 ; Fatima et al., 2018 ; Monferrer et al., 2019 ; Olesen & Bathula, 2022 ; Özden & Çelik, 2025 ). In a healthcare setting, service quality encompasses not just clinical outcomes but also the emotional and psychological aspects of patient care ( Cadet & Sainfort, 2023 ; Endeshaw, 2021 ). Factors such as the demeanor of healthcare staff, the clarity of communication, the responsiveness of the organization to patient needs, and the overall comfort and convenience of the healthcare environment play significant roles in shaping the patient experience. When patients perceive high service quality, they are more likely to feel valued and respected, which strengthens their emotional connection to the healthcare provider and encourages repeat visits ( Dinur et al., 2025 ). Additionally, loyalty in healthcare continues to be driven by satisfaction ( Liu et al., 2021 ; Meesala & Paul, 2018 ; Rather & Hollebeek, 2019 ). Baker et al. (2021) and Tan et al. (2023) have both identified patient satisfaction as an emotional outcome that is influenced by the patient’s evaluation of the care they receive. This evaluation is influenced by factors such as the interaction with healthcare professionals, the perceived competence of the medical staff, and the overall atmosphere of the healthcare environment. The institution’s reputation and brand image can be significantly impacted by patients who are satisfied with their care, as they are more likely to return for additional services and to disseminate positive word of mouth ( Fattahi et al., 2022 ; Dandis et al., 2022 ). Consequently, the connections between corporate governance, service quality, satisfaction, and loyalty, as well as entrepreneurial leadership, are intricate yet profoundly interconnected. Overall, the multifaceted nature of patient loyalty in healthcare necessitates a comprehensive and integrated approach to understanding its drivers. Entrepreneurial leadership, corporate governance, service quality, and patient satisfaction all play crucial roles in fostering and sustaining loyalty. Healthcare businesses can deal with the problems of today’s healthcare system, come up with new ideas, and make sure that patients get the best care possible by embracing entrepreneurial leadership. By doing this, they build a foundation for long-term patient loyalty, which is important for their long-term success and ability to compete in the healthcare field. 2. Literature review and hypothesis development 2.1 The relationship between entrepreneurial leadership and corporate governance Innovative ideas, being proactive, taking risks, and being able to see and take advantage of new chances are all important parts of entrepreneurial leadership ( Clarks et al., 2019 ; Kebede et al., 2024 ). Achieving long-term success in the fast-paced corporate world of today requires leaders to be flexible and have an entrepreneurial mindset. This type of leadership goes beyond traditional management practices by fostering a culture of creativity, flexibility, and continuous improvement, all of which are crucial in driving organizational performance. On the other hand, corporate governance encompasses the systems, structures, and procedures that guarantee that organizations are effectively managed and operated in compliance with ethical standards, laws, and regulations ( Shleifer & Vishny, 1997 ). Strong corporate governance practices are vital for establishing transparency, accountability, and trust within organizations, which are necessary for sustainable growth and stakeholder confidence. Entrepreneurial leadership has a significant influence on corporate governance by encouraging innovative governance structures and practices. Entrepreneurial leaders are more likely to prioritize transparency, ethical decision-making, and accountability, as they recognize the long-term value these practices bring to the organization. They tend to foster open communication and a decentralized decision-making structure, which enhances the responsiveness and adaptability of the organization. In addition, entrepreneurial leaders are proactive in anticipating challenges and opportunities, and they tend to implement governance practices that enable organizations to remain competitive and agile in the face of change ( Renko et al., 2015 ; Awad et al., 2024 ). Moreover, entrepreneurial leadership promotes a culture of risk management and responsibility. Leaders with an entrepreneurial orientation understand the importance of managing risks while pursuing opportunities, ensuring that corporate governance practices are designed to mitigate potential risks and enhance organizational stability. Additionally, they are more inclined to advocate for ethical governance and sustainability, underscoring the significance of long-term value generation over immediate benefits. Given these considerations, it is hypothesized that: H1. Entrepreneurial leadership has a significant effect on corporate governance. 2.2 The relationship between entrepreneurial leadership and service quality In contemporary organizations, entrepreneurial leadership has become a critical factor in determining success, particularly in service-oriented industries. This leadership style blends traditional leadership competencies with entrepreneurial thinking, allowing leaders to foster innovation, adaptability, and continuous improvement ( Clarks et al., 2019 ; Kebede et al., 2024 ). Unlike conventional leadership models, which may focus more on efficiency and stability, entrepreneurial leadership emphasizes proactivity, risk-taking, and the identification of opportunities, all of which are crucial in dynamic service environments ( Renko et al., 2015 ). Leaders with entrepreneurial orientation encourage creativity, empower employees to propose innovative solutions, and emphasize the importance of customer-centric strategies, which are fundamental to achieving high service quality ( Al-Dhaafri et al., 2016 ; Kim et al., 2018 ). Service quality, in turn, is a critical factor influencing customer satisfaction and loyalty. In service industries, where the interaction between employees and customers plays a central role, delivering consistent, high-quality service is paramount. Entrepreneurial leadership promotes a culture that nurtures continuous improvement, responsiveness, and active customer engagement, all of which directly contribute to enhancing service quality ( Hoang et al., 2024 ; Kebede et al., 2024 ). By encouraging innovation and creativity, entrepreneurial leaders help organizations respond to the evolving demands of customers, which is essential in maintaining a competitive edge in the marketplace. Entrepreneurial leaders motivate their teams to innovate and take calculated risks, fostering a proactive mindset that is crucial for identifying new opportunities to improve service delivery ( Corrêa et al., 2022 ). Such leadership is particularly valuable in environments where service quality is not solely defined by standardized procedures but also by the ability to adapt to customer needs and expectations. The capacity of entrepreneurial leaders to establish an environment that encourages risk-taking and experimentation is crucial for organizations to enhance their service offerings and uphold a high level of quality, which is crucial for customer retention and the development of long-term loyalty. Furthermore, entrepreneurial leadership’s emphasis on customer engagement and relationship-building directly impacts service quality. Leaders with an entrepreneurial orientation understand the importance of aligning organizational goals with customer needs, ensuring that service delivery is not just efficient but also tailored to the customer experience ( Renko et al., 2015 ). This approach leads to the development of services that are not only effective but also resonate with customers on an emotional level, fostering stronger customer relationships and satisfaction. Through these endeavors, entrepreneurial leadership establishes a strong foundation for ongoing enhancement, which subsequently enhances organizational performance and service quality. Given these insights, the following hypothesis is proposed: H2. Entrepreneurial leadership has a significant effect on service quality. 2.3 The relationship between corporate governance and patient satisfaction An organization’s overall performance and success are greatly influenced by corporate governance, especially in service-oriented industries like healthcare. It encompasses the structures, processes, and policies that guide organizational decision-making, ensuring transparency, accountability, and ethical practices ( Al Astal et al., 2024 ; Aguilera & Ruiz Castillo, 2025 ). In healthcare, strong corporate governance is essential for maintaining high standards of service delivery, ensuring that the interests of patients are prioritized and that healthcare organizations operate in a responsible and sustainable manner ( Shleifer & Vishny, 1997 ). In turn, patient satisfaction is a critical outcome of the delivery of healthcare services. The patient’s evaluation of the care they received is encapsulated in the statement, which is influenced by the comprehensive patient experience, the availability of resources, the proficiency of healthcare professionals, and the quality of medical treatment. The organization’s long-term success and reputation are directly impacted by the probability of satisfied patients returning for future treatments, recommending the healthcare provider to others, and engaging in positive word-of-mouth ( Huang et al., 2021 ). Corporate governance influences patient satisfaction by ensuring that healthcare organizations operate with integrity, transparency, and a commitment to continuous improvement. Organizations with strong governance structures are more likely to prioritize patient-centered care, invest in staff training, and implement policies that enhance the overall patient experience. Effective governance ensures that patient safety, privacy, and quality of care are always top priorities, which are crucial for building trust with patients. Moreover, governance structures that promote accountability and ethical decision-making foster an environment where healthcare providers are incentivized to meet or exceed patient expectations ( Knowles, 2024 ). When governance mechanisms are in place to monitor performance, allocate resources effectively, and maintain ethical standards, patients are more likely to perceive the healthcare institution as reliable and trustworthy, which significantly enhances their satisfaction ( Meesala & Paul, 2018 ; Sadeh, 2017 ). Given these considerations, it is hypothesized that: H3. Corporate governance has a significant effect on patient satisfaction. 2.4 The Relationship Between Corporate Governance and Patient Loyalty The long-term success and sustainability of healthcare organizations are significantly influenced by corporate governance. It pertains to the organizational systems, structures, and procedures that guarantee accountability, transparency, and ethical decision-making, all of which are indispensable for the organization’s efficient operation ( Shleifer & Vishny, 1997 ). In healthcare, corporate governance involves policies and practices that prioritize patient care, safety, and satisfaction, while also ensuring compliance with legal and ethical standards. Strong governance frameworks are necessary for fostering trust and confidence among patients, which directly influences their loyalty to healthcare providers. Patient loyalty is the term used to describe a patient’s enduring dedication to a specific healthcare provider, which is influenced by their contentment with the services they receive, trust, and positive experiences. The healthcare organization’s reputation, growth, and financial stability are substantially influenced by the likelihood of loyal patients returning for future medical care, adhering to prescribed treatment plans, and recommending the provider to others. Building patient loyalty necessitates not only the provision of high-quality care, but also the organization’s adherence to ethical standards, transparency, and responsiveness to patient needs and concerns. Corporate governance influences patient loyalty by creating an environment of trust and reliability. Healthcare organizations with strong governance practices are more likely to implement policies and procedures that align with patient needs, ensuring that services are consistently high-quality, accessible, and patient-centered. Effective governance fosters transparency in decision-making, ensures the proper allocation of resources, and promotes ethical practices that prioritize patient well-being. When patients perceive that a healthcare organization operates with integrity and accountability, they are more likely to develop a strong emotional attachment to the provider, which is essential for fostering long-term loyalty ( Meesala & Paul, 2018 ). Moreover, strong corporate governance encourages healthcare organizations to be responsive to patient feedback and continuously improve the quality of care. By adopting patient-centered policies, maintaining high standards of care, and ensuring that patients’ concerns are addressed in a timely and empathetic manner, organizations build a loyal patient base. Ethical governance practices, such as protecting patient privacy, enhancing the patient experience, and ensuring transparency in billing and treatment options, are crucial for building trust and loyalty. Patients who trust their healthcare provider are more likely to remain loyal, even in the face of alternative options ( Sadeh, 2017 ; Malenfant et al., 2022 ). Given these considerations, it is hypothesized that: H4. Corporate governance has a significant effect on patient loyalty. 2.5 The Relationship Between Service Quality and Patient Satisfaction In healthcare contexts, service quality is a critical factor in determining patient satisfaction, as it directly impacts patients’ perceptions of value, trust, and their overall experience with a healthcare provider ( Akthar et al., 2023 ; Alfarizi, 2022 ). The notion of service quality incorporates a variety of dimensions, such as the tangible aspects of care that meet or exceed patient expectations, reliability, responsiveness, assurance, and empathy ( Parasuraman et al., 1988 ; Zeithaml et al., 1996 ). Patients are more likely to have positive feelings about a hospital if it regularly provides high-quality services. This leads to higher levels of happiness and greater loyalty ( Fatima et al., 2018 ; Kim et al., 2017 ; Shabbir et al., 2016 ). In contrast, bad service quality, like treatment delays, staff members acting rudely, or not meeting patients’ needs, can cause dissatisfaction, bad word-of-mouth, and patients leaving, which hurts healthcare institutions’ reputation and bottom line ( Agarwal et al., 2024 ; Gangopadhyay & Ukil, 2022 ). Patients evaluate their experiences not only based on clinical outcomes but also on factors such as the attentiveness of healthcare providers, the clarity of communication, the cleanliness of facilities, and the ease of accessing services. Patients feel better about their care when the service is of high quality, which builds trust and emotional connections with healthcare workers. This is very important in the healthcare field, where patients’ mental and emotional health is just as important as their physical health ( Fatima et al., 2018 ; Meesala & Paul, 2018 ). Patients who are happy are not only more likely to return for more care, but they are also more likely to tell others about the healthcare center, which improves its reputation and helps it succeed in the long run ( Moreira & Silva, 2015 ; Smith, 2021 ). Oliver’s (1980) Expectation Disconfirmation Theory is a useful way to think about how service quality affects customer satisfaction. This idea says that happiness happens when what the patient expected and what they actually got don’t match up. When the quality of the service goes above and beyond what the patient expected, it leads to positive disconfirmation and high levels of happiness. If the quality of the service doesn’t live up to standards, on the other hand, negative disconfirmation happens, which makes the customer unhappy. This theory shows how important it is to meet and go beyond what patients expect to make sure they are completely satisfied. When it comes to healthcare, this means that people who get consistent, reliable, and quick service are more likely to feel like their needs were met or exceeded, which makes them happier. Patients are also rendered pleased by the quality of their service, which cultivates emotional connections and confidence between them and their healthcare providers ( Fatima et al., 2018 ; Meesala & Paul, 2018 ; Shan et al., 2016 ). A patient is more inclined to believe that the care they receive is of high quality if they have faith in their healthcare provider, even in the face of obstacles or complications during treatment. Patients who have a positive emotional experience and trust their therapists are more likely to be satisfied with the service as a whole. This increases the probability of their return and the establishment of enduring relationships. Service quality also enhances patient satisfaction by ensuring that patients feel valued and respected throughout their healthcare journey, from the initial contact to the follow-up after treatment. Hospitals that prioritize continuous service improvements—whether through staff training, adopting the latest technologies, or implementing patient feedback mechanisms—are better equipped to enhance patient satisfaction ( Bhati et al., 2023 ; Lee et al., 2012 ; Sunder et al., 2020 ). By fostering an environment of continuous improvement, healthcare institutions demonstrate their commitment to delivering high-quality care that evolves in response to patient needs and expectations. Training staff to be responsive, empathetic, and attentive to patient concerns is essential in improving the quality of service, as these interpersonal factors significantly influence patient satisfaction. Moreover, hospitals that actively seek and act on patient feedback can identify areas for improvement and ensure that the services provided align more closely with patient needs. Service quality affects more than just happiness. It also affects brand loyalty and patient retention, which are very important for the long-term success of healthcare organizations ( Meesala & Paul, 2018 ; Shabbir et al., 2016 ; Vimla & Taneja, 2021 ). When patients are happy with the quality of care they receive, they are more likely to return for more care and tell their family and friends about the provider. There are more patients who stay with the practice, and their group of loyal patients grows. Healthcare companies that put a lot of emphasis on service quality are better able to build and keep long-term relationships with their customers. This makes them more competitive in the market. Thus, the following hypothesis is proposed: H5. Service quality has a significant effect on patient satisfaction. 2.6 The relationship between service quality and patient loyalty Service quality is one of the most important factors in keeping patients coming back, which is important for healthcare workers’ long-term success and survival. Patients’ trust, satisfaction, and desire to build and keep long-term relationships with their healthcare providers are all directly affected by the quality of the care they receive ( Parasuraman et al., 1988 ). Service quality characteristics like dependability, responsiveness, empathy, and competence are important for giving patients good experiences that make them more loyal to a certain provider ( Cadet & Sainfort, 2023 ; Chen et al., 2024 ; Hannawa et al., 2022 ). When patients regularly feel these things about their healthcare provider, they are more likely to form a strong bond with them, which is important for keeping patients loyal. On the other hand, patients are more likely to switch providers if they think the level of service is poor or inconsistent. This makes it harder to keep patients and keep them loyal. The Social Exchange Theory ( Naidu, 2009 ; Swain & Kar, 2018 ) is a useful way to look at the connection between good service and loyal customers. This idea says that people interact with each other because they expect to get something in return. People who need medical care want value in the form of high-quality care, individualized treatment, and caring interactions with medical experts. People who have these needs met feel like the healthcare provider values their time, trust, and resources, which makes them more loyal to that provider. Patients who feel valued, respected, and cared for are more likely to return for future visits and tell others about the provider. This helps the provider get more patients and improves its image ( Malenfant et al., 2022 ; Sinclair et al., 2016 ). Service quality and patient loyalty are linked in a good way, and emotional ties and trust make that link even stronger. Patients feel safe and confident in their healthcare provider when they consistently receive high-quality care. This makes them less likely to look for care elsewhere ( Alodhialah et al., 2024 ; Widiastuti et al., 2024 ). These emotional bonds and trust are crucial for the long-term retention of patients. Trust, in particular, is a key determinant of patient loyalty, as it influences patients’ decisions to stay with a provider and seek ongoing care for future health needs. A healthcare provider that consistently demonstrates reliability, expertise, and genuine concern for patients’ well-being fosters a deeper emotional connection with patients, reinforcing their loyalty over time. Service quality also plays a critical role in patient engagement, another crucial factor in sustainable loyalty. Healthcare providers that continuously focus on improving service delivery, ensuring patient-centered care, and engaging in transparent communication are more likely to retain their patients and encourage long-term relationships ( Fukami, 2024 ; Omaghomi et al., 2024 ). Such institutions create an environment in which patients feel heard, valued, and understood, thus enhancing their overall experience. This emphasis on continuous service improvement and patient satisfaction not only leads to immediate patient retention but also lays the foundation for enduring loyalty. Additionally, healthcare providers who are transparent in their communications and address patient concerns in a timely and empathetic manner are more likely to foster positive relationships that transcend one-time visits and encourage ongoing care. Moreover, healthcare organizations that prioritize service quality are better positioned to create a differentiated competitive advantage. In an increasingly competitive healthcare environment, where patients have more choices than ever, organizations that provide superior service quality stand out. The consistency with which a provider delivers high-quality care influences patients’ perceptions of the provider’s commitment to their well-being, thus strengthening the emotional connection between patients and the institution. This emotional connection is crucial for long-term loyalty and retention. Patients who feel that their healthcare provider genuinely cares for them are more likely to remain loyal, even in the face of external options that may appear more convenient or less costly. Service quality affects patient loyalty in more ways than just clinical results. Patients’ general loyalty to a healthcare provider is based on how happy they are with their interactions with staff, how easy it is to get services, and how nice the space is. Patients are more likely to stay with the same healthcare provider for a long time if they think their whole experience, from making appointments to following up after care, was excellent. This all-around view of service quality makes sure that patient loyalty isn’t just based on medical results, but also on the whole service experience that healthcare institutions offer. Thus, we hypothesize: H6. Service quality has a significant effect on patient loyalty. 2.7 The relationship between patient satisfaction and patient loyalty Long-term patient loyalty in healthcare depends a lot on how happy and satisfied the patient is. An established link has been found between these two factors; happy patients are more likely to stay loyal to their healthcare providers, return for more care, and suggest the provider to others ( Meesala & Paul, 2018 ). Patient satisfaction has an effect on loyalty because of both the good experiences that happen right away and the emotional ties and trust that are built over time. When it comes to healthcare, satisfaction can mean a lot of different things, such as the quality of communication, responsiveness, dependability, empathy, and the general service experience. When these things match up with what the patient wants, they make an emotional link that leads to long-term loyalty. A good way to understand how patient happiness affects loyalty is to look at social exchange theory. This idea says that ties between people and groups are based on exchanges that are good for both sides ( Naidu, 2009 ; Swain & Kar, 2018 ). The exchange in healthcare means giving people high-quality care and services in exchange for their time, trust, and money. Patients are more likely to keep working with the same provider if they think they got good value for their time through quick, responsive care and a positive overall experience. This exchange of value makes the relationship between the patient and the healthcare provider stronger, which makes the patient happier and, in the end, more loyal. Researchers have found that patients who are happy with their care are more likely to form strong emotional bonds with their doctors, which can lead to long-term trust ( Dayan et al., 2022 ; Kumah, 2019 ; Vink et al., 2019 ). These patients believe their providers and feel safe with their care, which makes them less likely to look for services from other companies. This emotional connection goes beyond just getting what you want; it turns into a commitment to the healthcare worker as a person. Not only are happy patients likely to return for future medical needs, they also act as champions for the provider, telling family and friends about the healthcare institution, which makes them even more loyal ( Sadeh, 2017 ; Zhang et al., 2022 ). The main idea behind this is that patient happiness both leads to loyalty and helps keep that loyalty strong over time. Additionally, patient satisfaction plays a crucial role in reducing patient churn, which is the process of patients discontinuing services or switching providers. In highly competitive healthcare environments, where patients have a wide range of options, dissatisfaction can quickly lead to patient attrition. However, when patients feel satisfied with their care, they are less likely to consider alternatives. High satisfaction levels also contribute to patient retention, which is particularly valuable in healthcare settings where long-term relationships with patients are crucial for sustained organizational success. When healthcare providers consistently meet or exceed patient expectations, they reduce the likelihood of patient churn and build a loyal patient base ( Huang et al., 2021 ; Liu et al., 2021 ). Also, the emotional and relational parts of caring for a patient are just as important for building long-term loyalty as the clinical results. The emotional and mental needs of patients are closely linked to how they see the level of care, which in turn affects how satisfied they are. For instance, patients who feel like their healthcare providers listen, understand, and value them are more likely to be very satisfied, which makes them more loyal to that provider. This makes a point of showing that patient happiness isn’t just about how well they did in the medical setting, but also about how well they were treated by other people. When healthcare providers focus on these aspects of care, customer satisfaction goes up, which leads to more loyal patients. Based on these considerations, the following hypothesis is proposed: H7. Patient satisfaction has a significant effect on patient loyalty. Based on this explanation, the hypothesis model can be seen in Figure 2 . 3. Research methods 3.1 Population and sample The population for this study consists of executive patients who have received medical treatment at hospitals located in West Java, Indonesia. This regional focus ensures that the research reflects the specific healthcare environment within this area. A total of eight hospitals were selected from a pool of 50 hospitals in West Java, based on the following criteria: each hospital must have more than 200 beds and be classified as Type B. Type B hospitals were chosen due to their capacity to provide comprehensive healthcare services and their significant patient volume, making them representative of the broader healthcare system in the region. The total population of executive patients across these hospitals is 9,030. The inclusion criteria for this study were executive patients who have visited the hospital at least twice within the past year. A sample size of 384 was calculated using the Slovin formula with a 5% margin of error, ensuring that the sample size was statistically valid for the given population. The formula used is: n = N 1 + N e 2 = 9030 1 + 9030 ∗ 0.5 2 = 383,03 ≈ 384 Using this formula, the total sample size of 384 was determined. To ensure proportional representation across the hospitals, the sample was then distributed proportionally based on the total number of patients at each hospital. To calculate the proportional sample for each hospital, the following equation was used: Proportional Sample = Total Patient at Hospital Total Population × Total Sample Size The total number of patients and the proportional sample across the selected hospitals is shown in Table 1 . Table 1. Population of selected hospitals in West Java, Indonesia. No Hospital location Total patients Sample size 1 Jatinegara 1,213 52 2 Kemayoran 890 38 3 Bekasi 2,047 87 4 Depok 1,275 54 5 Daan Mogot 1,219 52 6 Bogor 1,030 44 7 Pasteur 919 39 8 Grand Wisata 437 19 Total 9,030 384 Figure 1. Estimated decline in percentage of executive patients in Indonesian hospitals (2020-2023). Source: Internal Report of Indonesian Hospitals (2023). Figure 2. Hypothesis model. Source: Author’s Own Work (2025). Ethical approval for this study was obtained from Universitas Brawijaya, effective from September 2024. The ethical approval process ensured patient confidentiality, informed consent, and that no coercion was involved in participation. This study was conducted from September to October 2024, with ethical approval obtained prior to the commencement of data collection. 3.2 Variables measurement A structured questionnaire made to measure key variables linked to the study was used to collect the data for this study. The way each variable was measured was based on well-known categories and scales from other research. Items from questionnaires that were used in other studies were changed to fit the needs of this study better. To find out how much people agreed with each statement, a 5-point Likert scale was used for each variable. The scale went from “strongly disagree” to “strongly agree.” Entrepreneurial Leadership ( Abubakar et al., 2018 ) was measured by assessing statements that reflect the leader’s role in fostering innovation, creating solutions for complex problems, being proactive in facing challenges, and having a clear strategic vision. The specific statements included: “The leader encourages innovation in the organization,” “The leader creates creative solutions for complex problems,” “The leader is proactive in facing challenges,” and “The leader has a clear strategic vision.” Corporate Governance ( Novatiani et al., 2022 ) was measured through statements that reflect transparency, accountability, and social responsibility. The relevant statements included: “Important information is communicated openly to stakeholders,” “The company is accountable for every decision it makes,” and “The company is actively involved in social responsibility.” Service Quality ( Altuntas et al., 2012 ) was assessed using statements based on the SERVQUAL model, which includes dimensions like reliability, responsiveness, assurance, and empathy. The statements used to measure service quality were: “The service provided meets expectations,” “The staff shows empathy toward patients,” “The medical staff understands the emotional needs of patients,” “The staff responds quickly to the needs of patients,” and “The staff possesses good competency in delivering services.” Patient Satisfaction ( Abekah-Nkrumah et al., 2021 ) was measured by statements reflecting whether patient expectations were met, their comfort during service delivery, and their emotional connection to the healthcare provider. The statements included: “The patient’s expectations of the service are met,” “The patient feels comfortable during the service process,” and “The patient has an emotional bond with the hospital.” Patient Loyalty ( Abekah-Nkrumah et al., 2021 ) was measured by statements evaluating the patient’s intention to return, recommend the service, and trust the healthcare provider. The relevant statements were: “The patient intends to return to use the service,” “The patient will recommend the service to others,” and “The patient has full trust in the hospital’s services.” 3.3 Data analysis techniques The data were analyzed with Partial Least Squares (PLS) via SmartPLS 4.0. PLS is a resilient technique that does not necessitate the data to conform to the normalcy assumptions of conventional statistical tests. This study is well-suited for examining correlations among various variables and forecasting their effects. The investigation sought to assess the interconnections among entrepreneurial leadership, corporate governance, service quality, satisfaction, and patient loyalty. To mitigate any common method bias, the study meticulously crafted the questionnaire items to reduce response biases, specifically by eliminating leading or confusing questions. The measurement devices’ validity and reliability were rigorously evaluated. Construct validity was evaluated by correlation analysis to confirm that the items sufficiently represented the target constructs. Reliability was assessed using Cronbach’s alpha, with all constructs surpassing the conventional criterion of 0.70, signifying strong internal consistency. 4. Results 4.1 Demographic respondent Table 2 provides a summary of the demographic characteristics of the respondents. The following important characteristics are present in the sample of 384 respondents: Table 2. Demographic information of respondents. Characteristic Frequency Percent (%) Gender Male 287 74.7 Female 97 25.3 Education level High school 136 35.42 Diploma 96 25 Bachelor’s degree 77 20.05 Master’s degree 66 17.19 Doctorate 9 2.34 Age group 0-17 years 8 2.08 17-30 years 99 25.78 30-40 years 148 38.54 40-50 years 82 21.35 50-60 years 38 9.90 Above 60 years 9 2.34 Occupation Private sector employee 195 50.78 Housewife 73 19.01 Entrepreneur/self-employed 35 9.11 Government employee/Army/Police 20 5.21 Other 61 15.89 Table 2 illustrates the demographic attributes of the respondents, indicating a heterogeneous sample regarding gender, education, age, and occupation. The bulk of responders were male, constituting 74.7% (287), and females accounted for 25.3% (97). The majority of respondents attained a high school education (35.42%), followed by those with a diploma (25%), a bachelor’s degree (20.05%), a master’s degree (17.19%), and a minor percentage with a PhD (2.34%). Regarding age, the largest group of respondents was between 30-40 years old, accounting for 38.54% (148). This was followed by the 17-30 years group (25.78%, 99), the 40-50 years group (21.35%, 82), and smaller proportions in the 50-60 years (9.90%, 38) and 0-17 years (2.08%, 8) groups. Only 2.34% (9) of respondents were above 60 years old. In terms of occupation, more than half of the respondents were private sector employees (50.78%, 195), while 19.01% (73) were housewives. Entrepreneurs and self-employed individuals represented 9.11% (35) of the sample, and government employees, including those from the army and police, made up 5.21% (20). The remaining 15.89% (61) of respondents fell under the “Other” category, which includes various occupations not specified in the other groups. 4.2 Measurement model The measuring model was evaluated to determine the reliability and validity of the constructs employed in this investigation. The evaluation concentrated on various critical criteria to guarantee the integrity of the measurement model ( Aburumman et al., 2022 ; Hair et al., 2017 , 2019 ). The criteria encompassed the reliability of the constructs, tested using Cronbach’s Alpha (CA) and Composite Reliability (CR), while convergent validity was examined through indicator loadings and Average Variance Extracted (AVE). Table 3 displays the outcomes of the measurement model evaluation. Table 3. Measurement model assessment. Variable Indicators Loading factor CA CR AVE Entrepreneurial Leadership EL1 0.827 0.890 0.912 0.657 EL2 0.838 EL3 0.868 EL4 0.887 EL5 0.893 EL6 0.904 EL7 0.905 EL8 0.914 EL9 0.912 EL10 0.886 EL11 0.870 EL12 0.871 EL13 0.871 Corporate Governance CG1 0.870 0.915 0.930 0.689 CG2 0.873 CG3 0.896 CG4 0.909 CG5 0.883 CG6 0.887 CG7 0.857 CG8 0.896 Service Quality SQ1 0.899 0.895 0.910 0.710 SQ2 0.904 SQ3 0.897 SQ4 0.908 SQ5 0.893 SQ6 0.901 SQ7 0.828 SQ8 0.860 SQ9 0.830 Satisfaction S1 0.892 0.920 0.940 0.749 S2 0.908 S3 0.906 S4 0.934 Patient Loyalty PL1 0.867 0.895 0.915 0.725 PL2 0.892 PL3 0.863 PL4 0.879 PL5 0.920 PL6 0.893 PL7 0.899 PL8 0.897 According to Table 3 , all items have factor loadings (FL) exceeding 0.7, signifying their validity and appropriateness for assessing their corresponding latent components. The AVE values for all variables surpass the 0.5 threshold, validating that the constructs adequately account for variance in their indicators. Moreover, the findings indicate that all variables and their measurement indicators satisfy the necessary reliability criteria, with both CA and CR ratings surpassing 0.7. The findings indicate that all variables and indicators satisfy the requisite validity and reliability standards, affirming their appropriateness for subsequent study ( Ahmed et al., 2024 ; Sarstedt et al., 2019 ). Following the evaluation of convergent validity and reliability, the subsequent phase in examining the constructs involves the discriminant validity test, executed by the Heterotrait-Monotrait (HTMT) ratio. The HTMT ratio is presented in Table 4 . Table 4. HTMT Ratio. Variable Entrepreneurial Leadership Corporate Governance Service Quality Satisfaction Patient Loyalty Entrepreneurial Leadership 0.763 Corporate Governance 0.512 0.796 Service Quality 0.478 0.502 0.781 Satisfaction 0.532 0.564 0.588 0.838 Patient Loyalty 0.490 0.529 0.547 0.623 0.746 The HTMT analysis findings are displayed in Table 4 , which demonstrates that all constructs have HTMT ratio values less than 0.90. This requirement has been satisfactorily satisfied in terms of discriminant validity ( Hair et al., 2017 ; Henseler et al., 2015 ). Consequently, every variable satisfies the criteria for discriminant validity and is accepted for the next testing phases. 4.3 Structural model The subsequent phase is to examine the structural model after assessing the reliability and validity of the measurement model. The variance inflation factor (VIF), the coefficient of determination (R 2 ), the cross-validated redundancy measure derived from blindfolding (Q 2 ), and the statistical significance and relevance of path coefficients are among the primary evaluation criteria. The results of the structural model assessment are summarized in Table 5 . Table 5. Structural model assesment. Hypothesis Path Coefficient T Statistic P-values VIF f 2 H1: Entrepreneurial leadership on corporate governance 0.946 109.029 0.000 1.718 0.172 H2: Entrepreneurial leadership on service quality 0.737 8.088 0.000 1.923 0.216 H3: Corporate governance on patient satisfaction 0.214 2.233 0.026 1.890 0.195 H4: Corporate governance on patient loyalty 0.315 5.389 0.000 2.122 0.255 H5: Service quality on patient satisfaction 0.198 1.337 0.181 2.329 0.278 H6: Service quality on patient loyalty 0.150 2.443 0.015 2.455 0.288 H7: Patient satisfaction on patient loyalty 0.172 2.412 0.016 2.561 0.294 The structural model assessment in Table 5 indicates that entrepreneurial leadership exerts a robust and statistically significant influence on corporate governance (path coefficient = 0.946, p-value = 0.000) and service quality (path coefficient = 0.737, p-value = 0.000), underscoring its vital role in improving these elements. Corporate governance has a substantial impact on patient loyalty (path coefficient = 0.315, p-value = 0.000), whereas its effect on patient satisfaction is minimal (path coefficient = 0.214, p-value = 0.026). The correlation between service quality and patient satisfaction is insignificant (path coefficient = 0.198, p-value = 0.181), signifying an absence of direct influence in this model. Service quality strongly influences patient loyalty (path coefficient = 0.150, p-value = 0.015), whereas patient happiness has a favorable effect on patient loyalty (path coefficient = 0.172, p-value = 0.016). Entrepreneurial leadership profoundly affects governance and service quality, thus influencing patient loyalty, while patient satisfaction is equally crucial in cultivating loyalty. Moreover, the VIF values, all beneath the threshold of 5, signify the absence of multicollinearity issues inside the model. This guarantees the stability and reliability of the path coefficient estimations, affirming that the relationships among the variables are not skewed by high correlation among predictors. The effect size (f 2 ) values demonstrate moderate to substantial impacts for the principal relationships in the model. Corporate governance (f 2 = 0.255), service quality (f 2 = 0.288), and patient satisfaction (f 2 = 0.294) have significant effects, with the most pronounced influence noted for patient satisfaction on patient loyalty (f 2 = 0.294). The R 2 values presented in Table 6 for corporate governance, service quality, patient happiness, and patient loyalty are 0.895, 0.908, 0.822, and 0.949, respectively. The elevated R 2 values indicate that the model accounts for a significant percentage of the variance in each construct, signifying a strong fit between the model and the data. The Q 2 values exceed 0.5 for all constructs, signifying that the model possesses substantial predictive relevance. Table 6. R-square and Q-square value. Construct R 2 Q 2 Corporate Governance 0.895 0.891 Service Quality 0.908 0.902 Patient Satisfaction 0.822 0.817 Patient Loyalty 0.949 0.935 5. Discussion This study’s findings offer significant insights into the interconnections among entrepreneurial leadership, corporate governance, service quality, patient satisfaction, and patient loyalty within healthcare environments. The examination of the structural model indicates the crucial influence of entrepreneurial leadership on improving corporate governance and service quality, along with its indirect impact on patient happiness and loyalty. Entrepreneurial leadership demonstrates a strong positive influence on corporate governance, as evidenced by the high path coefficient and significant p-value. This finding highlights the importance of proactive, innovative, and risk-taking leadership in shaping governance structures within healthcare organizations. Leaders who adopt an entrepreneurial mindset foster transparency, accountability, and ethical decision-making, which are essential for ensuring effective governance. In healthcare settings, especially those in rapidly changing environments, entrepreneurial leadership helps organizations remain adaptable, competitive, and patient-centered. By adopting innovative governance structures, these leaders can drive operational efficiency, enhance patient care, and maintain high standards of ethical practice. This aligns with previous research indicating that entrepreneurial leadership is key to the sustainable success of organizations ( Clarks et al., 2019 ; Kebede et al., 2024 ). Similarly, the significant relationship between entrepreneurial leadership and service quality underscores the critical role of leadership in improving the quality of care provided. Entrepreneurial leaders prioritize continuous improvement, innovation, and customer-centric strategies, which directly contribute to the enhancement of service quality. These leaders encourage staff creativity, empower teams to innovate, and foster a culture of responsiveness, all of which lead to improved patient outcomes and satisfaction. The path coefficient further supports the idea that entrepreneurial leadership is a significant driver of service quality in healthcare organizations ( Renko et al., 2015 ; Kim et al., 2018 ). Healthcare institutions led by entrepreneurial figures are better equipped to incorporate new technologies, respond to patient needs, and continuously refine service delivery to meet evolving expectations. However, while corporate governance was found to significantly influence both patient satisfaction and patient loyalty, the effect on patient satisfaction is moderate. This indicates that although strong governance practices contribute to improving patient satisfaction by ensuring transparency, ethical decision-making, and efficient resource allocation, other factors, such as service quality and leadership, may play more substantial roles. In healthcare, patient satisfaction is highly influenced by the direct interactions patients have with healthcare providers, as well as the overall service environment. Governance, while essential for creating an ethical and patient-centered environment, may not be as directly impactful on satisfaction compared to more immediate service experiences. In contrast, corporate governance has a more pronounced effect on patient loyalty, indicating that patients are more likely to remain loyal to providers that exhibit strong ethical standards, transparency, and accountability. Effective governance practices help establish long-term trust between patients and healthcare organizations, which is a crucial factor in patient loyalty. Hospitals with robust governance structures are more likely to consistently deliver high-quality care, address patient concerns in a timely manner, and adapt to changes in patient needs. These factors contribute to sustained patient loyalty, as patients perceive these organizations as reliable and trustworthy ( Meesala & Paul, 2018 ). The lack of a significant relationship between patient satisfaction and service quality implies that, in this model, patient satisfaction may not be directly and substantially influenced by service quality alone. This discovery may suggest that, although service quality is crucial, satisfaction levels are more significantly influenced by other variables, including interpersonal communication, emotional engagement, and patient-provider relationship. There is a possibility that patient satisfaction is more significantly impacted by factors such as staff empathy, communication, and personal care in healthcare settings than by the technical quality of the services provided. Conversely, it was found that patient loyalty is substantially influenced by service quality, which confirms that patients who perceive high service quality are more inclined to remain loyal to their healthcare provider. This is especially crucial in a healthcare market that is highly competitive, as patients have a plethora of choices. Healthcare providers that provide high-quality services, which are defined by responsiveness, empathy, and reliability, are more likely to establish strong emotional connections with their patients. These connections are essential for cultivating long-term loyalty. This is consistent with the Social Exchange Theory, which posits that patients perceive value from their healthcare provider, resulting in increased engagement and loyalty ( Naidu, 2009 ; Swain & Kar, 2018 ). Furthermore, the substantial influence of patient satisfaction on patient loyalty underscores the necessity of addressing both the technical and affective components of care. The likelihood of patients remaining loyal to their healthcare provider is higher when they are satisfied with the care they receive, including emotional support and clinical outcomes. The relational aspects of patient care, including the extent to which patients feel heard, respected, and comprehended, are equally important as clinical outcomes in the development of enduring loyalty ( Dayan et al., 2022 ; Liu et al., 2021 ). 6. Conclusion The data analysis reveals that entrepreneurial leadership has a significant positive effect on both corporate governance and service quality. Entrepreneurial leaders, by fostering innovation and proactivity, enhance governance structures that promote transparency, accountability, and ethical decision-making, leading to improved service delivery. Corporate governance was found to have a positive impact on both patient satisfaction and patient loyalty, with well-structured governance contributing to higher satisfaction and long-term loyalty. However, while corporate governance influences patient satisfaction, its effect is moderate compared to service quality and leadership. Service quality, although not directly influencing patient satisfaction, was found to significantly affect patient loyalty, showing that high service quality fosters emotional connections and long-term loyalty. Lastly, patient satisfaction was confirmed to be a critical driver of patient loyalty, as satisfied patients are more likely to return and recommend the healthcare provider. From a practical standpoint, healthcare organizations must focus on fostering entrepreneurial leadership, improving corporate governance, and prioritizing service quality to enhance patient satisfaction and loyalty. Leaders should be equipped with the skills to drive innovation, manage risks, and adapt to changing patient expectations. Furthermore, healthcare managers should ensure that governance structures are ethical, transparent, and accountable, with a focus on patient-centered care. Investment in service quality, particularly through staff training, process optimization, and patient feedback mechanisms, is also essential for creating a positive patient experience. This research has significant implications for the practice of healthcare. It implies that healthcare organizations should allocate resources to leadership development programs in order to cultivate entrepreneurial leadership that can facilitate patient care and innovation. In turn, healthcare providers will be able to operate with greater transparency and accountability, which will increase patient satisfaction and loyalty, as a result of the strengthening of corporate governance policies. Lastly, healthcare organizations will be able to maintain their competitiveness and establish enduring relationships with patients by continuing to prioritize service quality enhancements through staff training, patient engagement, and technological advancements. In the future, longitudinal studies should be conducted to evaluate the long-term impact of leadership, governance, and service quality on patient loyalty, as well as the potential mediation effects between the variables. The generalizability of the results could be improved by extending the findings to other healthcare systems, as this research is also founded on a specific sample. Ethical approval This study involving human participants was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval for all study procedures was obtained from the Ethics Committee of the Faculty of Administrative Science, University of Brawijaya, with approval number: 06210/UN10.F0301/B/PP/2025. Prior to participation, informed consent was obtained verbally from all respondents. Verbal consent was chosen over written informed consent due to the nature of the study, which involved minimal risk and was conducted in informal, community-based settings where participants expressed hesitation in signing formal documents. Many participants were more comfortable providing verbal agreement, which was considered culturally appropriate and less intimidating. The procedure for obtaining verbal consent, including a clear explanation of the study’s purpose, risks, benefits, and confidentiality measures, was approved by the Ethics Committee. The anonymity and confidentiality of participants were strictly maintained, and no personally identifiable information was collected. Participation in the study was entirely voluntary and did not influence any rights or access to services of the participants. Data availability statement Underlying data Raw Data for “Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction”, DOI: dx.doi.org/10.6084/m9.figshare.29625374 ( Hanafi et al., 2025c ). Extended data Figshare: Questionnaire for “Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction”, DOI: dx.doi.org/10.6084/m9.figshare.29486258 ( Hanafi et al., 2025a ). Reporting guidelines STROBE checklist for “Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction”, DOI: dx.doi.org/10.6084/m9.figshare.29486288 ( Hanafi et al., 2025b ). Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements The authors would like to thank all study participants for their valuable time and insights. 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 Business Administration, Universitas Brawijaya, Malang, East Java, 65145, Indonesia Iing Ichsan Hanafi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Taher Alhabsji Roles: Conceptualization, Methodology, Supervision, Validation Kadarisman Hidayat Roles: Conceptualization, Methodology, Supervision, Validation Ari Darmawan Roles: Conceptualization, Methodology, Validation, Visualization Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 14 Nov 2025, 14:1040 https://doi.org/10.12688/f1000research.166837.2 version 1 Published: 03 Oct 2025, 14:1040 https://doi.org/10.12688/f1000research.166837.1 Copyright © 2025 Hanafi II et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Hanafi II, Alhabsji T, Hidayat K and Darmawan A. Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.12688/f1000research.166837.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 03 Oct 2025 Views 0 Cite How to cite this report: Ansyori A. Reviewer Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r424374 ) The direct URL for this report is: https://f1000research.com/articles/14-1040/v1#referee-response-424374 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Oct 2025 Anis Ansyori , Institute of Science and Health Technology, Dr. Soepraoen Hospital, Malang, Indonesia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.183885.r424374 What the paper does well: Important topic for hospitals: how leadership and governance drive service quality, satisfaction, and loyalty. Strong method: survey of 384 “executive” patients in West Java; PLS-SEM with solid reliability/validity. ... Continue reading READ ALL What the paper does well: Important topic for hospitals: how leadership and governance drive service quality, satisfaction, and loyalty. Strong method: survey of 384 “executive” patients in West Java; PLS-SEM with solid reliability/validity. Clear findings: entrepreneurial leadership strongly improves governance and service quality; governance, service quality, and satisfaction support patient loyalty. Useful, practical implications for managers and policymakers. Small fixes before acceptance: Make results consistent: The abstract says service quality affects satisfaction, but the model shows this path is not significant—please align wording across abstract/results/discussion. Clarify “executive patients” : Define the segment briefly and note limits for generalization. Complete tables/figures: Ensure all tables (samples, demographics, measurement, structural paths) and figures (trend chart, model with coefficients/p-values) are fully labeled and readable. Sampling/math details : Show the proportional allocation per hospital and the Slovin formula clearly (with e=0.05). Minor editing : Fix typos/name inconsistencies and standardize references/citation style. Bottom line: A well-designed and relevant study. With these minor clarifications and formatting tweaks, it’s ready for indexing. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public relations and strategic health communication, health literacy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ansyori A. Reviewer Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r424374 ) The direct URL for this report is: https://f1000research.com/articles/14-1040/v1#referee-response-424374 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 24 Nov 2025 Iing Ichsan Hanafi , Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia 24 Nov 2025 Author Response What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of ... Continue reading What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of our findings. We are glad that the practical implications for managers and policymakers were evident. Small fixes before acceptance : Make results consistent : We have aligned the wording across the abstract , results , and discussion regarding the relationship between service quality and satisfaction . Specifically, we have corrected the abstract to reflect the non-significant path from service quality to satisfaction, which is consistent with the results and discussion. Clarify “executive patients” : We have added a brief definition of executive patients in the abstract and clarified that this subgroup represents patients who are insured under premium healthcare plans and often seek specialized care, which may limit generalization to the broader patient population. This explanation is now present in both the abstract and introduction for clarity. Complete tables/figures : We have ensured that all tables and figures are fully labeled and readable. Specifically, we have reviewed the following: Tables : Included full labels for sample size , demographics , and measurement . Figures : All figures, including the trend chart and structural model with coefficients/p-values , have been adjusted for clarity and readability. Sampling/math details : We have included the proportional allocation per hospital in the Research Methods section and clearly displayed the Slovin formula with e = 0.05 for sample size calculation, as requested. Minor editing : We have thoroughly proofread the manuscript to fix any typos , name inconsistencies , and standardized the references/citation style as per the journal guidelines. Bottom line : We appreciate your helpful feedback, and we have addressed all minor clarifications and formatting tweaks. We believe the manuscript is now ready for indexing. Thank you again for your constructive comments. What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of our findings. We are glad that the practical implications for managers and policymakers were evident. Small fixes before acceptance : Make results consistent : We have aligned the wording across the abstract , results , and discussion regarding the relationship between service quality and satisfaction . Specifically, we have corrected the abstract to reflect the non-significant path from service quality to satisfaction, which is consistent with the results and discussion. Clarify “executive patients” : We have added a brief definition of executive patients in the abstract and clarified that this subgroup represents patients who are insured under premium healthcare plans and often seek specialized care, which may limit generalization to the broader patient population. This explanation is now present in both the abstract and introduction for clarity. Complete tables/figures : We have ensured that all tables and figures are fully labeled and readable. Specifically, we have reviewed the following: Tables : Included full labels for sample size , demographics , and measurement . Figures : All figures, including the trend chart and structural model with coefficients/p-values , have been adjusted for clarity and readability. Sampling/math details : We have included the proportional allocation per hospital in the Research Methods section and clearly displayed the Slovin formula with e = 0.05 for sample size calculation, as requested. Minor editing : We have thoroughly proofread the manuscript to fix any typos , name inconsistencies , and standardized the references/citation style as per the journal guidelines. Bottom line : We appreciate your helpful feedback, and we have addressed all minor clarifications and formatting tweaks. We believe the manuscript is now ready for indexing. Thank you again for your constructive comments. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Nov 2025 Iing Ichsan Hanafi , Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia 24 Nov 2025 Author Response What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of ... Continue reading What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of our findings. We are glad that the practical implications for managers and policymakers were evident. Small fixes before acceptance : Make results consistent : We have aligned the wording across the abstract , results , and discussion regarding the relationship between service quality and satisfaction . Specifically, we have corrected the abstract to reflect the non-significant path from service quality to satisfaction, which is consistent with the results and discussion. Clarify “executive patients” : We have added a brief definition of executive patients in the abstract and clarified that this subgroup represents patients who are insured under premium healthcare plans and often seek specialized care, which may limit generalization to the broader patient population. This explanation is now present in both the abstract and introduction for clarity. Complete tables/figures : We have ensured that all tables and figures are fully labeled and readable. Specifically, we have reviewed the following: Tables : Included full labels for sample size , demographics , and measurement . Figures : All figures, including the trend chart and structural model with coefficients/p-values , have been adjusted for clarity and readability. Sampling/math details : We have included the proportional allocation per hospital in the Research Methods section and clearly displayed the Slovin formula with e = 0.05 for sample size calculation, as requested. Minor editing : We have thoroughly proofread the manuscript to fix any typos , name inconsistencies , and standardized the references/citation style as per the journal guidelines. Bottom line : We appreciate your helpful feedback, and we have addressed all minor clarifications and formatting tweaks. We believe the manuscript is now ready for indexing. Thank you again for your constructive comments. What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of our findings. We are glad that the practical implications for managers and policymakers were evident. Small fixes before acceptance : Make results consistent : We have aligned the wording across the abstract , results , and discussion regarding the relationship between service quality and satisfaction . Specifically, we have corrected the abstract to reflect the non-significant path from service quality to satisfaction, which is consistent with the results and discussion. Clarify “executive patients” : We have added a brief definition of executive patients in the abstract and clarified that this subgroup represents patients who are insured under premium healthcare plans and often seek specialized care, which may limit generalization to the broader patient population. This explanation is now present in both the abstract and introduction for clarity. Complete tables/figures : We have ensured that all tables and figures are fully labeled and readable. Specifically, we have reviewed the following: Tables : Included full labels for sample size , demographics , and measurement . Figures : All figures, including the trend chart and structural model with coefficients/p-values , have been adjusted for clarity and readability. Sampling/math details : We have included the proportional allocation per hospital in the Research Methods section and clearly displayed the Slovin formula with e = 0.05 for sample size calculation, as requested. Minor editing : We have thoroughly proofread the manuscript to fix any typos , name inconsistencies , and standardized the references/citation style as per the journal guidelines. Bottom line : We appreciate your helpful feedback, and we have addressed all minor clarifications and formatting tweaks. We believe the manuscript is now ready for indexing. Thank you again for your constructive comments. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Sallam M. Reviewer Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r421621 ) The direct URL for this report is: https://f1000research.com/articles/14-1040/v1#referee-response-421621 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Oct 2025 Mohammed Sallam , Mediclinic Parkview Hospital, Mediclinic Middle East, Dubai, United Arab Emirates Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.183885.r421621 Title: - Please revise the title to improve readability, specify the study context (Indonesian hospitals), and clearly reflect the mediating relationships. Suggestion: “Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and ... Continue reading READ ALL Title: - Please revise the title to improve readability, specify the study context (Indonesian hospitals), and clearly reflect the mediating relationships. Suggestion: “Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction” Abstract: - Please revise the phrase “This investigation investigates” to “This study examines the relationships...” - Please simplify the opening sentence for clarity and impact. - Please replace “This investigation investigates” with “This study examines.” - Please mention the study context (Indonesia) in the background to orient readers early. - Please highlight the specific research gap “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals” - Please add the study design “A cross-sectional survey was conducted…” - Please clarify why “executive patients” were chosen and how they represent the population - Please briefly mention the validated measurement sources or constructs - Please include key statistical indicators p-values - Please clarify the unexpected finding “service quality moderately influencing satisfaction” - Please specify the theoretical implication more clearly - Please conclude with a forward-looking statement highlighting the study’s broader implications Introduction: - The Introduction demonstrates comprehensive background knowledge and strong contextual grounding - Please focus on logical sequencing 1. Problem, 2. Gap, 3. Objective - Please integrate theory-based relationships - Please refine transitions to ensure coherence between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty Literature review and hypothesis development: - Please operationalize governance for hospitals and define governance dimensions you are using - Please define “sustainability” - H1 is directional but underspecified; “effect” could be positive or negative; also, level-of-analysis unclear. Please specify positive direction and level (organizational) - H2 direction missing; mediation intent not prefigured. Please state positive effect and indicate whether service quality mediates entrepreneurial leadership - H3: Please specify positive effect and please predefine level - H4: Please state whether you expect a direct positive effect and please add a mediation hypothesis - H5: Please state expected positive sign clearly - H6: Please add a mediation hypothesis and pre-specify testing - H7: Please add full-path mediation hypotheses and preregister which direct effects you expect to remain significant when mediators are included Research methods: - Please define “executive patient” operationally and please justify why this subgroup represents loyalty dynamics - Please specify the hospital sampling method (random or stratified) and compare selected vs non-selected hospitals on size, ownership, location to support representativeness - Please justify the ≥2 visits rule - Please justify how patients can reliably assess governance - Please justify PLS choice and report power analysis for the most complex regression - ““The data were analyzed using Partial Least Squares (PLS) via SmartPLS 4.0. PLS is a robust technique that does not require the data to conform to the normality assumptions…” Replace “resilient” with “robust” and “normalcy” with “normality” Results: - Please verify the appropriateness of including minors (0–17 years) in a survey targeting “executive patients - Please explain why male respondents dominate the sample (74.7%)? whether due to hospital policy, socioeconomic patterns, or sampling bias - Please discuss practical implications of key significant paths Discussion: - Please restate the purpose and confirm which hypotheses were supported or not supported - Please elaborate how entrepreneurial leadership behaviors operationally enhance governance outcomes - Please add the following supporting sentence to strengthen the discussion with a recent, real-world example that reinforces the empirical validity of your study. The cited study provides contemporary evidence linking leadership style and structured quality frameworks (Lean Six Sigma) to measurable improvements in healthcare service outcomes. “Similarly, the significant relationship between entrepreneurial leadership and service quality underscores the critical role of leadership in improving the quality of care provided. Recent findings from a Lean Six Sigma–driven improvement initiative at Mediclinic Parkview Hospital in Dubai highlighted how leadership style that integrates innovation with structured governance frameworks can substantially elevate healthcare service quality, patient satisfaction, and operational performance ( https://pharmacypractice.org/index.php/pp/article/view/3263 )” - Please differentiate between cognitive trust (governance-based) and affective trust (experience-based) - Please add a clear Study Limitations subsection after the Discussion 1. Please acknowledge the cross-sectional design, which prevents causal inference. 2. Please note that the data were self-reported from executive patients, which may introduce selection or response bias and limit generalizability. 3. Please mention the geographical limitation to Indonesian hospitals, suggesting caution in applying findings to other healthcare systems. 4. Please indicate that PLS-SEM analysis assumes linear relationships and does not capture complex nonlinear interactions. Conclusion: - Please emphasize theoretical contribution rather than restating statistical effects (highlight how entrepreneurial leadership operationally reinforces governance and service excellence in healthcare). Emphasize novelty in linking entrepreneurial leadership and governance to loyalty - Please avoid causal language; use “is associated with” or “predicts” considering the cross-sectional study design General: - Please ensure terminological and conceptual consistency. Use “patient satisfaction,” not “happiness” - Please include the full questionnaire as an appendix/supplementary file - Please review all figures and tables for clarity and labelling ‎- Please ensure that the reference list follows journal formatting guidelines ‎- Please ensure English proofreading is completed to maintain grammatical consistency, ‎avoid spelling mistakes, tense consistency, and ensure a uniform concise academic tone ‎throughout the manuscript Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Drug InformationHospital PharmacyPharmacovigilancePharmacy EducationPharmacodynamicsPatient SafetySOPClinical Data ManagementDescriptive StudiesPharmacy ManagementMedical SocietiesTransformational LeadershipLean Six SigmaLean ManagementOperations ManagementTotal Quality ManagementDrug Utilization ReviewAntimicrobial StewardshipAntimicrobial ResistanceMedication SafetyTeam ManagementPharmacy AdministrationDMAICArtificial IntelligenceAction ResearchProcess ImprovementLogistics ManagementTime-Driven Activity-Based Costing (TDABC) in HealthcareObesity managementPharmacoeconomics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sallam M. Reviewer Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r421621 ) The direct URL for this report is: https://f1000research.com/articles/14-1040/v1#referee-response-421621 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 24 Nov 2025 Iing Ichsan Hanafi , Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia 24 Nov 2025 Author Response Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : ... Continue reading Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : We have replaced “This investigation investigates” with “This study examines” for clarity. The opening sentence has been simplified for better impact. We’ve included the study context (Indonesia) early in the background. The specific research gap is now highlighted: “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals.” We’ve added “A cross-sectional survey was conducted...” to clarify the study design. We have clarified the selection of executive patients , noting that this subgroup represents patients with higher expectations and frequent interaction with healthcare systems, which are ideal for studying loyalty dynamics . Since this point is already explained in the main text, we did not repeat it in the abstract to maintain brevity. We briefly mention validated measurement sources or constructs and added key statistical indicators (e.g., p-values). We’ve clarified the unexpected finding regarding “service quality moderately influencing satisfaction.” The theoretical implications have been specified more clearly. We’ve included a forward-looking statement discussing the study’s broader implications. Introduction : We’ve reorganized the introduction to focus on logical sequencing: Problem , Gap , and Objective . Theory-based relationships have been integrated, particularly linking entrepreneurial leadership to governance , service quality , and patient loyalty . Transitions between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty have been refined for better coherence. Literature Review and Hypothesis Development : We’ve operationalized corporate governance for hospitals and defined its dimensions (transparency, accountability, social responsibility). Sustainability has been clearly defined. Hypotheses have been clarified: H1 : The positive direction is specified at the organizational level . H2 : Mediation intent is explicitly stated, and service quality mediates the effect of entrepreneurial leadership . H3 : The positive effect and level are now clearly defined. H4 : A direct positive effect is stated, and mediation hypotheses are added. H5 : The expected positive sign is explicitly stated. H6 : Mediation hypotheses are added with pre-specified testing. H7 : Full-path mediation hypotheses are now included with clear registration of direct effects. Research Methods : Executive patient has been clearly defined and justified as a relevant subgroup for studying loyalty dynamics . Sampling method : We have specified stratified sampling and compared selected vs. non-selected hospitals on size , ownership , and location . The ≥2 visits rule has been justified as necessary for ensuring participants’ sufficient exposure to the healthcare services to assess loyalty. Patient assessment of governance has been justified through their perception of transparency , accountability , and ethical decision-making in hospitals. We have justified the use of PLS-SEM and reported power analysis for the most complex regression. Corrected terminology: replaced “resilient” with “robust” and “normalcy” with “normality.” Results : We verified the appropriateness of including minors (0-17 years) in the survey, with an explanation that they likely accompanied executive patients and might not fully represent loyalty dynamics. We explained the dominance of male respondents (74.7%) , citing hospital policy , socioeconomic patterns , and potential sampling bias . We only presented the results of the statistical analysis, as requested, without introducing practical implications or discussing key significant paths, which are already covered in the Discussion section. Discussion : We restated the study’s purpose and confirmed the supported hypotheses. We elaborated on how entrepreneurial leadership behaviors operationally enhance governance outcomes . A supporting real-world example was added regarding the Lean Six Sigma initiative at Mediclinic Parkview Hospital in Dubai, which demonstrated the role of leadership in improving healthcare outcomes. We differentiated between cognitive trust (governance-based) and affective trust (experience-based). A Study Limitations section was added, addressing: Cross-sectional design (limits causal inference). Self-reported data (potential selection/response bias). Geographical limitation to Indonesian hospitals. PLS-SEM assumptions of linear relationships. Conclusion : We emphasized the theoretical contribution of linking entrepreneurial leadership and governance to patient loyalty . We avoided causal language, using “is associated with” and “predicts” based on the cross-sectional design . The conclusion focuses on novelty in the relationship between entrepreneurial leadership , governance , and loyalty rather than restating statistical effects. We appreciate the reviewer’s feedback, which has significantly improved the clarity and quality of the manuscript. All suggestions have been thoroughly addressed, and we believe the revisions strengthen both the theoretical contribution and practical relevance of this study. Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : We have replaced “This investigation investigates” with “This study examines” for clarity. The opening sentence has been simplified for better impact. We’ve included the study context (Indonesia) early in the background. The specific research gap is now highlighted: “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals.” We’ve added “A cross-sectional survey was conducted...” to clarify the study design. We have clarified the selection of executive patients , noting that this subgroup represents patients with higher expectations and frequent interaction with healthcare systems, which are ideal for studying loyalty dynamics . Since this point is already explained in the main text, we did not repeat it in the abstract to maintain brevity. We briefly mention validated measurement sources or constructs and added key statistical indicators (e.g., p-values). We’ve clarified the unexpected finding regarding “service quality moderately influencing satisfaction.” The theoretical implications have been specified more clearly. We’ve included a forward-looking statement discussing the study’s broader implications. Introduction : We’ve reorganized the introduction to focus on logical sequencing: Problem , Gap , and Objective . Theory-based relationships have been integrated, particularly linking entrepreneurial leadership to governance , service quality , and patient loyalty . Transitions between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty have been refined for better coherence. Literature Review and Hypothesis Development : We’ve operationalized corporate governance for hospitals and defined its dimensions (transparency, accountability, social responsibility). Sustainability has been clearly defined. Hypotheses have been clarified: H1 : The positive direction is specified at the organizational level . H2 : Mediation intent is explicitly stated, and service quality mediates the effect of entrepreneurial leadership . H3 : The positive effect and level are now clearly defined. H4 : A direct positive effect is stated, and mediation hypotheses are added. H5 : The expected positive sign is explicitly stated. H6 : Mediation hypotheses are added with pre-specified testing. H7 : Full-path mediation hypotheses are now included with clear registration of direct effects. Research Methods : Executive patient has been clearly defined and justified as a relevant subgroup for studying loyalty dynamics . Sampling method : We have specified stratified sampling and compared selected vs. non-selected hospitals on size , ownership , and location . The ≥2 visits rule has been justified as necessary for ensuring participants’ sufficient exposure to the healthcare services to assess loyalty. Patient assessment of governance has been justified through their perception of transparency , accountability , and ethical decision-making in hospitals. We have justified the use of PLS-SEM and reported power analysis for the most complex regression. Corrected terminology: replaced “resilient” with “robust” and “normalcy” with “normality.” Results : We verified the appropriateness of including minors (0-17 years) in the survey, with an explanation that they likely accompanied executive patients and might not fully represent loyalty dynamics. We explained the dominance of male respondents (74.7%) , citing hospital policy , socioeconomic patterns , and potential sampling bias . We only presented the results of the statistical analysis, as requested, without introducing practical implications or discussing key significant paths, which are already covered in the Discussion section. Discussion : We restated the study’s purpose and confirmed the supported hypotheses. We elaborated on how entrepreneurial leadership behaviors operationally enhance governance outcomes . A supporting real-world example was added regarding the Lean Six Sigma initiative at Mediclinic Parkview Hospital in Dubai, which demonstrated the role of leadership in improving healthcare outcomes. We differentiated between cognitive trust (governance-based) and affective trust (experience-based). A Study Limitations section was added, addressing: Cross-sectional design (limits causal inference). Self-reported data (potential selection/response bias). Geographical limitation to Indonesian hospitals. PLS-SEM assumptions of linear relationships. Conclusion : We emphasized the theoretical contribution of linking entrepreneurial leadership and governance to patient loyalty . We avoided causal language, using “is associated with” and “predicts” based on the cross-sectional design . The conclusion focuses on novelty in the relationship between entrepreneurial leadership , governance , and loyalty rather than restating statistical effects. We appreciate the reviewer’s feedback, which has significantly improved the clarity and quality of the manuscript. All suggestions have been thoroughly addressed, and we believe the revisions strengthen both the theoretical contribution and practical relevance of this study. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Nov 2025 Iing Ichsan Hanafi , Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia 24 Nov 2025 Author Response Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : ... Continue reading Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : We have replaced “This investigation investigates” with “This study examines” for clarity. The opening sentence has been simplified for better impact. We’ve included the study context (Indonesia) early in the background. The specific research gap is now highlighted: “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals.” We’ve added “A cross-sectional survey was conducted...” to clarify the study design. We have clarified the selection of executive patients , noting that this subgroup represents patients with higher expectations and frequent interaction with healthcare systems, which are ideal for studying loyalty dynamics . Since this point is already explained in the main text, we did not repeat it in the abstract to maintain brevity. We briefly mention validated measurement sources or constructs and added key statistical indicators (e.g., p-values). We’ve clarified the unexpected finding regarding “service quality moderately influencing satisfaction.” The theoretical implications have been specified more clearly. We’ve included a forward-looking statement discussing the study’s broader implications. Introduction : We’ve reorganized the introduction to focus on logical sequencing: Problem , Gap , and Objective . Theory-based relationships have been integrated, particularly linking entrepreneurial leadership to governance , service quality , and patient loyalty . Transitions between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty have been refined for better coherence. Literature Review and Hypothesis Development : We’ve operationalized corporate governance for hospitals and defined its dimensions (transparency, accountability, social responsibility). Sustainability has been clearly defined. Hypotheses have been clarified: H1 : The positive direction is specified at the organizational level . H2 : Mediation intent is explicitly stated, and service quality mediates the effect of entrepreneurial leadership . H3 : The positive effect and level are now clearly defined. H4 : A direct positive effect is stated, and mediation hypotheses are added. H5 : The expected positive sign is explicitly stated. H6 : Mediation hypotheses are added with pre-specified testing. H7 : Full-path mediation hypotheses are now included with clear registration of direct effects. Research Methods : Executive patient has been clearly defined and justified as a relevant subgroup for studying loyalty dynamics . Sampling method : We have specified stratified sampling and compared selected vs. non-selected hospitals on size , ownership , and location . The ≥2 visits rule has been justified as necessary for ensuring participants’ sufficient exposure to the healthcare services to assess loyalty. Patient assessment of governance has been justified through their perception of transparency , accountability , and ethical decision-making in hospitals. We have justified the use of PLS-SEM and reported power analysis for the most complex regression. Corrected terminology: replaced “resilient” with “robust” and “normalcy” with “normality.” Results : We verified the appropriateness of including minors (0-17 years) in the survey, with an explanation that they likely accompanied executive patients and might not fully represent loyalty dynamics. We explained the dominance of male respondents (74.7%) , citing hospital policy , socioeconomic patterns , and potential sampling bias . We only presented the results of the statistical analysis, as requested, without introducing practical implications or discussing key significant paths, which are already covered in the Discussion section. Discussion : We restated the study’s purpose and confirmed the supported hypotheses. We elaborated on how entrepreneurial leadership behaviors operationally enhance governance outcomes . A supporting real-world example was added regarding the Lean Six Sigma initiative at Mediclinic Parkview Hospital in Dubai, which demonstrated the role of leadership in improving healthcare outcomes. We differentiated between cognitive trust (governance-based) and affective trust (experience-based). A Study Limitations section was added, addressing: Cross-sectional design (limits causal inference). Self-reported data (potential selection/response bias). Geographical limitation to Indonesian hospitals. PLS-SEM assumptions of linear relationships. Conclusion : We emphasized the theoretical contribution of linking entrepreneurial leadership and governance to patient loyalty . We avoided causal language, using “is associated with” and “predicts” based on the cross-sectional design . The conclusion focuses on novelty in the relationship between entrepreneurial leadership , governance , and loyalty rather than restating statistical effects. We appreciate the reviewer’s feedback, which has significantly improved the clarity and quality of the manuscript. All suggestions have been thoroughly addressed, and we believe the revisions strengthen both the theoretical contribution and practical relevance of this study. Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : We have replaced “This investigation investigates” with “This study examines” for clarity. The opening sentence has been simplified for better impact. We’ve included the study context (Indonesia) early in the background. The specific research gap is now highlighted: “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals.” We’ve added “A cross-sectional survey was conducted...” to clarify the study design. We have clarified the selection of executive patients , noting that this subgroup represents patients with higher expectations and frequent interaction with healthcare systems, which are ideal for studying loyalty dynamics . Since this point is already explained in the main text, we did not repeat it in the abstract to maintain brevity. We briefly mention validated measurement sources or constructs and added key statistical indicators (e.g., p-values). We’ve clarified the unexpected finding regarding “service quality moderately influencing satisfaction.” The theoretical implications have been specified more clearly. We’ve included a forward-looking statement discussing the study’s broader implications. Introduction : We’ve reorganized the introduction to focus on logical sequencing: Problem , Gap , and Objective . Theory-based relationships have been integrated, particularly linking entrepreneurial leadership to governance , service quality , and patient loyalty . Transitions between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty have been refined for better coherence. Literature Review and Hypothesis Development : We’ve operationalized corporate governance for hospitals and defined its dimensions (transparency, accountability, social responsibility). Sustainability has been clearly defined. Hypotheses have been clarified: H1 : The positive direction is specified at the organizational level . H2 : Mediation intent is explicitly stated, and service quality mediates the effect of entrepreneurial leadership . H3 : The positive effect and level are now clearly defined. H4 : A direct positive effect is stated, and mediation hypotheses are added. H5 : The expected positive sign is explicitly stated. H6 : Mediation hypotheses are added with pre-specified testing. H7 : Full-path mediation hypotheses are now included with clear registration of direct effects. Research Methods : Executive patient has been clearly defined and justified as a relevant subgroup for studying loyalty dynamics . Sampling method : We have specified stratified sampling and compared selected vs. non-selected hospitals on size , ownership , and location . The ≥2 visits rule has been justified as necessary for ensuring participants’ sufficient exposure to the healthcare services to assess loyalty. Patient assessment of governance has been justified through their perception of transparency , accountability , and ethical decision-making in hospitals. We have justified the use of PLS-SEM and reported power analysis for the most complex regression. Corrected terminology: replaced “resilient” with “robust” and “normalcy” with “normality.” Results : We verified the appropriateness of including minors (0-17 years) in the survey, with an explanation that they likely accompanied executive patients and might not fully represent loyalty dynamics. We explained the dominance of male respondents (74.7%) , citing hospital policy , socioeconomic patterns , and potential sampling bias . We only presented the results of the statistical analysis, as requested, without introducing practical implications or discussing key significant paths, which are already covered in the Discussion section. Discussion : We restated the study’s purpose and confirmed the supported hypotheses. We elaborated on how entrepreneurial leadership behaviors operationally enhance governance outcomes . A supporting real-world example was added regarding the Lean Six Sigma initiative at Mediclinic Parkview Hospital in Dubai, which demonstrated the role of leadership in improving healthcare outcomes. We differentiated between cognitive trust (governance-based) and affective trust (experience-based). A Study Limitations section was added, addressing: Cross-sectional design (limits causal inference). Self-reported data (potential selection/response bias). Geographical limitation to Indonesian hospitals. PLS-SEM assumptions of linear relationships. Conclusion : We emphasized the theoretical contribution of linking entrepreneurial leadership and governance to patient loyalty . We avoided causal language, using “is associated with” and “predicts” based on the cross-sectional design . The conclusion focuses on novelty in the relationship between entrepreneurial leadership , governance , and loyalty rather than restating statistical effects. We appreciate the reviewer’s feedback, which has significantly improved the clarity and quality of the manuscript. All suggestions have been thoroughly addressed, and we believe the revisions strengthen both the theoretical contribution and practical relevance of this study. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Oct 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 14 Nov 25 read read Version 1 03 Oct 25 read read Mohammed Sallam , Mediclinic Parkview Hospital, Mediclinic Middle East, Dubai, United Arab Emirates Anis Ansyori , Institute of Science and Health Technology, Dr. Soepraoen Hospital, Malang, Indonesia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ansyori A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Nov 2025 | for Version 2 Anis Ansyori , Institute of Science and Health Technology, Dr. Soepraoen Hospital, Malang, Indonesia 0 Views copyright © 2025 Ansyori A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions After reviewing the authors' revisions and their responses to my previous comments, I believe all issues have been addressed well. The revisions have clarified and strengthened the article overall. The authors have provided clear and appropriate responses to the feedback. I have no further comments and fully support the publication of this article. Competing Interests No competing interests were disclosed. Reviewer Expertise Public relations and strategic health communication, health literacy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Ansyori A. Peer Review Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.191071.r432540) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1040/v2#referee-response-432540 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Sallam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Nov 2025 | for Version 2 Mohammed Sallam , Mediclinic Parkview Hospital, Mediclinic Middle East, Dubai, United Arab Emirates 0 Views copyright © 2025 Sallam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the thoughtful and well-executed revisions; the clarifications and improvements effectively address the earlier concerns and strengthen the manuscript. Competing Interests No competing interests were disclosed. Reviewer Expertise Drug Information, Hospital Pharmacy, Pharmacovigilance, Pharmacy Education, Pharmacodynamics, Patient Safety, SOP, Clinical Data Management, Descriptive Studies, Pharmacy Management, Medical Societies, Transformational Leadership, Lean Six Sigma, Lean Management, Operations Management, Total Quality Management, Drug Utilization Review, Antimicrobial Stewardship, Antimicrobial Resistance, Medication Safety, Team Management, Pharmacy Administration, DMAIC, Artificial Intelligence, Action Research, Process Improvement, Logistics Management, Time-Driven Activity-Based Costing (TDABC) in Healthcare, Obesity Management, Pharmacoeconomics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Sallam M. Peer Review Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.191071.r432539) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1040/v2#referee-response-432539 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ansyori A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Oct 2025 | for Version 1 Anis Ansyori , Institute of Science and Health Technology, Dr. Soepraoen Hospital, Malang, Indonesia 0 Views copyright © 2025 Ansyori A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions What the paper does well: Important topic for hospitals: how leadership and governance drive service quality, satisfaction, and loyalty. Strong method: survey of 384 “executive” patients in West Java; PLS-SEM with solid reliability/validity. Clear findings: entrepreneurial leadership strongly improves governance and service quality; governance, service quality, and satisfaction support patient loyalty. Useful, practical implications for managers and policymakers. Small fixes before acceptance: Make results consistent: The abstract says service quality affects satisfaction, but the model shows this path is not significant—please align wording across abstract/results/discussion. Clarify “executive patients” : Define the segment briefly and note limits for generalization. Complete tables/figures: Ensure all tables (samples, demographics, measurement, structural paths) and figures (trend chart, model with coefficients/p-values) are fully labeled and readable. Sampling/math details : Show the proportional allocation per hospital and the Slovin formula clearly (with e=0.05). Minor editing : Fix typos/name inconsistencies and standardize references/citation style. Bottom line: A well-designed and relevant study. With these minor clarifications and formatting tweaks, it’s ready for indexing. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Public relations and strategic health communication, health literacy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 24 Nov 2025 Iing Ichsan Hanafi, Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia What the paper does well : Thank you for your positive feedback. We appreciate your recognition of the importance of the topic, the strength of our methodology, and the clarity of our findings. We are glad that the practical implications for managers and policymakers were evident. Small fixes before acceptance : Make results consistent : We have aligned the wording across the abstract , results , and discussion regarding the relationship between service quality and satisfaction . Specifically, we have corrected the abstract to reflect the non-significant path from service quality to satisfaction, which is consistent with the results and discussion. Clarify “executive patients” : We have added a brief definition of executive patients in the abstract and clarified that this subgroup represents patients who are insured under premium healthcare plans and often seek specialized care, which may limit generalization to the broader patient population. This explanation is now present in both the abstract and introduction for clarity. Complete tables/figures : We have ensured that all tables and figures are fully labeled and readable. Specifically, we have reviewed the following: Tables : Included full labels for sample size , demographics , and measurement . Figures : All figures, including the trend chart and structural model with coefficients/p-values , have been adjusted for clarity and readability. Sampling/math details : We have included the proportional allocation per hospital in the Research Methods section and clearly displayed the Slovin formula with e = 0.05 for sample size calculation, as requested. Minor editing : We have thoroughly proofread the manuscript to fix any typos , name inconsistencies , and standardized the references/citation style as per the journal guidelines. Bottom line : We appreciate your helpful feedback, and we have addressed all minor clarifications and formatting tweaks. We believe the manuscript is now ready for indexing. Thank you again for your constructive comments. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Ansyori A. Peer Review Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r424374) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1040/v1#referee-response-424374 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Sallam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Oct 2025 | for Version 1 Mohammed Sallam , Mediclinic Parkview Hospital, Mediclinic Middle East, Dubai, United Arab Emirates 0 Views copyright © 2025 Sallam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Title: - Please revise the title to improve readability, specify the study context (Indonesian hospitals), and clearly reflect the mediating relationships. Suggestion: “Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction” Abstract: - Please revise the phrase “This investigation investigates” to “This study examines the relationships...” - Please simplify the opening sentence for clarity and impact. - Please replace “This investigation investigates” with “This study examines.” - Please mention the study context (Indonesia) in the background to orient readers early. - Please highlight the specific research gap “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals” - Please add the study design “A cross-sectional survey was conducted…” - Please clarify why “executive patients” were chosen and how they represent the population - Please briefly mention the validated measurement sources or constructs - Please include key statistical indicators p-values - Please clarify the unexpected finding “service quality moderately influencing satisfaction” - Please specify the theoretical implication more clearly - Please conclude with a forward-looking statement highlighting the study’s broader implications Introduction: - The Introduction demonstrates comprehensive background knowledge and strong contextual grounding - Please focus on logical sequencing 1. Problem, 2. Gap, 3. Objective - Please integrate theory-based relationships - Please refine transitions to ensure coherence between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty Literature review and hypothesis development: - Please operationalize governance for hospitals and define governance dimensions you are using - Please define “sustainability” - H1 is directional but underspecified; “effect” could be positive or negative; also, level-of-analysis unclear. Please specify positive direction and level (organizational) - H2 direction missing; mediation intent not prefigured. Please state positive effect and indicate whether service quality mediates entrepreneurial leadership - H3: Please specify positive effect and please predefine level - H4: Please state whether you expect a direct positive effect and please add a mediation hypothesis - H5: Please state expected positive sign clearly - H6: Please add a mediation hypothesis and pre-specify testing - H7: Please add full-path mediation hypotheses and preregister which direct effects you expect to remain significant when mediators are included Research methods: - Please define “executive patient” operationally and please justify why this subgroup represents loyalty dynamics - Please specify the hospital sampling method (random or stratified) and compare selected vs non-selected hospitals on size, ownership, location to support representativeness - Please justify the ≥2 visits rule - Please justify how patients can reliably assess governance - Please justify PLS choice and report power analysis for the most complex regression - ““The data were analyzed using Partial Least Squares (PLS) via SmartPLS 4.0. PLS is a robust technique that does not require the data to conform to the normality assumptions…” Replace “resilient” with “robust” and “normalcy” with “normality” Results: - Please verify the appropriateness of including minors (0–17 years) in a survey targeting “executive patients - Please explain why male respondents dominate the sample (74.7%)? whether due to hospital policy, socioeconomic patterns, or sampling bias - Please discuss practical implications of key significant paths Discussion: - Please restate the purpose and confirm which hypotheses were supported or not supported - Please elaborate how entrepreneurial leadership behaviors operationally enhance governance outcomes - Please add the following supporting sentence to strengthen the discussion with a recent, real-world example that reinforces the empirical validity of your study. The cited study provides contemporary evidence linking leadership style and structured quality frameworks (Lean Six Sigma) to measurable improvements in healthcare service outcomes. “Similarly, the significant relationship between entrepreneurial leadership and service quality underscores the critical role of leadership in improving the quality of care provided. Recent findings from a Lean Six Sigma–driven improvement initiative at Mediclinic Parkview Hospital in Dubai highlighted how leadership style that integrates innovation with structured governance frameworks can substantially elevate healthcare service quality, patient satisfaction, and operational performance ( https://pharmacypractice.org/index.php/pp/article/view/3263 )” - Please differentiate between cognitive trust (governance-based) and affective trust (experience-based) - Please add a clear Study Limitations subsection after the Discussion 1. Please acknowledge the cross-sectional design, which prevents causal inference. 2. Please note that the data were self-reported from executive patients, which may introduce selection or response bias and limit generalizability. 3. Please mention the geographical limitation to Indonesian hospitals, suggesting caution in applying findings to other healthcare systems. 4. Please indicate that PLS-SEM analysis assumes linear relationships and does not capture complex nonlinear interactions. Conclusion: - Please emphasize theoretical contribution rather than restating statistical effects (highlight how entrepreneurial leadership operationally reinforces governance and service excellence in healthcare). Emphasize novelty in linking entrepreneurial leadership and governance to loyalty - Please avoid causal language; use “is associated with” or “predicts” considering the cross-sectional study design General: - Please ensure terminological and conceptual consistency. Use “patient satisfaction,” not “happiness” - Please include the full questionnaire as an appendix/supplementary file - Please review all figures and tables for clarity and labelling ‎- Please ensure that the reference list follows journal formatting guidelines ‎- Please ensure English proofreading is completed to maintain grammatical consistency, ‎avoid spelling mistakes, tense consistency, and ensure a uniform concise academic tone ‎throughout the manuscript Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Drug InformationHospital PharmacyPharmacovigilancePharmacy EducationPharmacodynamicsPatient SafetySOPClinical Data ManagementDescriptive StudiesPharmacy ManagementMedical SocietiesTransformational LeadershipLean Six SigmaLean ManagementOperations ManagementTotal Quality ManagementDrug Utilization ReviewAntimicrobial StewardshipAntimicrobial ResistanceMedication SafetyTeam ManagementPharmacy AdministrationDMAICArtificial IntelligenceAction ResearchProcess ImprovementLogistics ManagementTime-Driven Activity-Based Costing (TDABC) in HealthcareObesity managementPharmacoeconomics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 24 Nov 2025 Iing Ichsan Hanafi, Business Administration, Universitas Brawijaya, Malang, 65145, Indonesia Title : We have revised the title as suggested: "Entrepreneurial Leadership and Patient Loyalty in Indonesian Hospitals: The Mediating Roles of Corporate Governance, Service Quality, and Patient Satisfaction." Abstract : We have replaced “This investigation investigates” with “This study examines” for clarity. The opening sentence has been simplified for better impact. We’ve included the study context (Indonesia) early in the background. The specific research gap is now highlighted: “Few studies have empirically examined how entrepreneurial leadership and governance jointly shape patient satisfaction and loyalty in Indonesian hospitals.” We’ve added “A cross-sectional survey was conducted...” to clarify the study design. We have clarified the selection of executive patients , noting that this subgroup represents patients with higher expectations and frequent interaction with healthcare systems, which are ideal for studying loyalty dynamics . Since this point is already explained in the main text, we did not repeat it in the abstract to maintain brevity. We briefly mention validated measurement sources or constructs and added key statistical indicators (e.g., p-values). We’ve clarified the unexpected finding regarding “service quality moderately influencing satisfaction.” The theoretical implications have been specified more clearly. We’ve included a forward-looking statement discussing the study’s broader implications. Introduction : We’ve reorganized the introduction to focus on logical sequencing: Problem , Gap , and Objective . Theory-based relationships have been integrated, particularly linking entrepreneurial leadership to governance , service quality , and patient loyalty . Transitions between entrepreneurial leadership, governance, service quality, and satisfaction leading to loyalty have been refined for better coherence. Literature Review and Hypothesis Development : We’ve operationalized corporate governance for hospitals and defined its dimensions (transparency, accountability, social responsibility). Sustainability has been clearly defined. Hypotheses have been clarified: H1 : The positive direction is specified at the organizational level . H2 : Mediation intent is explicitly stated, and service quality mediates the effect of entrepreneurial leadership . H3 : The positive effect and level are now clearly defined. H4 : A direct positive effect is stated, and mediation hypotheses are added. H5 : The expected positive sign is explicitly stated. H6 : Mediation hypotheses are added with pre-specified testing. H7 : Full-path mediation hypotheses are now included with clear registration of direct effects. Research Methods : Executive patient has been clearly defined and justified as a relevant subgroup for studying loyalty dynamics . Sampling method : We have specified stratified sampling and compared selected vs. non-selected hospitals on size , ownership , and location . The ≥2 visits rule has been justified as necessary for ensuring participants’ sufficient exposure to the healthcare services to assess loyalty. Patient assessment of governance has been justified through their perception of transparency , accountability , and ethical decision-making in hospitals. We have justified the use of PLS-SEM and reported power analysis for the most complex regression. Corrected terminology: replaced “resilient” with “robust” and “normalcy” with “normality.” Results : We verified the appropriateness of including minors (0-17 years) in the survey, with an explanation that they likely accompanied executive patients and might not fully represent loyalty dynamics. We explained the dominance of male respondents (74.7%) , citing hospital policy , socioeconomic patterns , and potential sampling bias . We only presented the results of the statistical analysis, as requested, without introducing practical implications or discussing key significant paths, which are already covered in the Discussion section. Discussion : We restated the study’s purpose and confirmed the supported hypotheses. We elaborated on how entrepreneurial leadership behaviors operationally enhance governance outcomes . A supporting real-world example was added regarding the Lean Six Sigma initiative at Mediclinic Parkview Hospital in Dubai, which demonstrated the role of leadership in improving healthcare outcomes. We differentiated between cognitive trust (governance-based) and affective trust (experience-based). A Study Limitations section was added, addressing: Cross-sectional design (limits causal inference). Self-reported data (potential selection/response bias). Geographical limitation to Indonesian hospitals. PLS-SEM assumptions of linear relationships. Conclusion : We emphasized the theoretical contribution of linking entrepreneurial leadership and governance to patient loyalty . We avoided causal language, using “is associated with” and “predicts” based on the cross-sectional design . The conclusion focuses on novelty in the relationship between entrepreneurial leadership , governance , and loyalty rather than restating statistical effects. We appreciate the reviewer’s feedback, which has significantly improved the clarity and quality of the manuscript. All suggestions have been thoroughly addressed, and we believe the revisions strengthen both the theoretical contribution and practical relevance of this study. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Sallam M. Peer Review Report For: Exploring Patient Loyalty: The Effect of Entrepreneurial Leadership Through Corporate Governance, Service Quality, and Satisfaction [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1040 ( https://doi.org/10.5256/f1000research.183885.r421621) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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