Organizational Communication in Managing Online Customer Reviews in Building Hospital Reputation: A Case Study at Yogyakarta City General Hospital (RSUD Kota Yogyakarta), Indonesia

1. Introduction

Hospitals play a strategic role as providers of comprehensive healthcare services, encompassing medical, support, nursing, rehabilitation, and promotive and preventive measures. This is in accordance with UU No.44 2009 in the Republic of Indonesia, concerning Hospitals that hospitals are required to provide outpatient, inpatient, and emergency services. Therefore, hospitals are not only places of healing, but also institutions for education, research, and scientific development.

Over the past two decades, Indonesia's healthcare sector has shown a significant upward trend, both in terms of the number of hospitals, service classes, and bed availability ratios. However, improvements in physical facilities do not necessarily meet public expectations for service quality. Patients, as service users, have the same right to receive safe, high-quality, and affordable services, as stipulated in UU No.44 2009 in the Republic of Indonesia. Therefore, patient satisfaction and safety are two key indicators that determine a hospital's reputation.

Despite the establishment of various regulations, the reality on the ground still shows a gap between ideal standards and service practices. Research (Pratikno et al., 2020) and (Imran et al., 2021) reveal numerous patient complaints, ranging from doctor delays, complicated administrative processes, to inadequate facilities. These complaints directly impact a hospital's image and reputation, especially when they are published through digital platforms accessible to the public.

Digital transformation has brought about fundamental changes in communication patterns between patients and hospitals. While previously patient feedback was delivered through conventional methods such as guest books, comment cards, paper surveys, or telephone hotlines, people now prefer digital channels, which are considered faster, more practical, and more transparent. One such platform is Google Reviews, where patients can leave open reviews in the form of text or star ratings. These reviews are public, easily accessible, and influence the perceptions of hospital quality by both potential patients and the wider community.

Data from the Indonesian Internet Service Providers Association (APJII) in 2023 showed that internet penetration in Indonesia had reached 78.19%, equivalent to 215 million users. This figure confirms that people are increasingly relying on the internet, including for seeking health information and assessing hospital reputations. Online reviews not only record individual experiences but also form collective opinions that influence potential patient decisions.

Furthermore, digital reviews have the characteristics of big data. (Chatterjee et al., 2021). This means that the collection of patient reviews available on Google Reviews can be analyzed to identify patterns, trends, and strategic issues related to service delivery. Reviews, ranging from descriptive, narrative, and evaluative texts, provide a direct overview of patient experiences. Star ratings serve as a simple yet powerful indicator that quickly shapes public perception. (Lackermair et al., 2013) emphasize that ratings are a crucial measure of service quality in the decision-making process.

In the context of hospitals, positive reviews have the potential to build reputation and increase public trust, while negative reviews can quickly damage an image. Case of Jombang (East Java, Indonesia) Regional General Hospital in 2022 demonstrates how a single viral incident on social media can trigger a flood of negative reviews on Google Reviews, plummeting the hospital's rating and impacting the healthcare institution's reputation in the public eye.

This phenomenon demonstrates that managing online reviews is not merely an additional activity, but rather an integral part of a hospital's communication strategy. Digital reviews should be viewed as a dialogue space between patients and the hospital, where patient voices are interpreted, acted upon, and used as a basis for improvement

Based on this background, this study attempts to analyze how hospitals in the Special Region of Yogyakarta, specifically General Hospital of Yogyakarta City, manage online customer reviews. The analysis focuses on membership negotiation, coordination activities, self-structuring, and institutional positioning regarding negative reviews. Using the Four Flows Model approach, this article provides an analysis of the management of online customer reviews in hospitals, thus providing theoretical contributions to the study of organizational communication as well as practical recommendations for managing hospital reputation in the digital era.

2. Literature Review

Previous studies have emphasized the importance of patient reviews as an evaluation instrument for hospital service quality. (Gopi et al., 2019) and (Upadhyai et al., 2022) confirmed that organizational culture and internal surveys significantly influence service quality. Other studies have used various theoretical frameworks, such as the PCP (Pivotal-Core-Peripheral) model (Izzudin et al., 2021) and Servqual (Service Quality)(Pramanik, 2016); (Singh & Dixit, 2020), which emphasize the role of staff attitudes, the hospital environment, and differences in service quality between urban and rural areas. Online reviews also serve as real-time feedback (Izzudin et al., 2021); (Shemirani & Castrillon, 2017), which showed that one-star comments often reveal critical issues such as doctor dishonesty or staff unfriendliness. Thus, online reviews serve a dual role : as a reflection of service quality and as an alert system for hospital management.

Research on patient perceptions through online reviews also found interesting findings. (Skrypczak et al., 2020) showed that half of private orthodontic practices received negative reviews on Google and Yelp, highlighting the importance of patient perception management. (Bardach et al., 2017) added that there were significant differences between patient and family perceptions regarding patient safety issues. This confirms that patient reviews are not just about medical services, but also encompass emotional, relational, and safety dimensions during treatment.

Studies on online ratings are also relevant to understanding hospital reputation. Berns et al. (2022) found that positive staff interactions with patients influenced online ratings of surgeons, while Allen et al. (2020) showed variations in ratings based on institution type. These findings demonstrate that online ratings are more than just numbers; they represent interpersonal relationships, professionalism, and public trust in healthcare institutions.

Zwier (2019) developed the Triple A Response concept (Acknowledgement, Apology, Action) in responding to patient reviews. This strategy has been shown to be influenced by the number of reviews received and the average star rating. In other words, an organization's response not only influences the individual reviewer's satisfaction but also shapes the broader public's perception of the institution's professionalism and empathy.

Other studies highlight the role of reviews in influencing patients' healthcare decisions. (McGrath et al., 2018) and (Raza & Dehury, 2021) emphasize that negative reviews related to unprofessional staff, poor infrastructure, or high treatment costs can lead to low ratings and decreased patient engagement. Conversely, positive reviews act as a driving factor in patients' decisions to choose a particular hospital.

Studies by Seltzer et al., 2022 and Tong et al., 2022 show that positive reviews generally reflect a satisfactory care experience, while negative reviews can reveal issues of service discrimination that are not detected through formal metrics. Muhammad et al., 2019 even found the role of the Alodokter app as a means of accessing information and connecting patients with hospitals in Indonesia, confirming that digital reviews are also related to ease of access to health information.

On the other hand, research using the Four Flows Model framework is still relatively limited. (Wiggins & Bowers, 2015) examined participatory digital culture, Bruscella & Bisel in (Stephen W. Littlejohn, 2021) expanded the model by emphasizing the role of material resources in organizational formation, while (Jahn & Johansson, 2018) used this model to understand crisis communication management during forest fires in Sweden. Other studies (Nordbäck et al., 2017) ; (Yudhapramesti et al., 2021) ; (Hülscher, 2019) ; (Levonius & Sivunen, 2024) highlighted policy flexibility, public organization adaptation, work efficiency, and the use of social media by healthcare workers. However, no research has specifically examined the management of online customer reviews in hospitals using the Four Flows Model.

Several studies also confirm that online reviews play a crucial role in shaping a hospital's reputation. (Johnson, 2014) and (Horn et al., 2015) emphasize the importance of open dialogue and patient experience as strategic reputation factors. (Vafeiadis, 2023) shows that negative reviews have a detrimental impact on patient decisions, but can be minimized with a positive response. Meanwhile, (Benlahbib & Nfaoui, 2020) found that review attributes such as sentiment, relevance, and user credibility contribute to online reputation.

This study provides an analysis of online patient reviews as an integral part of hospital organizational communication, which not only impacts service improvement, but also institutional positioning and reputation strengthening in the digital era.

3. Theoretical Framework

This research is rooted in a theoretical framework that combines the basic concepts of communication, organizational communication, online customer reviews (OCRs), the Four Flows Model, digital public relations, digital media, and organizational reputation. This integration of frameworks is necessary to understand how online customer reviews in the healthcare context serve not only as information but also as a structure for organizational communication and influence the hospital's legitimacy and reputation.

Communication is understood as a relational process of creating and interpreting messages that generate responses (Grifin et al., 2022). Within this framework, communication encompasses three main components: (1) message creation, (2) message characteristics, and (3) interpretation and response. This is reinforced by Silvio Waisbord's concept in Theories of Human Communication (Littlejohn et al., 2021), which emphasizes the function of communication in connection, dialogue, persuasion, and symbolic interaction. The interpretive approach further highlights the meaning of communication as a result of social interaction, where language and symbols shape social reality.

In the realm of organizational communication, the Communicative Constitution of Organizations (CCO) approach (Miller, 2012) and (Grifin et al., 2022) emphasize that organizations are not simply comprised of communication, but rather "created" by it. Organizational structures, rules, and norms are constructed through communicative practices. Therefore, responding to online reviews is not merely understood as a service activity but as a practice that actively shapes the identity and legitimacy of the hospital organization.

OCRs are seen as a form of electronic Word of Mouth (e-WOM) that has a strong influence on consumer perceptions (Hennig-Thurau et al., 2004) ; (Filieri, 2015) . Online reviews provide a symbolic interaction space, where patient experiences are publicized and influence other potential patients. In addition to being a means of information, OCRs also serve as an instrument of social control over the quality of hospital services. In other words, online reviews serve a dual function: as a form of public evaluation and as a means of constructing an organization's reputation in the digital space.

(Mcphee & Zaug, 2009) through the Four Flows Model offers a framework that explains how organizations are formed through four communication flows: membership negotiation, activity coordination, organizational self-structuring, and institutional positioning. In the context of hospitals, online patient reviews are part of a communication flow that demands organizational responses in all four dimensions: 1) Membership Negotiation: how the hospital negotiates its professional membership identity with patients and the public through responses to reviews. 2) Activity Coordination: how cross-divisional units coordinate in responding to reviews to maintain service quality. 3) Organizational Self-Structuring: how SOPs, policies, and procedures are reorganized in response to patient complaints. 4) Institutional Positioning: how the hospital's response to online reviews shapes its image, reputation, and position among other healthcare institutions.

In the digital era, public relations no longer relies solely on traditional media, but utilizes digital media to build conversations, strengthen image, and respond to the public in real-time (Seitel, 2017). The presence of social media, Google Reviews, and other digital platforms makes OCRs a strategic arena in hospital digital Public Relations.

Organizational reputation is seen as a valuable asset formed through symbolic interactions between the organization and stakeholders (Fombrun, 2018) ; (Carroll, 2013). Online reviews are one of the determining factors of reputation, because they openly show public perception and influence public trust.

4. Research methods

This research uses a qualitative approach with a single case study (Yin, 2018). The case study was chosen because it provides an in-depth understanding of organizational communication practices in managing online customer reviews in hospitals. The research focuses on exploring the management of online customer reviews, including elements of membership negotiation, coordination activities, self-structuring, and institutional positioning.

The research location was determined in the Yogyakarta Special Region, Indonesia, with the following considerations: 1) Yogyakarta Special Region ranks first in the national digital literacy index with a score of 3.64 (Santika, 2023), 2) The ratio of hospital beds to the population ranks 5th nationally, with a figure of 1.9 per 1,000 residents, the highest ratio in Java (databoks, 2022), 3) Accessibility to health services is better than surrounding areas (for example Solo Raya), with a sufficient number of hospitals for its population, 4) There is a type A national referral hospital, namely dr. Sardjito General Hospital, which is located in the Yogyakarta Special Region as an important health service center in Indonesia.

The research focused on Yogyakarta City Regional General Hospital. The selection was carried out by purposive sampling with the following considerations: Both have a Bed Occupancy Ratio (BOR) below 60%, lower than the ideal average, have a Google Review rating below 4.0 with more than 1,000 reviews, some of which are negative, the pattern of complaints that emerged showed problems related to the speed of service, staff friendliness, and the availability of facilities.

Informants were selected using the principle of purposive sampling with the criteria of relevance of experience, diversity of perspectives, accessibility, and direct involvement in the research phenomenon (Yin, 2018). The informants included: The customer review management team, especially the Head of Sub Legal and Customer Service (HKPP), Direct service officers, including the Head of the Emergency Room, Head of the Medical Services Division, Head of the Nursing Division.

The number of informants is not determined with certainty, following the saturation principle, namely that the interview is stopped if the information obtained is repeated and does not produce new findings (Cresswel, 2009).

Data Collection Techniques. This study uses two main techniques: First, documentation: in the form of administrative documents, organizational structures, meeting reports, chronology of events, internal evaluations, and digital archives (e.g., Google Review reviews, hospital responses, and social media), Semi-structured interviews to explore informants' experiences and views on online review management practices. Second: Interview questions were structured following the Four Flows Model framework (McPhee & Zaug, 2009), including: Membership Negotiation: negotiation mechanisms between divisions in responding to reviews, Activity Coordination: cross-unit coordination in managing complaints and online reviews, Organizational Self-Structuring: structures, procedures, and policies that frame hospital responses, Institutional Positioning: hospital strategies in building image, reputation, and relationships with the public through online reviews.

Data analysis was conducted using a qualitative content analysis approach (Yin, 2018) through the following stages: Transcription and data organization: interviews were transcribed and documents were classified, Open coding: identification of themes, patterns, and categories based on field data, Categorization: grouping codes into dimensions according to the Four Flows Model framework: Thematic interpretation: interpreting the relationships between categories, with a focus on organizational communication practices in managing of customer reviews, Source triangulation: comparing data from interviews, documentation, and observations to increase the validity of findings, Reporting results: compiled in narrative form

5. Results

5.1. Membership Negotiation

Research findings indicate that the membership negotiation process in hospitals occurs through the internalization of service values and the division of roles between divisions. This negotiation relates not only to formal membership as part of the organization but also to how staff understand their responsibilities in responding to negative customer reviews. Negative customer reviews are categorized as customer complaints. Through regular training and coaching, employees are guided to align their attitudes, behaviors, and communication styles with organizational standards. Role clarity and involvement in handling customer complaints demonstrate that membership negotiations are dynamic, emphasizing the importance of commitment to the hospital's service quality. The results of the study can be described as follows: First: Internalization of service culture: The motto of Smile, Greeting, Polite, Courteous becomes a collective identity, instilled through morning roll call, training, and work contracts, Second: Excellent service training: Conducted periodically (every 2-3 years) for all employees, including third party partners, as an effort to instill excellent service values, Third: Appreciation for positive reviews: Delivered in morning roll call as a form of collective appreciation and motivation, Fourth: Leadership by example: Leaders, especially Human Resources become role models through simple practices (smiles, greetings, greetings) that are imitated by staff, Fifth: Reward & punishment: Exemplary employees are selected based on indicators of being free of patient complaints and positive reviews.

5.2. Activity Coordination

The Legal and Customer Service plays a crucial role in coordinating online review management at the Yogyakarta City General Hospital (RSUD Kota Yogyakarta). This unit occupies a central position as the primary coordinating actor, tasked with connecting the hospital with customers and bridging communication across internal units. The Legal and Customer Service’s role is not only administrative but also strategic in managing the complaint follow-up process, enabling the hospital to respond quickly and measurably.

Coordination is conducted across units, involving relevant units mentioned in customer reviews, such as the Emergency Department, Nursing Department, Medical Services Department, and the Human Resources Sub-Division. Each unit contributes according to its function and authority: the Emergency Room handles clarification of emergency service cases, Nursing Department tracks aspects of nursing services, Medical Services Department ensures that medical service standards are maintained, while the Human Resources Sub-Division plays a role in fostering discipline and enforcing organizational rules. This mechanism demonstrates that coordination emphasizes not only case resolution but also ensures ongoing organizational learning.

In terms of communication media, WhatsApp has become the primary channel for quickly distributing customer reviews to relevant structural officials and service units. This channel complements the Hospital Management Information System and medical records electronics, which allow for more detailed patient chronology tracking. This integration between media allows for a more effective and accurate clarification process.

One key practice in coordination is the development of a chronology of each patient complaint. The chronology is compiled by the relevant service unit to verify and track the patient's experience. This document is then discussed in a hospital-wide forum to identify the root cause and formulate solutions. As a result, each complaint is not simply addressed through administrative responses but also contributes to collective learning to improve service quality.

In general, coordination activities have three main characteristics. First, they are responsive, characterized by prompt follow-up, especially on complaints rated red, which could potentially tarnish the hospital's reputation. Second, they are integrated, as online review management is linked to quality reports, incident forums, and internal reporting systems. Third, they are evaluative, as each complaint serves as the basis for improving policies and service practices.

Coordination activities in managing online reviews at the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) not only serve to calm customers or resolve complaints, but also play a vital role in building a responsive, collaborative, and evaluation-based organizational communication mechanism.

5.3. Self-Structuring

The research results show that online customer review management operates within a strong organizational self-structuring framework. This structure is supported by official documents, work guidelines, and formal communication channels that regulate complaint handling mechanisms. A central role is played by the Legal and Customer Service Unit (HKPP), which acts as the primary coordinator in monitoring, summarizing, and distributing all customer reviews, both positive and negative, to relevant units.

Hierarchically, the complaint management structure is layered, starting with the Deputy Director of General Affairs and Finance as the highest-ranking person, through the Legal and Customer Service (HKPP) as the strategic liaison, maintaining legality and public communication, and extending down to the technical complaint management level. Thus, every customer complaint is not merely received but processed through a cross-sectoral forum for clarification, evaluation, and follow-up.

Customer complaint management in the Emergency Room is carried out with a structured division of tasks, the Legal and Customer Service (HKPP) unit acts as the main coordinator, the Emergency Room plays a role in providing clarification regarding reported cases.

In the Nursing Division, she is responsible for handling complaints, particularly those related to direct interactions between patients and nursing staff. Complaints arising in the nursing service area are followed up through the hierarchy, starting with the staff member, then the ward head, and then forwarded to the nursing division for resolution. Human resources are involved in a coordination forum after receiving negative reviews shared by the Legal and Customer Service (HKPP). Information from Google Reviews or other media is channeled through a structural group, then discussed together to determine clarification and follow-up steps. In this forum, each complaint is investigated to identify the root cause and determine the responsibilities of the relevant units, including nursing, medical, and general. In the Medical Services Division, a hierarchical structure involving the Head of Medical Services, the outpatient and inpatient teams, and policy analysis staff demonstrates a systematic coordination pattern in responding to customer reviews. Reviews received through Google Reviews are submitted by the Legal and Customer Service through a structural WhatsApp group , then analyzed and followed up by the relevant units, particularly regarding negative reviews.

These findings confirm that self-structuring at the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) is not merely an administrative tool but also an organizational learning mechanism. the Legal and Customer Service Unit (HKPP) serves as a communication gateway, while service areas implement follow-up actions. Thus, the organizational structure plays a dual role: ensuring a sustainable response to customer complaints while strengthening the hospital's service quality evaluation system.

5.4. Institutional Positioning

The findings on the institutional positioning element confirm that the hospital builds its image and reputation through an integrated public communication strategy. Responses to customer reviews, both positive and negative, are carried out in a measured manner to demonstrate concern and increase public trust. Furthermore, the hospital actively uses social media, customer forums, and public hearings to strengthen the institution's position in the community. Positioning efforts go beyond facility promotion, but also include service transparency, performance evaluation, and ongoing interaction with customers and external networks. With this strategy, the hospital strives to maintain a positive reputation while minimizing potential losses from negative reviews. Institutional positioning is carried out as follows:

First, the Legal and Customer Service Unit (HKPP) plays a role not only in resolving technical complaints but also in strengthening the hospital's image through service promotion, facility awareness, and ongoing communication with the public. This strategy is reinforced by direct follow-up with customers, both through personal contact (phone/WhatsApp) and through responses on Google Reviews, although official channels are considered more effective in maintaining ongoing communication.

Second, affirms its position as an accountable and informative public institution through annual monitoring and evaluation of information transparency. For three consecutive years, has maintained its informative category with a high score (90/100), demonstrating organizational commitment, infrastructure readiness, and the role of human resources in supporting transparency.

Third, in terms of digital image, the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) actively responds to both positive and negative reviews on Google Reviews and other social media platforms. Prompt responses to customer appreciation and engagement with public comments demonstrate an effort to build interactive, two-way communication. This strategy also leverages social media algorithms to amplify the hospital's positive image.

Overall, the institutional positioning is built on three main pillars : First: Proactive public information (service promotion, education, customer meetings), Second: Transparency and accountability (public openness monitoring and evaluation with informative categories), Third: Digital image management (active response to reviews, both positive and negative).

With this strategy, the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) asserts itself not only as a healthcare provider, but also as a modern, responsive, and trusted public institution that maintains its reputation in both the digital and social spaces.

6. Discussion

6.1. Membership Negotiation

Findings regarding membership negotiation indicate that the membership process at Yogyakarta City General Hospital is not only based on structural formalities but also on the internalization of service values as a collective identity. The motto "Smile, Greet, Polite, Courteous" and the service excellence training program are important instruments in shaping employee behavior. This aligns with (Mcphee & Zaug, 2009), who emphasize that membership negotiation is an arena for the formation of organizational identity through members' commitment to organizational norms and culture.

The presence of rewards and punishments, appreciation for positive reviews, and leadership that demonstrates role models emphasize that negotiations are dynamic, emphasizing loyalty and discipline. Thus, customer reviews are not only an external instrument but also part of the organization's internal mechanism for affirming the identity and role of staff members.

6.2. Activity Coordination

Research findings on activity coordination demonstrate the strategic coordinating role of the Legal and Customer Service. As the primary coordinator, the Legal and Customer Service ensures that customer complaints are promptly distributed to relevant units via communication channels (WhatsApp, Hospital Management Information System, and medical records electronics for looking for information relate to the condition of patient). The practice of compiling case chronologies serves as a concrete example of how coordination extends beyond administrative responses and fosters collective learning.

The responsive, integrated, and evaluative characteristics of coordination align with McPhee's definition of activity coordination as a communication flow that enables work between organizational members to proceed despite differences in interests, expertise, and structural positions. In other words, coordination not only unifies cross-divisional work but also maintains the continuity of service quality amidst digital reputation pressures.

6.3. Self-Structuring

In terms of self-structuring, it demonstrates an organized complaint management system through official documents, formal workflows, and multi-layered coordination. The central role of the Legal and Customer Service (HKPP) as a communication gateway demonstrates a structure that maintains consistent responses and accountability.

The hierarchical structure involving the Deputy Director, the Legal and Customer Service Unit (HKPP), and technical service units illustrates that the organization has established a formal, standardized mechanism for responding to customer feedback. Consistent with McPhee's concept, self-structuring serves as a mechanism for maintaining organizational form through rules, policies.

Interestingly, the findings reveal a dual function of this structure: in addition to its administrative role, it also serves as a learning tool for the organization. This means that customer complaints are not simply resolved but processed into evaluation material for improving service quality.

6.4. Institutional Positioning

In terms of institutional positioning, the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) affirms its institutional reputation through an integrated public communications strategy. HKPP is at the forefront of presenting the hospital as an informative, accountable, and responsive institution to the dynamics of the digital space.

This strategy is realized through three main pillars: (1) proactive in public information, service promotion, customer meetings, public education; (2) transparency and accountability, demonstrated by achieving the “informative” category in public openness monitoring and evaluation for three consecutive years; (3) digital image management, active response to Google Review reviews and interaction with public comments on social media.

Consistent with the literature on organizational reputation (Johnson, 2014; Horn et al., 2015), positioning based on transparency and digital interaction has been shown to strengthen an organization's legitimacy in the eyes of the public. the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) does not simply respond to complaints but manages online reviews as a strategic tool for building a positive image while maintaining public trust.

7. Conclusion

This study confirms that the management of online customer reviews at Yogyakarta City General Hospital can be explained through McPhee’s Four Flows Model. In membership negotiation, the hospital emphasizes internalizing service values through mottos, training, and reward-punishment systems, making reviews an instrument for staff loyalty and service commitment. In activity coordination, cross-unit collaboration supported by digital tools and case chronologies creates responsive, integrated, and evaluative follow-up. In self-structuring, a layered structure led by Legal and Customer Service (HKPP) ensures consistent responses while functioning as a learning mechanism. In institutional positioning, the hospital builds an informative, transparent, and responsive image through service promotion, public information disclosure, and digital engagement. Overall, online reviews are not merely complaint responses but part of a broader communication strategy to strengthen identity, structure, coordination, and reputation as a modern, accountable, and customer-oriented healthcare organization.

Author Contributions: Each author has made a significant contribution to this writing. Agus Susanto conceptualized the research, conducted fieldwork, collected and analyzed the data, and drafted the manuscript. Ismi, Tiwi, and Andre provided supervisory support through structural refinement, methodological guidance, and theoretical alignment, offering continuous feedback and critical insights throughout the research and writing process.

Conflicts of Interest: The author declares no conflicts of interest

Informed Consent Statement: Informed consent was obtained from all individuals prior to their inclusion in the research process.

Institutional Review Board Statement: The study received full ethical approval by the authorities, in this case, the Yogyakarta City General Hospital (RSUD Kota Yogyakarta) with the number: 56/KEPK/RSUD/X/2024

Declaration of Generative AI and AI-assisted Technologies: This study has not used any generative AI tools or technologies in the preparation of this manuscript.