<![CDATA[The high operational density of 24-hour community health centers (Puskesmas) frequently leads to prolonged waiting times and reduced physical comfort, which may negatively affect patient loyalty. This study aimed to analyze the effects of service quality and the health center's image on patient loyalty, both directly and indirectly through patient satisfaction as a mediating variable. A quantitative approach using Structural Equation Modeling–Partial Least Squares (SEM-PLS) with SmartPLS and SPSS was employed to analyze data from 120 outpatients at the Cilincing District Community Health Center, North Jakarta. The findings revealed that service quality (p = 0.000) and the health center's image (p = 0.026) had significant positive effects on patient satisfaction. Furthermore, the health center's image (p = 0.048) and patient satisfaction (p = 0.000) significantly influenced patient loyalty. In contrast, service quality did not have a significant direct effect on patient loyalty (p = 0.572). Mediation analysis confirmed that patient satisfaction significantly mediated the effects of service quality (p = 0.003) and the health center's image (p = 0.027) on patient loyalty. Patient satisfaction acted as a full mediator in the relationship between service quality and patient loyalty, indicating that high-quality services alone do not automatically generate patient loyalty unless they first create patient satisfaction. This finding may be attributed to the tiered referral system under Indonesia's national health insurance scheme and the greater importance patients place on clinical outcomes compared with non-clinical comfort. Therefore, health center management should prioritize reducing waiting times, improving waiting room comfort, and optimizing medical staff competencies to maintain and strengthen patient loyalty]]>
