Background
Methods
Results
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Number of active beds: alternative term for ‘available beds’ [16].
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Number of beds or hospital size: “Hospital beds include all beds that are regularly maintained and staffed and are immediately available for use. They include beds in general hospitals, mental health, and substance abuse hospitals, and other specialty hospitals. Beds in nursing and residential care facilities are excluded” [17].
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Number of inpatient admissions: Mean number of hospital admissions in a certain hospital per year [16].
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Number of bed-days: “number of days during which a person is confined to a bed and in which the patient stays overnight in a hospital” [18].
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Bed occupancy rate (BOR): “The occupancy rate for curative (acute) care beds is calculated as the number of hospital bed-days related to curative care divided by the number of available curative care beds, multiplied by 365”.
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Bed turnover rate (BTR): the number of times there is change of occupant for a bed during a given time period [17].
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Average length of stay (ALS): “Average length of stay refers to the average number of days that patients spend in hospital. It is generally measured by dividing the total number of days stayed by all inpatients during a year by the number of admissions or discharges. Day cases are excluded” [17].
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Day surgery: Day surgery is defined as the release of a patient who was admitted to a hospital for a planned surgical procedure and was discharged the same day [16].
Author | Year | Country | Hospital type | Number of hospitals | Method used to calculate efficiency | Input and outputs | Source of inefficiency |
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Al-Shammari [19] | 1999 | Jordan | Hospitals of MoH* | 15 | DEA | Inputs: Numbers of bed-days, physicians, health workforce Outputs: Numbers of inpatient days, minor operations, major operations | Excess resources |
Ramanathan [20] | 2005 | Oman | Regional and Wilayat hospitals (MoH), Sultan Qaboos University Hospital, Hospital of the Royal Oman Police | 20 | DEA (Malmquist index) | Inputs: Numbers of beds, physicians, and other medical workforces. Outputs: Number of visits, in-patient services, surgical operations | Partial utilization of inputs, lack of full compliance with technological changes |
Hajialiafzali [21] | 2007 | Iran | Hospitals affiliated with the Social Security Organization | 53 | DEA (frontier-based methods) | Inputs: Total numbers of FTE* medical doctors, of FTE nurses, of other FTE workforces, number of beds Outputs: Numbers of outpatient visits and emergency visits, ratio of major surgeries to total surgeries, total numbers of medical interventions and surgical procedures | Partial utilization of inputs |
Hatam [15] | 2008 | Iran | Hospitals affiliated with the Social Security Organization | 18 | DEA (frontier-based methods) | Inputs: Numbers of beds, FTE, total expense Outputs: Patient-days, BOR*, BTR,* ALS*, ratio of available beds to constructed beds, hoteling expense, bed-day costs, workforce costs | Unused beds |
Goshtasebi [22] | 2009 | Iran | MoH hospitals | 6 | Pabon Lasso | Output: ALS, BOR, BTR | Underutilization of resources, high BOR |
Jandaghi [23] | 2010 | Iran | Public and private hospitals | 8 | DEA (frontier-based methods) | Inputs: Numbers of physicians, nurses, medical workforce, official workforce, annual costs of hospital Outputs: Numbers of clinical visits, emergency visits, and bed-days | Excess resources |
Hatam [24] | 2010 | Iran | General public hospitals | 21 | DEA (frontier-based methods) | Inputs: Numbers of hospital beds, FTE physicians, nurses, and other workforces Outputs: BOR, patient–day admissions, bed-days, ALS, BTR | Lack of motivation to select inputs to minimize expenses caused by the fact that hospitals are public and therefore do not seek profitability. |
Shahhoseini [25] | 2011 | Iran | Provincial hospitals | 12 | DEA (frontier-based methods) | Inputs: Numbers of active beds, nurses, physicians, and other professionals Outputs: Number of surgeries, outpatients visits, BOR, ALS, inpatient days | Excess resources |
Ketabi [26] | 2011 | Iran | Hospitals in Isfahan | 23 | DEA | Inputs: Average numbers of active beds, medical equipment, workforce (such as doctors, nurses and technicians) Outputs: BOR (%), ALS, total percentage of survival, performance ratio | Excess medical equipment, workforce and technology for teaching and private hospitals. Teaching hospitals are less efficient because of bureaucratic processes and private hospitals have lower BORs. |
Bahadori [27] | 2011 | Iran | Hospitals affiliated with Urmia University of Medical Sciences | 23 | Pabon Lasso | Output: ALS, BOR, BTR | Poor performance in BOR and/or BTR in 60.87% of hospitals. |
Al-Shayea [28] | 2011 | Saudi Arabia | Khalid University Hospital | 1 (9 departments) | DEA | Inputs: doctors’ total salary, nurses’ total salary Outputs: Numbers of in-patients, outpatients, bed and average turnover rate | High costs of inputs |
Kiadaliri [29] | 2011 | Iran | General hospitals affiliated with Ahvaz Jondishapour University of Medical Sciences | 19 | DEA (frontier-based methods) | Inputs: beds, human resources Outputs: inpatient days, outpatient days, number of surgeries, BOR | Inappropriate hospital sizes |
Osmani [30] | 2012 | Afghanistan | District Hospitals | 68 | DEA and Tobit regression analysis model | Inputs: Numbers of physicians, midwives, nurses, non-medical workforce, and beds Outputs: Numbers of outpatient visits, inpatient admissions, and patient days, ALS, BOR, number of hospital beds (proxy for hospital size), bed-physician and outpatient physician ratio, number of physicians | Excess numbers of doctors, nurses, and beds |
Farzianpour [31] | 2012 | Iran | Teaching hospitals of Tehran University of Medical Sciences | 16 | DEA (frontier-based methods) | Inputs: Numbers of physicians, practicing nurses in health facilities, and active beds Outputs: Numbers of inpatients, outpatients, ALS | Excess inputs or insufficient outputs |
Chaabouni [32] | 2012 | Tunisia | Public hospitals | 10 | DEA and The Bootstrap Approach | Inputs: Numbers of physicians, nurses, dentists and pharmacists, other workforces, and beds Outputs: Numbers of outpatient visits, admissions, post-admission days | High hospital expenditures |
Barati Marnani [33] | 2012 | Iran | Affiliated with Shahid Beheshti University of Medical Sciences | 23 | Pabon Lasso model and DEA (frontier-based methods) | Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: BOR, numbers of patients and surgeries | Excess resources |
Sheikhzadeh [34] | 2012 | Iran | Elected public and private hospitals of East Azerbaijani Province | 6 | DEA (frontier-based methods) | Inputs: Numbers of specialist physicians, general physicians, nurses, residents, medical team workforce with a degree (Bachelor’s), medical team, nonmedical and support workforce, and active beds Outputs: Numbers of emergency patients, outpatients, and inpatients, average daily inpatients residing in hospital | Excess and inefficient inputs: lack of medical services for the amount of resources used. |
Yusefzadeh [35] | 2013 | Iran | Public hospitals | 23 | DEA | Inputs: Numbers of active beds, doctors, and other workforces Outputs: Number of outpatients’ admissions and day-beds | Excess inputs or insufficient outputs |
Gholipour [36] | 2013 | Iran | Obstetrics and gynaecology teaching hospitals | 2 | Pabon Lasso | Output: ALS, BOR, BTR | Low BOR |
Arfa [37] | 2013 | Tunisia | Public hospitals | 101 | DEA | Five fixed inputs: Numbers of physicians, dentists, mid-wives, nurses or equivalents, and beds. One variable input: budget Outputs: Numbers of outpatient visits and admissions | Hospitals are not operating at full capacity |
Ajlouni [38] | 2013 | Jordan | Public hospitals | 15 | DEA and Pabon-Lasso | Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of bed-days, physicians per year, and health workforce per year Outputs: Patient days, numbers of minor operations and major operations | Poor management, treatment of diseases requiring long patient stays |
Abou El-Seoud [39] | 2013 | Saudi Arabia | Public hospitals that have been reformed to operate under private sector management through the full operating system in Saudi Arabia | 20 | DEA | Inputs: Numbers of specialists, nurses, allied workforce, and beds Outputs: Numbers of visits, patient hospital admissions, laboratory tests, and beneficiaries of radiological imaging | Administrative weakness to overcome external environmental factors rather than inability to manage internal operations |
Bastani [40] | 2013 | Iran | Hospitals affiliated to the MoH | 139 | Four hospital performance indicators | Output: ALS, BOR, BTR | Inappropriate hospital sizes |
Younsi [41] | 2014 | Tunisia | 30 public and 10 private hospitals | 40 | Pabon Lasso | Output: ALS, BOR, BTR | Low bed density which may not match population hospital needs. Hospital bed numbers should be increased or maintained. |
Torabipour [42] | 2014 | Iran | Teaching and non-teaching hospitals of Ahvaz County | 12 | DEA (Malemquist index) | Inputs: Numbers of nurses, beds, and physicians. Outputs: Numbers of outpatients and inpatients, ALS, number of major operations | Lack of familiarity of managers with advanced hospital technologies, lack of equipment and inappropriate use of technology in diagnosis, care and treatment. |
Syed Aziz Rasool [43] | 2014 | Pakistan | Non-profit private organization (branches of LRBT hospitals) | 16 | DEA | Inputs: Numbers of beds, specialists, nurses Outputs: Numbers of outpatient visits, inpatient admissions, and total numbers of surgeries | Lack of government funds to hospitals run by non-profit organizations. |
Pourmohammadi [44] | 2014 | Iran | All hospitals affiliated with the Social Security Organization | 64 | The Cobb-Douglas model | Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: Number of outpatients and inpatients | Excess workforce |
Mehrtak [45] | 2014 | Iran | All general hospitals located in Iranian Eastern Azerbijan Province | 18 | Pabon Lasso and DEA | Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of active beds, physicians, nurses, discharged patients Outputs: Number of surgeries and discharged patients, BOR | Excess inputs: larger hospitals are more efficient than smaller hospitals. |
Lotfi [46] | 2014 | Iran | All hospitals of Ahvaz (8 hospitals affiliated with Jundishapur University of Medical Sciences and 8 non-affiliated hospitals) | 16 | Pabon Lasso and DEA | Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: BOR, numbers of patients and surgeries | Underuse of resources, excess hospital inputs |
Kalhor [47] | 2014 | Iran | Hospitals affiliated with Qazvin University | 6 | Pabon Lasso | Output: ALS, BOR, BTR | Poor managerial decisions |
Goudarzi [48] | 2014 | Iran | Teaching hospitals affiliated with Tehran University of Medical Sciences | 12 | DEA (frontier-based methods) | Inputs: Numbers of medical doctors, nurses, and other workforces, active beds, and outpatient admissions Outputs: Number of inpatient admissions | Excess numbers of nurses and active beds |
Askari [49] | 2014 | Iran | Hospitals affiliated with Yazd University of Medical Sciences | 13 | DEA | Inputs: Numbers of active beds, nurses, physicians, and non-clinical workforce Outputs: hospitalization admissions, BOR (%), and number of surgeries | High excess inputs, particularly the excess number of nurses. |
Adham [50] | 2014 | Iran | Teaching and non-teaching hospitals | 14 | Pabon Lasso | Output: ALS, BOR, BTR | Low BOR |
Imamgholi [51] | 2014 | Iran | Hospitals affiliated to Busheher University of Medical Sciences | 7 | Pabon Lasso | Output: ALS, BOR, BTR | Non-optimal hospital sizes |
Shetabi [52] | 2015 | Iran | Hospitals affiliated to Kermanshah University of Medical Sciences | 7 | DEA | Inputs: Numbers of active beds, doctors, nurses, and other workforces Outputs: Numbers of accepted inpatients, outpatients and BOR (%) | Excess inputs |
Masoompourb [53] | 2015 | Iran | Teaching Hospital | 1 | Pabon Lasso | ALS, BOR, BTR | Decrease in ALS |
Chaabouni [54] | 2016 | Tunisia | Public Hospitals | 10 | DEA (frontier-based methods) | Inputs: Numbers of physicians, nurses, dentists, pharmacists, and beds, total cost Outputs: Numbers of outpatient visits, admissions, and post-admission days, price of labor | large hospital sizes |
Safdar [55] | 2016 | Pakistan | A large public hospital | 1 | DEA | Inputs: Waiting time at the pharmacy, length of waiting line Outputs: Consultation time at the pharmacy | High waiting times: low efficiency levels (less than 50% efficiency) are associated with high waiting times. |
Mohammadi [56] | 2016 | Iran | Public hospitals | 67 | Cobb-Douglas production function | Inputs: Human resources (including net working hours of specialized workforce) and bed numbers (including the number of active beds) | Insufficient inputs: Inpatient service production levels were lower than expected in 40% of hospitals. A 10% increase in net working hours of specialized human resources would generate a 8.8% increase in average inpatient service production levels. A 10% increase in the number of active beds would generate a 1.1% increase in average inpatient service production levels. |
Mahate [57] | 2016 | United Arab Emirates | Private and public hospitals in the UAE | 96 | DEA | Inputs: Numbers of beds, doctors, dentists, nurses, pharmacists and allied health workforce, and administrative workforce Outputs: Numbers of treated inpatients, outpatients, ALS | Waste of 41 to 52% of inputs during service delivery. |
Kalhor [58] | 2016 | Iran | Tehran city general hospitals | 54 | DEA | Inputs: Total numbers of FTE medical doctors, and nurses, numbers of supporting medical workforce including ancillary service workforce, and beds Outputs: Numbers of patient days, outpatient visits, patients receiving surgery, ALS | Ownership type (lower efficiency of university hospitals because of more expenditures) |
Kakemam [59] | 2016 | Iran | Hospitals of public, private, or social security ownership types in Tehran | 54 | DEA | Inputs: Numbers of active beds, physicians, nurses, and other medical workforces Outputs: Numbers of outpatient visits, surgeries, and hospitalized days, ALS | Lack of resource optimization. Poor adaptation of the sizes, types of practices, and ownerships of hospitals, affecting their technical efficiency. Approximately 70% of the hospitals were inefficient. |
Hassanain [60] | 2016 | Saudi Arabia | Hospitals affiliated to the MoH | 12 | Lean | On-time start, room turnover times, percent of overrun cases, average weekly procedure volume and OR utilization | Ppoor hospital infrastructure, old technology, suboptimal management of human resources, the absence of employee engagement, frequent scheduling changes, inefficient process flow |
Hamidi [61] | 2016 | Palestine | 22 government hospitals | 22 | DEA (frontier-based methods) | Inputs: Numbers of beds, doctors, nurses, and non-medical workforce Outputs: Numbers of admitted patients, hospital days, operations, outpatient visits, ALS | Mismanagement of available resources, shortage of the numbers of doctors and nurses and excess number of non-medical staff |
Nabilou [62] | 2016 | Iran | Hospitals affiliated to Tehran University of Medical Sciences | 17 | DEA (Malmquist index) | Inputs: Active beds, nurses, doctors and other workforces Outputs: outpatient admissions, bed-days, number of surgical operations | Due to hospitals’ technological changes, a lack of knowledge of hospital workforce on proper applications of technology for patient treatment became the main cause of low hospital productivity and inefficiency. |
Rezaei [63] | 2016 | Iran | Kurdistan teaching hospitals | 12 | DEA (frontier-based methods) | Inputs: Numbers of active beds, nurses, physicians, and other workforce members Outputs: Inpatient admissions | Waste of inputs during service delivery |
Farzianpour [64] | 2017 | Iran | Training and non-training hospitals of Tabriz city | 19 | DEA | Inputs: Numbers of physicians, total workforce, and active beds Outputs: Number of outpatients and BOR | Poor management of human and financial resources. |
Arfa [65] | 2017 | Tunisia | Public district hospitals | 105 | DEA | Inputs: Numbers of physicians, surgical dentists, midwives, nurses and equivalents, and beds, operating budget Outputs: Outpatient visits in stomatology wards, outpatient visits in emergency wards, outpatient visits in external wards, numbers of admissions, and admissions in maternity wards | Inadequate number of workforce, equipment, beds, and medical supply, health quality and lack of fitting operating budgets: tackling these sources of inefficiency would reduce net user needs and the bypassing of the public district hospitals, to increase their capacity utilization. Social health insurance should be turned into a direct purchaser of curative and preventive care for the public hospitals. |
Aly Helal [66] | 2017 | Saudi Arabia | Public hospitals | 270 | DEA | Inputs: Numbers of beds, doctors, nurses, and allied medical workforce Outputs: Numbers of individuals visiting admitted patients, radiography service beneficiaries, laboratory testing beneficiaries, and inpatients | Excess inputs |
Mousa [67] | 2017 | Saudi Arabia | Public hospitals | 270 | DEA | Inputs: Numbers of physicians, nurses, pharmacists, allied health professionals, beds Outputs: Numbers of outpatient visits, inpatients, laboratory investigations, X-rays patients, X-rays films, total number of surgical operations | Inadequate resources: some resources should be switched between regions to improve efficiency. |
Moradi [68] | 2017 | Iran | Public hospitals | 11 | Pabon Lasso | ALS, BOR, BTR | Low number of hospital beds, and need for hospital expansion |
Sultan [69] | 2017 | Jordan | General public hospitals | 27 | DEA | Inputs: Numbers of beds, physicians, healthcare workforce, administrative workforce Outputs: Inpatient days, outpatient visits, emergency departments, and ambulances | Diseconomies of scale affect the operational efficiency, poor management, poor productivity in outpatient services and low numbers of physicians. |
Kassam [70] | 2017 | Iraq | Hospitals in Baghdad | 3 | DEA and Luenberger Productivity Indicator (LPI) | Inputs: Numbers of doctors, nurses, and other health workforces Outputs: Numbers of outpatients, laboratory tests, radiology tests, sonar tests, emergency visits | The cause of the inefficiencies is undetermined. |
Rezaee [71] | 2018 | Iran | Hospitals affiliated with Kermanshah University of Medical Sciences | 15 | Pabon Lasso | Output: ALS, BOR, BTR | Excess inputs |
Yazan Khalid Abed-Allah Migdadi [72] | 2018 | Jordan | Public hospitals | 15 | DEA | Inputs: Numbers of physicians, nurses, and beds Outputs: ALS, number of Surgeries, BOR | Low BOR |
Sajadi [73] | 2018 | Iran | All hospitals in Isfahan City | 54 | Cross-sectional descriptive study comparing performance indicators | Outputs: BOR, BTR, bed-days, inpatients visits, number of surgeries in all types of hospitals, outpatient visits in all non-private hospitals, emergency visits in public and social security hospitals, and natural deliveries in public and semi-public hospitals | Inefficient use of limited resources |
Source of inefficiency | Common sources of inefficient performance | Proposed actions | |
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Hospital products and services | overuse or supply of equipment, investigations, and procedures | - Inappropriate payment systems (fee-for-service payment mechanisms) - Misuse or inappropriate use of technology in patient treatment and diagnosis like imaging and lab services due to lack of knowledge and skills of health professional and lack of adopted evidenced-based guidelines. - Overuse or oversupply of equipment - Lack of or defective hospital equipment - Poor standards for use of technologies | -Reform incentive and payment structures, developing appropriate tariff and payment systems (e.g. use capitation or diagnosis-related group mechanism for reimbursement) -Raising workforce awareness and training workforce and managers about new information systems and technologies -Raising workforce awareness of energy management through frequent training -Develop and implement clinical guidelines |
Hospital workforce | inappropriate or costly workforce mix | - Lack of or failure to use specialized managers in hospital administration - Suboptimal use of workforce capabilities, including those of physicians, nurses, paramedics, and support workforce, resulting in excess workforce in some departments - Inadequate management of hospital resources like workforce | -Recruiting workforce based on hospital needs (both in terms of numbers and specialties required) -Preventing the recruitment and maintenance of specialist workforce who are not significantly relevant to hospital and patient needs. -Using work measurement and time management techniques for optimal use of the workforce with respect to the volume of hospital operations |
unmotivated workforce | - Lack of motivation due to high workload - Lack of workforce motivation in the public sector because of inadequate salaries | -Introducing performance-based payments -Use appropriate incentive, reward and appraisal systems | |
Hospital services delivery | inappropriate hospital admissions and length of stay | - Inappropriate ALS*, unnecessary admissions, low BORs* and unnecessary referrals to specialists due to inadequate knowledge and training of workforce about best practice. | -Developing and implementing policies to accelerate admission and discharge processes and increase the quality of services -Developing strategies to reduce ALS*, including full-time presence of physicians and modification of hospital funding policies -Establishing a two-way electronic referral system, to provide physicians with feedback -Effective marketing using appropriate customer information, and improving communication and customer loyalty |
inappropriate hospital size (low use of infrastructure) | - Inefficient hospital size, lack of scale efficiency and too many hospitals and inpatient beds in some areas, not enough in others - Suboptimal use of available capacities such as infrastructure and active beds, resulting in excess beds in some departments (lack of planning) | -Modifying hospital size: selecting an efficient size and preventing hospital overdevelopment. if inefficient (downsizing or merging hospitals) -Making optimal use of hospital beds based on community needs. -Use of cost analysis and DEA model and other efficiency measurement models for incorporate inputs and output estimation into hospital planning. -Improving workforce, equipment, and beds based on evidence -Designing a basic framework for optimal resource allocation by health policymakers -Diversifying the outputs required for compensating hospital inefficiency -Redistributing hospital resources among regions -Training to raise knowledge about efficient admission practice | |
medical errors and suboptimal quality of care | - Poor care management skills of physicians and other workforces. - Inadequate managerial skills and lack of training for hospital managers. - Inadequate skills and training of the hospital workforce. | -Designing on-the-job training courses tailored to workforce roles. -Using experienced and well-educated managers with management or healthcare management degrees, performance evaluation of hospital managers and provide feedback -Introducing managers to management techniques and methods of economic analysis -Improve hygiene standards in hospitals; provide more continuity of care; undertake more clinical audits; monitor hospital performance | |
Hospital system leakages | waste, corruption and fraud | - Inappropriate suboptimal allocation of funds among hospitals and unclear resource allocation guidance. - Hospital reliance on public funds and budgets, and lack of competition with other organizations. | -Modifying hospital budget structures -Improve regulation/governance, including strong sanction mechanisms; assess transparency/vulnerability to corruption; undertake public spending tracking surveys; promote codes of conduct |