The short-term effect on technical and scale efficiency of establishing regional health systems and general management in Greek NHS hospitals

An examination of health care efficiency in Canada: a two-stage semi-parametric approach

Using data envelopment analysis, we examine the efficiency of Canada's universal health care system by considering a set of labour (physicians) and capital (beds) inputs, which produce a level of care (measured in terms of health quality and quantity) in a given region. Data from 2013-2015 were collected from the Canadian Institute for Health Information regarding inputs and from the Canadian Community Health Survey and Statistics Canada regarding our output variables, health utility (quality) and life expectancy (quantity). We posit that variation in efficiency scores across Canada is the result of regional heterogeneity regarding socioeconomic and demographic disparities. Regressing efficiency scores on such covariates suggests that regional unemployment and an older population are quite impactful and associated with less efficient health care production. Moreover, regional variation indicates the Atlantic provinces (Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick) are quite inefficient, have poorer economic prospects, and tend to have an older population than the rest of Canada. Oaxaca-Blinder decompositions suggest that the latter two factors explain about one-third of this efficiency gap. Based on our two-stage semi-parametric analysis, we recommend Canada adjust their transfer payments to reflect these disparities, thereby potentially reducing inequality in regional efficiency.

Applications of data envelopment analysis in acute care hospitals: a systematic literature review, 1984-2022

This study reviews scholarly publications on data envelopment analysis (DEA) studies on acute care hospital (ACH) efficiency published between 1984 and 2022 in scholarly peer-reviewed journals. We employ systematic literature review (SLR) method to identify and analyze pertinent past research using predetermined steps. The SLR offers a comprehensive resource that meticulously analyzes DEA methodology for practitioners and researchers focusing on ACH efficiency measurement. The articles reviewed in the SLR are analyzed and synthesized based on the nature of the DEA modelling process and the key findings from the DEA models. The key findings from the DEA models are presented under the following sections: effects of different ownership structures; impacts of specific healthcare reforms or other policy interventions; international and multi-state comparisons; effects of changes in competitive environment; impacts of new technology implementations; effects of hospital location; impacts of quality management interventions; impact of COVID-19 on hospital performance; impact of teaching status, and impact of merger. Furthermore, the nature of DEA modelling process focuses on use of sensitivity analysis; choice of inputs and outputs; comparison with Stochastic Frontier Analysis; use of congestion analysis; use of bootstrapping; imposition of weight restrictions; use of DEA window analysis; and exogenous factors. The findings demonstrate that, despite several innovative DEA extensions and hospital applications, over half of the research used the conventional DEA models. The findings also show that the most often used inputs in the DEA models were labor-oriented inputs and hospital beds, whereas the most frequently used outputs were outpatient visits, followed by surgeries, admissions, and inpatient days. Further research on the impact of healthcare reforms and health information technology (HIT) on hospital performance is required, given the number of reforms being implemented in many countries and the role HIT plays in enhancing care quality and lowering costs. We conclude by offering several new research directions for future studies.

Do adjustment costs constrain public healthcare providers' technical efficiency? Evidence from the New Zealand Public Healthcare System

Efficiency analysis is crucial in healthcare to optimise resource allocation and enhance patient outcomes. However, the prompt adaptation of inputs can be hindered by adjustment costs, which impact Long-Run Technical Efficiency (LRTE). To bridge this gap in healthcare literature, this research employs a Bayesian Dynamic Stochastic Frontier Model to estimate parameters and explore healthcare efficiency dynamics over time. The study reveals the LRTE for New Zealand District Health Boards (DHBs) as 0.76, indicating around 32% more input utilisation due to adjustment costs. Most DHBs exhibit consistent short-run operational efficiency, with the national Short-Run Technical Efficiency (SRTE) very close to the LRTE. Among the tertiary providers, Auckland and Capital & Coast DHBs operate below the LRTE level, setting them apart from other tertiary providers. Similarly, Tairawhiti and West Coast DHBs also fall below the LRTE level, as indicated by their SRTE scores, potentially influenced by their unique healthcare settings and resource challenges. This research brings a new perspective to policy discussions by incorporating the temporal dynamics of decision-making and considering adjustment costs. It underscores the need to balance short-term and long-term technical efficiency, underlining their collective significance in fostering a sustainable and efficient healthcare system in New Zealand.

The Existence-Relatedness-Growth Theory for Job Satisfaction and Motivation of Greek National Healthcare Service Employees in the Context of Severe Financial Constraints

The hospital environment is often quite complicated due to interdisciplinary workflow procedures and multitasking staff, which are exacerbated during periods of economic crisis. This study aimed to examine the motivation and job satisfaction factors of Greek National Healthcare Service (NHS) employees in relation to the Existence-Relatedness-Growth (ERG) theory of motivation during a period of severe financial constraints. A cross-sectional study was conducted in three public hospitals in Greece from 2018 to 2019, utilizing a survey tool to measure the factors of motivation and job satisfaction among Greek NHS employees. The study also aimed to identify the most relevant motivational theory applicable to the complex Greek hospital environment. Exploratory factor analysis (EFA) was employed to extract the structural factors of the survey tool, and analysis of variance (ANOVA) was used to identify statistical differences between the means of three or more independent groups. A sample of 363 Greek NHS employees participated in this study. Statistically significant differences were detected between hospital units and job satisfaction factors, as well as between the functions of hospital clusters and job positions. Specifically, managerial staff presented higher levels of job satisfaction, while nursing staff had the lowest scores in terms of psychological contracts when compared to medical and administrative staff. This study demonstrated that job satisfaction in Greek public hospitals, in a context of severe financial constraints, was mainly driven by strong interpersonal connections and employee trust in management, despite significant cuts in salaries, staff numbers, and hospital budgets.

Assessing the Efficiency and Productivity of the Hospital Clinics on the Island of Rhodes during the COVID-19 Pandemic

(1) Background: The aim was to measure the efficiency and productivity of 15 specialty clinics during the COVID-19 pandemic period 2020-2021 in the General Hospital of Rhodes. (2) Methods: An input-oriented data envelopment analysis and the Malmquist productivity index are used. Labor and capital were used as inputs, and in-patient discharges and days were used as outputs. (3) Results: Five out of the seven clinics in the pathology sector appeared fully efficient with an optimal productivity, and the rest showed progress in 2021. In 2020 the COVID-19 pathology clinic appeared to be inefficient and less productive, while in 2021, it showed a positive performance change. The surgical sector showed very high efficiency rates or even reached an optimal efficiency in both years. The productivity measurement, in most of the surgical clinics, was satisfactory to very high. In 2020 the COVID-19 surgical clinic appeared to be more efficient and productive than in 2021 when its performance declined. (4) Conclusions: The hospital responded to the pressure during the pandemic, by increasing its efficiency and productivity from 2020 to 2021. This was due to the accomplishment of the appropriate organizational changes in the infrastructure, human resources, and technology. The efficiency and productivity assessments should be incorporated in the hospitals' decision making.

The Core of Healthcare Efficiency: A Comprehensive Bibliometric Review on Frontier Analysis of Hospitals

Parametric and non-parametric frontier applications are typical for measuring the efficiency and productivity of many healthcare units. Due to the current COVID-19 pandemic, hospital efficiency is the center of academic discussions and the most desired target for many public authorities under limited resources. Investigating the state of the art of such applications and methodologies in the healthcare sector, besides uncovering strategical managerial prospects, can expand the scientific knowledge on the fundamental differences among efficiency models, variables and applications, drag research attention to the most attractive and recurrent concepts, and broaden a discussion on the specific theoretical and empirical gaps still to be addressed in future research agendas. This work offers a systematic bibliometric review to explore this complex panorama. Hospital efficiency applications from 1996 to 2022 were investigated from the Web of Science base. We selected 65 from the 203 most prominent works based on the Core Publication methodology. We provide core and general classifications according to the clinical outcome, bibliographic coupling of concepts and keywords highlighting the most relevant perspectives and literature gaps, and a comprehensive discussion of the most attractive literature and insights for building a research agenda in the field.

Relative Efficiency of Radiation Treatment Centers: An Application of Data Envelopment Analysis

This study determines the relative efficiencies of a number of cancer treatment centers in Ontario, taking into account the differences among them so that their performances can be compared against the provincial targets. These differences can be in physical and financial resources, and patient demographics. An analytical framework is developed based on a three-step data envelopment analysis (DEA) model to build efficiency metrics for planning, delivery, and quality of treatment at each center. Regression analysis is used to explain the efficiency metrics and demonstrates how these findings can inform continuous improvement efforts.

Efficiency and management factors: finding the balance in Thalassaemia care centres

BACKGROUND

Optimizing efficiency has become increasingly critical with the growing demand for finite healthcare resources driven by population growth and an ageing society. Hence, policymakers are urgently finding more efficient ways to deliver health services. Thalassemia is a complex inherited blood disorder with significant prevalence in Malaysia. The high number of patients put substantial strain on the healthcare system. This study aims to evaluate the technical efficiency of thalassaemia care centres throughout Malaysia and the determinants that affect the efficiency.

METHOD

Data from 30 public hospitals with thalassaemia care centres were collected. A double bootstrap data envelopment analysis (DEA) approach is used with the assumption of input-oriented and variable-to-scale DEA models to generate technical efficiency scores. Bootstrap truncated regression was later conducted to identify the factors affecting the efficiency scores.

RESULTS

The mean bias-corrected technical efficiency score has improved to 0.75 in 2017 from 0.71 in 2016. In both years, more than 50% of thalassaemia care centres showed good efficiency scores (0.8-1.0). Management factors that affect the efficiency scores include separation of patient management (β = 0.0653) and budget (β = 0.0843), where they are found to positively affect the efficiency scores. In contrast, having longer operating hours is found to inversely influence the performance levels (β = - 0.4023).

CONCLUSIONS

The study provides a pioneering framework to evaluate the technical efficiency of thalassaemia treatment centres in public healthcare settings and could provide a useful guide for policymaker and thalassaemia care centre managers to improve efficiency in service delivery to thalassaemia patients and their caregivers without compromising quality of care.

Efficiency and productivity of health systems in prevention and control of non-communicable diseases in China, 2008-2015

This article examines the health system performance impact of China's new round of healthcare reform adopted in 2009. Specifically, we evaluated productivity and efficiency of health production pre- and post-reform period, compared the effects across all the 31 provinces of mainland China and identified potential determinants. As a major source of disability and premature mortality in China, non-communicable diseases (NCDs) had been the focus of our analysis, and the period during 2008-2015 was considered to allow enough time for the policy to have meaningful impact on the country's health system. Productivity and efficiency performance were analyzed using a bootstrapping data envelopment analysis (DEA) and the Malmquist productivity index (MPI) techniques, while a Tobit regression technique was used to identify determinants of inefficiency. We find that after the reform efficiency and productivity had declined across large number of provinces. Mean overall technical efficiency (OTE) post 2009 was about 30% lower than the potential maximum capacity, while productivity also fell at a rate of 7.57% per annum. Trends in productivity and efficiency performance were largely linked to patterns of scale of technological change observed during the study period. The findings suggest that efficiency and productivity can be improved through enhancing financial security, optimizing health resource allocation, particularly between human resources for health and hospital beds, and expanding cost-effective technology within the health sector. Better urban planning practices and investment in education were also found to contribute to improved efficiency of NCDs services.

Assessment of technical efficiency of public hospitals in Turkey

BACKGROUND

Turkish public hospitals have been subjected to health care reform because of increasing cost pressure, inequities in access to health care, poor quality of care and limited patient responsiveness in the last three decades. This study investigates the impact of recent hospital reforms on the efficiency of public hospitals.

METHODS

The study provides a comprehensive evaluation of the efficiency of Turkish hospitals by using Data Envelopment Analysis (DEA). The estimation of efficiency of 669 public hospitals of Turkey is performed by an output-oriented model of DEA under the assumption of variable return-to-scale by using data collected from the Ministry of Health (MoH) over the period 2013-17.

RESULTS

The average efficiency score is equal to 0.83 for all MoH hospitals. Considering the hospital type, the efficiency scores of training and research hospitals are higher than those of the general and branch hospitals. In addition, considering the hospital size, huge-scale hospitals have the highest efficiency score in all years. Moreover, overcrowded regions such as Marmara and South-eastern Anatolia regions had higher efficiency scores than other geographical regions.

CONCLUSIONS

The results indicate that recent health reforms did not significantly enhance hospital efficiency. Thus, policymakers and managers should take the necessary precautions to increase hospital efficiency.

Integrated Analysis of Healthcare Efficiency: A Systematic Review

Data Envelopment Analysis (DEA) has been used as a performance measurement tool in efficiency assessment of healthcare systems. However, over the years, researchers and health practitioners presented the theoretical and methodological limitations of DEA that limits the full view of healthcare efficiency. To address these limitations, a commonly used strategy is to integrate other statistical methods and techniques with DEA to provide better efficiency evaluation. This paper reviews 57 studies with DEA applications in the healthcare industry to illustrate the integrated analysis of healthcare efficiency. With DEA as the central method, regression models in conjunction with statistical tests are commonly used. Input-oriented radial DEA models using predominantly capacity-related inputs and activity-related outputs and following either constant return to scale or variable return to scale assumptions are mostly applied to measure healthcare efficiency.

Fuzzy Linguistic Summarization with Genetic Algorithm: An Application with Operational and Financial Healthcare Data

It is now well recognized that knowledge extracted from rich healthcare data play a vital role for delivery, management and planning of healthcare services. So far, however, there is not much study done on the domain of operational and financial healthcare data since, up to now, a great deal of works are dedicated to clinical/medical healthcare data for the purposes of diagnosis and treatment of diseases. In this paper, an attempt is made, by applying fuzzy linguistic summarization, for the first time to discover knowledge from operational and financial healthcare data. Fuzzy linguistic summarization, in its simplest term, provides natural language based summaries from a dataset in a human consistent way along with a degree of truth attached to each summary. While basically valuable, its benefit can be increased by only generating summaries with a degree of truth above than an indicated threshold value. A genetic algorithm is developed within this context in order to eliminate less promising and useless linguistic summaries. We assess the proposed approach experimentally on a real data and evaluate the generated summaries to gain actionable insights from them.

A window-DEA based efficiency evaluation of the public hospital sector in Greece during the 5-year economic crisis

The main objective of this study was to apply the non-parametric method of Data Envelopment Analysis (DEA) to measure the efficiency of Greek NHS hospitals between 2009–2013. Hospitals were divided into four separate groups with common characteristics which allowed comparisons to be carried out in the context of increased homogeneity. The window-DEA method was chosen since it leads to increased discrimination on the results especially when applied to small samples and it enables year-by-year comparisons of the results. Three inputs -hospital beds, physicians and other health professionals- and three outputs—hospitalized cases, surgeries and outpatient visits- were chosen as production variables in an input-oriented 2-year window DEA model for the assessment of technical and scale efficiency as well as for the identification of returns to scale. The Malmquist productivity index together with its components (i.e. pure technical efficiency change, scale efficiency change and technological scale) were also calculated in order to analyze the sources of productivity change between the first and last year of the study period. In the context of window analysis, the study identified the individual efficiency trends together with “all-windows” best and worst performers and revealed that a high level of technical and scale efficiency was maintained over the entire 5-year period. Similarly, the relevant findings of Malmquist productivity index analysis showed that both scale and pure technical efficiency were improved in 2013 whilst technological change was found to be in favor of the two groups with the largest hospitals.

Efficiency and optimal size of hospitals: Results of a systematic search

Background

National Health Systems managers have been subject in recent years to considerable pressure to increase concentration and allow mergers. This pressure has been justified by a belief that larger hospitals lead to lower average costs and better clinical outcomes through the exploitation of economies of scale. In this context, the opportunity to measure scale efficiency is crucial to address the question of optimal productive size and to manage a fair allocation of resources.

Methods and findings

This paper analyses the stance of existing research on scale efficiency and optimal size of the hospital sector. We performed a systematic search of 45 past years (1969–2014) of research published in peer-reviewed scientific journals recorded by the Social Sciences Citation Index concerning this topic. We classified articles by the journal’s category, research topic, hospital setting, method and primary data analysis technique. Results showed that most of the studies were focussed on the analysis of technical and scale efficiency or on input / output ratio using Data Envelopment Analysis. We also find increasing interest concerning the effect of possible changes in hospital size on quality of care.

Conclusions

Studies analysed in this review showed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200–300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.

Performance indicators: healthcare professionals’ views

Purpose

– The purpose of this paper is to capture factors behind professional views of indicator usefulness as a common structure for assessing healthcare performance and their important characteristics to design limited key performance indicators (PIs) for holistic hospital management.

Design/methodology/approach

– Two surveys were conducted using self-administered questionnaires, in which hospital manager/staff respondents were asked to rate the 52 PIs’ usefulness. In total, 228 manager and 894 staff responses were collected.

Findings

– Eight factors were elicited from manager and staff responses as performance measures with 72 percent cumulative variance accounted for. Hospital managers and staff showed similar performance measure perceptions: high-utility acknowledgment on safety, operational efficiency and patient/employee satisfaction but relatively low-employee development concerns. Manager indicator usefulness perceptions were rather homogeneous and significantly higher than staff for almost all performance measures.

Practical implications

– Homogeneous manager views mean that a single key PI set for hospital management may be established regardless of hospital attributes. The following aspects may be measures that should be managed in a healthcare organization based on their key PIs: patient/employee safety, operational efficiency, financial effectiveness and patient/employee satisfaction.

Originality/value

– This is a pilot study on hospital management PIs in Japan. The eight-dimensional factor structure and findings about healthcare provider perceptions may be useful for healthcare management.

The effect of physicians’ financial incentives on the diagnosis related group-based prospective reimbursement scheme in Taiwan

This study examines whether the implementation of a Physician Compensation Program (PCP) improved departmental performance in a large private not-for-profit hospital’s performance after it implemented the Taiwan Diagnosis Related Group-based (Tw-DRG) prospective reimbursement scheme. Because hospitals in Taiwan are structurally similar to staff-model HMOs, the effects of PCPs on hospital performance under the Tw-DRG scheme in Taiwan may have implications for staff-model HMOs. The data sample contains 624 monthly observations of the 26 departments in the case hospital for the period 2009–2010. Of the 26 departments, 18 have implemented the Tw-DRG scheme and are classified as the Tw-DRG group; and the other eight departments are classified as the non-Tw-DRG group. Since the introduction of the scheme, the physicians in both groups have been paid under the PCP. Overall, the results show that the case hospital’s performance deteriorated after the scheme was implemented. The findings imply that conflicts arise in hospitals where some departments have implemented the Tw-DRG scheme that encourages hospitals to reduce the utilization of medical resources, while physicians in those departments are still paid under the PCP and are, therefore, motivated to expand medical services without trying to reduce costs. As a result, the Tw-DRG scheme may fail or only have a limited effect. This study also provides evidence that physicians’ behavior affects their clinical performance, especially under a strict cost containment payment policy. Taiwan’s experience provides a good opportunity to evaluate, simultaneously, the effects of cost containment mechanisms and physicians’ incentive plans within a staff-model context.

Analysis of the cost and efficiency relationship: experience in the Turkish pay for performance system

This paper analyzes the effects of the pay for performance (PFP) system on the efficiencies of public and private hospitals in Turkey. In order to evaluate these effects, we examine the relationship between hospital efficiency and health care costs in Turkey, and address the impact of the PFP system on the efficiencies of public and private hospitals. In an effort to analyze the efficiencies of public and private hospitals, this study uses data envelopment analysis. The Malmquist Productivity Index is also used to analyze the patterns of efficiency change for the study years from 2001 to 2008. This study shows that health care costs and hospital efficiency are negatively correlated for private hospitals, while they are positively correlated for public hospitals. In other words, increased health care costs might reduce efficiency in private hospitals in contrast to public hospitals. Our findings also indicate that average efficiencies of public hospitals tend to increase, particularly during the implementation period of PFP system. The efficiency trend of private hospitals, conversely, decreased in the latter periods of the PFP system. Suggestions for improvement are provided to the health care policy makers regarding the impact of health care reforms on public and private hospitals.

Regional Decentralisation in the Greek Health Care System: Rhetoric and Reality

Decentralisation is a complex, yet basic feature of health care systems in many countries entailing the transfer of authority or dispersal of power in public planning, management and decision making from higher to lower levels of government. This paper describes the attempts made in Greece from 1923 until today to decentralise its highly centralised health care system, drawing on a thorough documentary analysis of legislative acts and official reports regarding regional health policy. The analysis shows that, although decentralisation has been attempted on several occasions, in the end it was abandoned every time. The first ever implementation of a decentralised system of governance in 2001 was also curtailed, resulting in only minor decentralisation of authority and real powers. It is suggested that decentralisation has been impeded by many factors, especially obstruction by opposition from key interest groups, absence of policy continuity between governments, the inability to tackle the bureaucratic and highly centralised system and lack of political will.

Reengineering NHS Hospitals in Greece: Redistribution Leads to Rational Mergers

The purpose of this study was to record and evaluate existing public hospital infrastructure of the National Health System (NHS), in terms of clinics and laboratories, as well as the healthcare workforce in each of these units and in every health region in Greece, in an attempt to optimize the allocation of these resources. An extensive analysis of raw data according to supply and performance indicators was performed to serve as a solid and objective scientific baseline for the proposed reengineering of the Greek public hospitals. Suggestions for “reshuffling” clinics and diagnostic laboratories, and their personnel, were made by using a best versus worst outcome indicator approach at a regional and national level. This study is expected to contribute to the academic debate about the gap between theory and evidence based decision-making in health policy.

Cardiac echo-lab productivity in times of economic austerity

The present study attempts to offer insight into the volume, cost, and productivity of the operation of a cardiac echocardiographic laboratory (echo-lab) in a major public hospital of Greece and thus to contribute, on a practical level, to the widening of knowledge in the strategic field of secondary and tertiary healthcare management. The conducted research includes the basic step of the deployment of a primary data registry in the echo-lab and unfolds in three levels, i.e. the variability measurement of the quantity and cost of medical services provided to different patient populations, the assessment of operating costs and the development of productivity indexes. The results show that the mean costs of provision do change among distinct patient populations. The most important, from a financial standpoint, population cluster appears to be the one corresponding to outpatients. Productivity indices presented in this analysis constitute an essential piece of information which the public healthcare system is currently largely lacking, and which, combined with the pricing and the diagnosis-related group coding system of hospitals, can be used to improve efficiency in the management of secondary and tertiary care.

Greek economic crisis and health care reforms: correcting the wrong prescription

In an era of economic crisis in Greece and with many uninsured citizens, the Troika (lenders of Greece) suggests reforms and promotes the internal market, resulting in a public-private system becoming more privatized. This article contradicts these proposals and attempts to suggest the necessary reforms to achieve equity of access for all and to promote efficiency, taking into account the existing needs of the population and the recession of the Greek economy.

Managing for efficiency in health care: the case of Greek public hospitals

This paper evaluates the efficiency of public hospitals with two alternative conceptual models. One model targets resource usage directly to assess production efficiency, while the other model incorporates financial results to assess economic efficiency. Performance analysis of these models was conducted in two stages. In stage one, we utilized data envelopment analysis to obtain the efficiency score of each hospital, while in stage two we took into account the influence of the operational environment on efficiency by regressing those scores on explanatory variables that concern the performance of hospital services. We applied these methods to evaluate 96 general hospitals in the Greek national health system. The results indicate that, although the average efficiency scores in both models have remained relatively stable compared to past assessments, internal changes in hospital performances do exist. This study provides a clear framework for policy implications to increase the overall efficiency of general hospitals.

How efficient are Greek hospitals? A case study using a double bootstrap DEA approach

The purpose of this study was to measure Greek hospital performance using different input-output combinations, and to identify the factors that influence their efficiency thus providing policy makers with valuable input for the decision-making process. Using a unique dataset, we estimated the productive efficiency of each hospital through a bootstrapped data envelopment analysis (DEA) approach. In a second stage, we explored, using a bootstrapped truncated regression, the impact of environmental factors on hospitals' technical and scale efficiency. Our results reveal that over 80% of the examined hospitals appear to have a technical efficiency lower than 0.8, while the majority appear to be scale efficient. Moreover, efficiency performance differed with inclusion of medical examinations as an additional variable. On the other hand, bed occupancy ratio appeared to affect both technical and scale efficiency in a rather interesting way, while the adoption of advanced medical equipment and the type of hospital improves scale and technical efficiency, correspondingly. The findings of this study on Greek hospitals' performance are not encouraging. Furthermore, our results raise questions regarding the number of hospitals that should operate, and which type of hospital is more efficient. Finally, the results indicate the role of medical equipment in performance, confirming its misallocation in healthcare expenditure.

A theoretical framework for holistic hospital management in the Japanese healthcare context

OBJECTIVE

This paper develops a conceptual framework for performance measurement as a pilot study on holistic hospital management in the Japanese healthcare context.

METHODS

We primarily used two data sources as well as expert statements obtained through interviews: a systematic review of literature and a questionnaire survey to healthcare experts. The systematic survey searched PubMed and PubMed Central, and 24 relevant papers were elicited. The expert questionnaire asked respondents to rate the degree of "usefulness" for each of 66 indicators on a three-point scale.

RESULTS

Applying the theoretical framework, a minimum set of performance indicators was selected for holistic hospital management, which well fit the healthcare context in Japan. This indicator set comprised 35 individual indicators and several factors measured through questionnaire surveys. The indicators were confirmed by expert judgments from viewpoints of face, content and construct validities as well as their usefulness.

CONCLUSION

A theoretical framework of performance measurement was established from primary healthcare stakeholders' perspectives. Performance indicators were largely divided into healthcare outcomes and performance shaping factors. Indicators in the former category may be applied for the detection of operational problems, while their latent causes can be effectively addressed by the latter category in terms of process, structure and culture/climate within the organization.

Efficiency measurement in developing countries: application of data envelopment analysis for Iranian hospitals

Hospitals have been at the core of health care in most countries during past decades, in view of the importance and criticality of their services and absorbing the highest quota of health care financial resources. Specific problems associated with these organizations in developing countries, such as Iran, have further added to the attention they have received over the course of those years. Efficiency measurement of hospitals based on simple ratios has long been utilized to remedy these problems in Iran. However, application of data envelopment analysis as an advanced method for measuring efficiency of health care organizations is mostly unexplored in this country. The current study has applied this method to investigate technical efficiency of a group of provincial hospitals in Iran. The findings showed that just under 60% of all hospitals at the province were technically efficient, and the remainder faced excess number of inputs (specifically in their non-clinical human resources) that should be attended to by the managers. Implications for practice and research on the efficiency of hospitals in the country and similar settings are provided.

Measuring Efficiency and Productivity Across Hospitals in the Regional Health Authority of Thessaly, in Greece

The aim of the article is to assess performance in seven homogenous specialty clinics across all National Health System (NHS) hospitals in the Regional Health Authority of Thessaly (RHAT), over the period 2002–2006. Data Envelopment Analysis by using the Malmquist Productivity Index and its decompositions has been applied in order to measure the technical efficiency and productivity. Clinics were considered to transform inputs labour (medical and nursing staff) and capital (hospital beds) into health services, approximated by the number of in-patient discharges and in-patient days, used as outputs. The model is output-oriented and assumes variable return to scale. Data were collected from hospitals’ records. Overall productivity progressed in all clinics. Technical change progressed except the general medicine clinics. Technical efficiency regressed in four clinics. Diachronically the size of the clinics influences the overall effects on hospital performance and the maximum level of outputs produced has not been achieved using the given labour and capital inputs, except orthopaedic clinics. Homogeneity in assessing hospitals’ performance provides evidence on the efficiency and productivity gains among clinics and suggests improvements in those which appear inefficient. The difficult economic situation Greece is facing nowadays makes the assessment of NHS hospitals’ performance a priority in the decision-making.

Forecasting the stochastic demand for inpatient care: the case of the Greek national health system

The aim of this study is to estimate the unexpected demand of Greek public hospitals. A multivariate model with four explanatory variables is used. These are as follows: the weekend effect, the duty effect, the summer holiday and the official holiday. The method of the ordinary least squares is used to estimate the impact of these variables on the daily hospital emergency admissions series. The forecasted residuals of hospital regressions for each year give the estimated stochastic demand. Daily emergency admissions decline during weekends, summer months and official holidays, and increase on duty hospital days. Stochastic hospital demand varies both among hospitals and over the five-year time period under investigation. Variations among hospitals are larger than time variations. Hospital managers and health policy-makers can be availed by forecasting the future flows of emergent patients. The benefit can be both at managerial and economical level. More advanced models including additional daily variables such as the weather forecasts could provide more accurate estimations.

Burnout and training satisfaction of medical residents in Greece: will the European Work Time Directive make a difference?

BACKGROUND

The aim of this study is to determine the prevalence of burnout in Greek medical residents, investigate its relationship with training satisfaction during residency and survey Greek medical residents' opinion towards the European Work Time Directive (EWTD).

METHODS

A Multi-centre, cross-sectional survey of Greek residents was performed. The Maslach Burnout Inventory (MBI) was used to measure burnout, which was defined as high emotional exhaustion, combined with high depersonalization or low personal accomplishment. In addition, seven questions were designed for this study to evaluate self-reported resident training satisfaction and three questions queried residents' opinion on the EWTD and its effects on their personal and social life as well as their medical training. Univariate, bivariate and multivariate statistical models were used for the evaluation of data.

RESULTS

Out of 311 respondents (77.8% response rate), 154 (49.5%) met burnout criteria and 99 (31.8%) indicated burnout on all three subscale scores. The number of residents that were dissatisfied with the overall quality of their residency training were 113 individuals (36.3%). Only 32 residents (10.3%) believed that the EWTD implementation will not have any beneficial effects for them.

CONCLUSIONS

Both burnout and training dissatisfaction were common among Greek residents. Systemic interventions are thus required within the Greek health system, aimed at reducing resident impairment due to burnout and at improving their educational and professional perspectives. Although residents' opinion on the EWTD was not associated with burnout levels, the EWTD was found to be predominantly supported and anticipated by Greek residents and should be implemented to alleviate their workload and stress.

The effect of environmental factors on technical and scale efficiency of primary health care providers in Greece

BACKGROUND

The purpose of this study was to compare technical and scale efficiency of primary care centers from the two largest Greek providers, the National Health System (NHS) and the Social Security Foundation (IKA) and to determine if, and how, efficiency is affected by various exogenous factors such as catchment population and location.

METHODS

The sample comprised of 194 units (103 NHS and 91 IKA). Efficiency was measured with Data Envelopment Analysis (DEA) using three inputs, -medical staff, nursing/paramedical staff, administrative/other staff- and two outputs, which were the aggregated numbers of scheduled/emergency patient visits and imaging/laboratory diagnostic tests. Facilities were categorized as small, medium and large (<15,000, 15,000-30,000 and >30,000 respectively) to reflect catchment population and as urban/semi-urban or remote/island to reflect location. In a second stage analysis, technical and scale efficiency scores were regressed against facility type (NHS or IKA), size and location using multivariate Tobit regression.

RESULTS

Regarding technical efficiency, IKA performed better than the NHS (84.9% vs. 70.1%, Mann-Whitney P < 0.001), smaller units better than medium-sized and larger ones (84.2% vs. 72.4% vs. 74.3%, Kruskal-Wallis P < 0.01) and remote/island units better than urban centers (81.1% vs. 75.7%, Mann-Whitney P = 0.103). As for scale efficiency, IKA again outperformed the NHS (89.7% vs. 85.9%, Mann-Whitney P = 0.080), but results were reversed in respect to facility size and location. Specifically, larger units performed better (96.3% vs. 90.9% vs. 75.9%, Kruskal-Wallis P < 0.001), and urban units showed higher scale efficiency than remote ones (91.9% vs. 75.3%, Mann-Whitney P < 0.001). Interestingly 75% of facilities appeared to be functioning under increasing returns to scale. Within-group comparisons revealed significant efficiency differences between the two primary care providers. Tobit regression models showed that facility type, size and location were significant explanatory variables of technical and scale efficiency.

CONCLUSION

Variations appeared to exist in the productive performance of the NHS and IKA as the two main primary care providers in Greece. These variations reflect differences in primary care organization, economical incentives, financial constraints, sociodemographic and local peculiarities. In all technical efficiency comparisons, IKA facilities appeared to outperform NHS ones irrespective of facility size or location. In respect to scale efficiency, the results were to some extent inconclusive and observed differences were mostly insignificant, although again IKA appeared to perform better.