Employing post-DEA Cross-evaluation and Cluster Analysis in a Sample of Greek NHS Hospitals

To increase Data Envelopment Analysis (DEA) discrimination of efficient Decision Making Units (DMUs), by complementing “self-evaluated” efficiencies with “peer-evaluated” cross-efficiencies and, based on these results, to classify the DMUs using cluster analysis. Healthcare, which is deprived of such studies, was chosen as the study area. The sample consisted of 27 small- to medium-sized (70–500 beds) NHS general hospitals distributed throughout Greece, in areas where they are the sole NHS representatives. DEA was performed on 2005 data collected from the Ministry of Health and the General Secretariat of the National Statistical Service. Three inputs -hospital beds, physicians and other health professionals- and three outputs -case-mix adjusted hospitalized cases, surgeries and outpatient visits- were included in input-oriented, constant-returns-to-scale (CRS) and variable-returns-to-scale (VRS) models. In a second stage (post-DEA), aggressive and benevolent cross-efficiency formulations and clustering were employed, to validate (or not) the initial DEA scores. The “maverick index” was used to sort the peer-appraised hospitals. All analyses were performed using custom-made software. Ten benchmark hospitals were identified by DEA, but using the aggressive and benevolent formulations showed that two and four of them respectively were at the lower end of the maverick index list. On the other hand, only one 100% efficient (self-appraised) hospital was at the higher end of the list, using either formulation. Cluster analysis produced a hierarchical “tree” structure which dichotomized the hospitals in accordance to the cross-evaluation results, and provided insight on the two-dimensional path to improving efficiency. This is, to our awareness, the first study in the healthcare domain to employ both of these post-DEA techniques (cross efficiency and clustering) at the hospital (i.e. micro) level. The potential benefit for decision-makers is the capability to examine high and low “all-round” performers and maverick hospitals more closely, and identify and address problems typically overlooked by first-stage DEA.     

A Proposed Instrument for the Assessment of Job Satisfaction in Greek Mental NHS Hospitals

Since its introduction in 1983, the Greek NHS is under an almost constant reform, aiming improvement on the efficiency and the quality of provided services. The national program of psychiatric reform “Psychargos” introduced new models of therapeutic approach to the care of the mentally ill, that required expansion of the existing roles and development of new roles of the healthcare staff. Consequently, the efficient management of the healthcare workforce in Greek mental facilities was identified as a primary determinant of the successful implementation of the program. Primary objective of this study was the development of a research framework for the assessment of job satisfaction in Greek Mental Health Hospitals. Among the objectives was the evaluation of the capacity of the underlying motivators and hygiene factors and the identification of potential correlations of the global job satisfaction and the motivation and retention factors with the demographic, social and occupational characteristics of the employees. A custom questionnaire was developed, based on Herzberg two-factor theory, after a systematic review of the relevant literature. The instrument was constructed by two parts and 37 items. Ten items addressed the sociodemographic characteristics of the subjects, while the remaining 27 items were distributed in 11 subscales which addressed the global satisfaction index and the “retention” and the “motivation” variables. The instrument was validated by means of the Cronbach alpha for each subscale and by confirmatory factor analysis. The study was conducted at the Public Mental Hospital of Chania (PMHC). From the 300 employees of the PMHC, 133 subjects successfully responded to the questionnaire (response rate, 44.3%). In accordance to former surveys, subjects presented average scores in the global satisfaction index (GSI). The professional category of the employee was identified as the primary determinant of the GSI. Nurses presented statistically significant lower scores in comparison to the rest of the employees. Strong Pearson correlations were detected between GSI and “working conditions”, “interpersonal relations”, “organization”, “salary” and “supervision” factors. The retention factors presented stronger impact on GSI in comparison to the motivation ones. The results of the study indicate that the proposed instrument presents satisfactory validity and reliability for the assessment of job satisfaction in Greek mental NHS hospitals.     

The Impact of Payer-Specific Hospital Case Mix on Hospital Costs and Revenues for Third-Party Patients

Competition among hospitals and managed care have forced hospital industry to be more efficient. With higher degrees of hospital competition and managed care penetration, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. By developing a payer-specific case mix index (CMI) for third-party patients, this paper examined the effect of hospital case mix on hospital cost and revenue for third-party patients in California using the hospital financial and utilization data covering 1986–1998. This study found that the coefficients for CMIs in the third-party hospital revenue model were greater than those in the hospital cost model until 1995. Since 1995, however, the coefficients for CMIs in the third-party hospital revenue model have been less than those in hospital cost models. Over time, the differences in coefficients for CMIs in hospital revenue and cost models for third-party patients have become smaller and smaller although those differences are statistically insignificant.     

应用灰色关联分析法综合评价医院病床使用效率

目的构建评估医院病床工作效率差异的方法,为医院病床管理提供参考。方法建立包括平均病床周转次数、病床使用率、出院者平均住院日等指标在内的综合指标体系,对某三甲医院各个分院的病床工作效率进行灰色关联分析。结果被评估的医院的病床工作效率由高到低依次为:B医院、A医院、C医院、D医院、E医院、F医院。结论用灰色关联分析可以有效比较不同医院的病床工作效率,值得应用推广。     

The Impact of Non-Discretionary Factors on DEA and SFA Technical Efficiency Differences

The purpose of this study was to examine if factors of the external operating environment can explain differences in technical efficiency derived from Data Envelopment Analysis (DEA) and Stochastic Frontier Analysis (SFA). In a sample of 124 dialysis facilities, technical efficiency was compared according to ownership, region, years in operation and size. With second-stage Tobit regression, DEA and SFA efficiency was regressed against these environmental factors to determine their potential for predicting technical efficiency, as well as the efficiency differences between the two frontier methods. DEA expectedly generated lower mean efficiency scores than SFA (68.2% vs. 79.4%, P < 0.001), due to the “random effects” term computed by the latter, in addition to “true” inefficiency. This finding was consistent for the subgroups formed on the basis of the environmental factors. Half the variation in the DEA-SFA efficiency differences was explained by environmental factors. This suggests that in addition to market instabilities, luck, and other related phenomena, decision-makers in their effort to determine optimal resource allocation, should point their attention to the potentially useful insight provided by environmental factors.     

Clinical Information System Availability and Use in Urban and Rural Hospitals

Clinical information systems (CIS) capture clinical data to support more efficient and effective decision making and clinical care delivery. Only a few estimates of CIS availability and use in hospitals are available nationally. The purpose of the current research is to examine differences in CIS availability and use between urban and rural hospitals. A survey addressing this purpose was completed by 74 (63.7%) of Iowa hospitals. Rural hospitals lag behind urban hospitals in terms of many CIS applications. More than 80% of the urban hospitals, but only between 30 and 40% of the rural hospitals, reported using computers to collect basic clinical information for potential use in an electronic medical record (EMR) and computerized provider order entry (CPOE) system. Comparison of CIS within one state’s urban and rural hospitals sheds light on variation in clinical support applications, decision support, and electronic medical record “readiness” in these settings.     

新医改以来四川省医院床位配置与利用现况研究

目的：分析新医改以来四川省不同类别医院的床位工作效率,为医院床位的合理化配置提供依据。方法运用归一分析法判断医院床位工作效率,使用服务目标法计算医院床位的需求量。结果新医改以来四川省不同类别医院的床位总量不断增加;中西医结合医院床位效率指数排名第一,民族医院处于低效运行状态;综合医院、中医医院和专科医院床位供求平衡,2014年中西医结合医院和民族医院床位短缺。结论运用科学方法测算医院床位,可提升医院床位配置水平,提高不同类别医院床位的利用效率。     

Patient Safety-Related Information Technology Utilization in Urban and Rural Hospitals

Ongoing research has linked certain information technology applications to reduction of medical errors and improved patient outcomes. The purpose of this study was to assess both the use of patient safety-related information technologies (PSIT) in urban and rural hospitals, as well as the organizational factors which may be linked to overall PSIT adoption. Floridas 199 acute care hospitals (170 urban; 29 rural) were surveyed regarding their utilization of PSIT. Of the 10 technologies studied, rural hospitals averaged 30% utilization compared to 48% for urban hospitals. Individual PSIT applications such as pharmacy-based systems, clinical decision support systems, and outcomes and quality management tools were all more likely to be present in urban hospitals. Hospital bed size (less than 100 beds), tax status (not-for-profit vs. for-profit), and system-affiliation appeared to be related to overall PSIT utilization. These findings are valuable for those interested in the current status of hospital PSIT and set the stage for further studies relating these applications to clinical outcomes in urban and rural hospitals.     

Efficiency of Federal Hospitals in the United States

This study evaluates the technical efficiency of federal hospitals in the United States using a variable returns to scale, input-oriented, data envelopment analysis (DEA) methodology. Hospital executives, health care policy-makers, taxpayers, and other stakeholders, benefit from studies that improve the efficiency of federal hospitals. Data for 280 federal hospitals in 1998 and 245 in 2001 were analyzed using DEA to measure hospital efficiency. Results indicate overall efficiency in federal hospitals improved from 68% in 1998 to 79% in 2001. However, based upon 2001 spending of 42.5 billion for federal hospitals potential savings of42.5 billion for federal hospitals potential savings of 2.0 billion annually are possible through more efficient management of resources. From a policy perspective, this study highlights the importance of establishing more specific policies to address inefficiency in the federal health care industry.     

不同管理系统下的医院运营效率比较

目的：评价并比较北京地区国家卫生和计划生育委员会直属（委属）与北京市医院管理局直属（市属）综合公立医院的运营效率,为提升公立医院整体效率、完善公立医院改革的相关政策提供依据。方法：从2011-2014年北京市卫生统计直报数据中,获取得到8家委属和8家市属大型综合医院的投入与产出数据。以数据包络分析作为医院运营效率的测量工具;采用CCR和BCC模型计算16家医院在2011年度和2014年度的综合技术效率、纯技术效率、规模效率及规模报酬情况;采用Malmquist指数模型对16家医院进行跨期分析,求解2011-2014年间两类医院全要素生产率变化、技术变动、综合技术效率变化、纯技术效率变化及规模效率变化情况。结果：2011年委属医院的综合技术效率、规模效率和纯技术效率均高于市属医院,其中委属医院综合技术效率均值为0.918,市属医院为0.873;到了2014年,委属医院的各效率指标则均低于市属医院,其中委属医院综合技术效率均值为0.906,市属医院为0.951。Malmquist指数模型结果显示,市属医院全要素生产率变化大于委属医院,前者平均每年增长5.9%,后者平均每年增长2.8%;技术变动方面,委属、市属医院均为技术进步状态,委属医院平均每年增长3.2%,市属医院为2.9%;委属医院纯技术效率的增长幅度远低于市属医院;委属医院规模效率的下降幅度大于市属医院。结论：不同管理体系下两类医院的运营效率及变化有很大差异,其中技术进步和管理水平是影响医院效率的最重要因素;结合规模报酬情况及北京地区宏观卫生政策,委属和市属医院仍需进一步推进优质资源向市中心区以外转移,同时应注重医院技术水平和管理水平的提升。     

Separating Managerial Inefficiency from Influences of the Operating Environment: An Application in Dialysis

In any production unit, the ability to achieve technical efficiency is influenced by characteristics of the external operating environment. This study uses the Greek dialysis sector to employ a previously reported frontier procedure to obtain a measure of managerial inefficiency that controls for exogenous features. The sample consisted of 124 dialysis facilities. Two inputs —nursing staff and dialysis machines— and one output —dialysis sessions— were used in an input-oriented, variable-returns-to-scale DEA model. Input slacks were regressed against environmental characteristics such as ownership, location, operating years and facility size, and parameter estimates were used to adjust primary input data. New efficiency scores were generated to measure managerial inefficiency. Older, public, regional facilities were operating under unfavorable circumstances, whereas newer, private, Athens-based facilities under favorable conditions. This respectively generated lower and higher efficiency scores than would have been attained on a level “playing field”. After adjustment, scores reflected only management inefficiency and could be compared fairly. This study emphasizes the importance of efficiency comparisons, which take into account external conditions beyond the influence of management, as these have been shown to under— or overstate true management inefficiency.     

A 12-year Analysis of Malmquist Total Factor Productivity in Dialysis Facilities

This study examined total factor productivity of dialysis facilities in Greece over a 12-year period, using nationally representative panel data. Data Envelopment Analysis (DEA) was used to compute Malmquist productivity indices, which were decomposed into technical efficiency change and technological change. The sample consisted of 73 dialysis facilities operating throughout the entire study period (1993–2004), corresponding to 97.3% and 58.9% of all facilities in the first and last study years respectively. Production variables were nursing staff and dialysis machines (inputs) and dialysis sessions (output). The DEA model was input-oriented allowing for constant returns to scale (CRS). Technical efficiency change was decomposed into scale efficiency change and variable returns to scale (VRS) “pure” technical efficiency change. Mean overall efficiency, throughout the study years, ranged from 39.6 to 63.1% with an all-time average of 56.7%, and only 2–4% of the facilities were fully efficient in each study year. Productivity indices indicated year-by-year progress or regress up to 5%, but the efficiency and technological components differed, in some cases, by as much as 30%. Although interesting subperiod effects were observed, conclusions could not be generalized for the entire study period due to alternating trends. We suggest that preliminary insight to productivity in this sector has been obtained, but particular subperiods must be isolated and further investigated.     

Variation in length of stay as a measure of efficiency in Manitoba hospitals.

OBJECTIVE: To examine the efficiency of Manitoba hospitals by analysing variations in length of stay for patients with similar characteristics. DESIGN: Retrospective study. Multiple regression analyses were used to adjust for patient (case-mix) characteristics and to identify differences in length of stay attributable to the hospital of admission for 14 specific, frequently encountered diagnostic categories and for all acute admissions. SETTING: The eight major acute care hospitals in Manitoba. PARTICIPANTS: Manitoba residents admitted to any one of the eight hospitals during the fiscal year 1989-90, 1990-91 or 1991-92. Patients transferred to or from another institution, those with atypically long stays and those who died in hospital were excluded. OUTCOME MEASURE: Length of hospital stay. RESULTS: The length of stay was strongly influenced by hospital of admission, even after adjustment for key patient characteristics. Excluding the most seriously ill patients and those with the longest stays, approximately 186 beds could potentially have been saved if each hospital had discharged its patients as efficiently as the hospital with the shortest overall length of stay. CONCLUSIONS: A substantial proportion of days currently invested in treating acute care patients could be eliminated. At least some bed closures in Manitoba hospitals could be accommodated simply through more efficient treatment of patients in the remaining beds, without decreasing access to hospital care.     

Benchmarking mechanical ventilation services in teaching hospitals

The purpose of this investigation was to examine the technical efficiency of mechanical ventilation nonsurgery (DRG 475) among University Hospital Consortium (UHC) hospitals that consists of volunteer, teaching hospitals across the nation. The data for this study was retrieved from the 1997 UHC database that includes charge and discharge information for 69 hospitals. Data on 7961 patients classified with mechanical ventilation were aggregated to the hospital level. We retained data from a total of 62 hospitals, the other seven hospitals had missing data. The research questions were (1) Do UHC hospitals differ significantly in their efficiencies in the treatment of mechanically ventilated patients? (2) What inputs and outputs contribute most to the inefficiencies associated with mechanical ventilation? Of the 62 hospitals analyzed using data envelopment analysis technique, 10 were considered efficient and 52 were inefficient as compared to their benchmark peers. Efficient and inefficient hospitals did significantly differ between the transferred output variable and between the respiratory, laboratory, and radiology input variables. All inputs demonstrated excessive resource utilization among inefficient hospitals as compared to efficient hospitals. A total reduction of about $19 million dollars in ancillary services would need to occur for inefficient hospitals to approach the frontier of efficient hospitals. This study demonstrates that mechanical ventilation is costly, yet the specified ancillary services are capable of being reduced yielding technical efficiency as demonstrated by 10 efficient hospitals.     

Use of RSS Feeds for the Implementation of Clinical Reminder

A computer-based reminder system can help physicians get right information and make right decisions in daily clinical work in time. This study presents a RSS-based Clinical Reminding System (RCRS) designed for reminding clinicians to deal with their varied unfinished clinical works. The RCRS was implemented in a hospital to automatically generate messages for every clinician on the basis of clinical information gathered from the hospital information system (HIS) and send them by RSS feed. In order to allow all physicians to participate in the project, the RCRS was integrated with the Computerized Physician Order Entry (COPE) system to provide messages whenever a clinician logs in the HIS; the connection on screen lets the clinician easily make some response. The system can help clinicians focus on patient care without keeping track of the schedule of clinical chores stored in various systems. Two physicians, also directors from Clinical Informatics Research & Development Center (CIRD) who were appointed as project leaders of the RCRS project who went through the entire development process were chosen as interviewees to obtain a preliminary evaluation of the system. The results show the “Information Content” of this system was suggested to be modified, and “Information Accuracy”, “Formats”, “Ease of use” and “Timeliness” of the system were appropriate to meet the system design purposes.     

Data Envelopment Analysis Comparison of Hospital Efficiency and Quality

Using a sample of Virginia hospitals, performance measures of quality were examined as they related to technical efficiency. Efficiency scores for the study hospitals were computed using Data Envelopment Analysis (DEA). The study found that the technically efficient hospitals were performing well as far as quality measures were concerned. Some of the technically inefficient hospitals were also performing well with respect to quality. DEA can be used to benchmark both dimensions of hospital performance: technical efficiency and quality. The results have policy implications in view of growing concern that hospitals may be improving their efficiency at the expense of quality.     

Characterizing Cancer Information Systems

The objective is to determine the extent to which information systems (IS) for cancer are unique and necessary. Via an analysis of Medical Subject Headings used to index relevant literature and other bibliometric techniques, cancer IS are compared and contrasted with IS of other specialties. Cancer IS are relatively little discussed and primarily connect radiation equipment with the radiation oncology staff. By contrast, clinical laboratory and radiology IS are frequently discussed and connect specialized equipment to the hospital. A “Specialty Need” model accounts for these patterns and says that the “need for a specialty IS” is proportional to the “uniqueness of the specialty tools” plus the “degree to which the information from those tools is needed throughout the particular health care entity.”     

Trends in Hospital Efficiency Among Metropolitan Markets

This study evaluates trends in efficiency among American hospital markets. A total of 6010 hospitals were identified for use in the analysis from the American Hospital Association's Annual Surveys for 1989 and 1993. Using data envelopment analysis (DEA), a longitudinal study of hospital efficiency was conducted on all 314 metropolitan markets in the United States. Results suggest that large hospital markets generally demonstrated higher inefficiency. The major inefficiencies exist in the availability of hospital services, the number of operating beds, the utilization of hospital staffing and operating expenses. Consequently, the large hospital market had a significant excess of health manpower that resulted in inefficiency that amounted to approximately $23 billion. From a policy perspective, this study has shed some light on the need to establish more specific policies to address inefficiency in the health care industry.     

北京市三级公立医院效率及其影响因素

目的：评价北京市2006-2015年间三级公立医院的综合技术效率,探讨其影响因素,并提出相应的政策建议。方法：使用数据包络分析测算北京市三级公立医院的综合技术效率、单纯技术效率和规模效率,利用Malmquist指数模型分析其动态效率情况,最后运用随机效应面板Tobit模型分析综合技术效率影响因素。结果：北京市三级公立医院的平均综合技术效率和单纯技术效率水平较高,分别由2006年的0.44和0.51升至2015年的0.62和0.68,两种效率值在0.5～0.8之间所占比例最高;规模效率值绝大部分分布于0.8～1.0之间,大部分医院处于规模报酬递减状态;医院全要素生产率平均每年以5.78%的速度进步,得益于技术效率和生产技术分别以年3.77%和1.94%的速度在进步,进一步分解技术效率进步,单纯技术效率在以年3.21%的平均速度进步,规模效率仅有0.53%的年平均进步速度。综合技术效率与床位周转率、医师年均担负诊疗人次、医护比呈正相关,与床位数、门诊住院人次比、卫生技术人员占比和药占比呈负相关。结论：严格控制三级公立医院规模,注重医院生产技术的创新和应用,转变医院内部管理水平和管理模式,推进精细化管理,以实现可持续发展。     

Waiting times for nursing-home placement: the impact of patients' choices.

OBJECTIVE: To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home. DESIGN: Cohort study. PARTICIPANTS: All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990. MAIN OUTCOME MEASURE: Length of time waiting for nursing-home placement and relative rates of placement. RESULTS: The variable found to shorten the waiting time the most was the patient's choice of a for-profit or nonprofit secular facility; other significant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait. CONCLUSION: The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.