Healthcare institution efficiency: meta-analysis and case study

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Healthcare institution efficiency: meta-analysis and case study

Sirle Salmistu,

Oleksii Demikhov,

Nadiia Demikhova,

Karina Taraniuk,

Magdalena Sochacka,

Nataliia Letunovska

ABSTRACT

The article analyses the factors that influence the efficiency of a medical institution. The VOSviewer bibliometric analysis allowed to identify four main clusters that determine the dominant areas of scientific research related to the topic of the medical institution efficiency. The largest cluster was the one describing the relationships between factors that directly determine the healthcare facility efficiency (decision-making, use of information technologies (artificial intelligence, blockchain, Internet of Things, etc.), effectiveness of solving medical problems of patients, etc.) The second largest cluster combines research areas related to the organisation, management, standardisation, audit, professional development, quality and productivity in healthcare facilities. The third and fourth clusters are related to the service and resource components in ensuring the efficiency ofa medical institution, respectively. The article presents various approaches to classifying performance indicators of a medical institution: by type ofperformance, by form, by costs, by measurement of results, by scope of work, by stages. The national approaches to the medical industry development in the UK, Ukraine and Germany are analysed. The mechanisms for decentralising the management of medical institutions, increasing their autonomy, productivity and quality of medical services are described on the example of Ukraine. Using the pattern of a typical medical institution in a small city of Ukraine, the mechanisms for increasing efficiency are analysed: in terms of staffing, patient care, financing, corporate culture, patient-centeredness, and control over financial flows separately for each level of medical care. Priority steps to improve the infrastructure support of the subject of analysis, possible measures to improve the quality of medical services, the preferred resources for financing the planned measures, the implementation period and the expected results of proposed measures are identified. From the theoretical point of view, this article deepens knowledge about the nature of the medical institution efficiency. From a practical point of view, recommendations and ways to improve the medical institution efficiency make it possible to form a roadmap for promising changes. Their implementation will increase the primary healthcare facility efficiency and ensure a vivid rise in the medical provision efficiency at the secondary level in the short and medium term.

Keywords: healthcare facility; efficiency; bibliometric analysis; public health; resources; medical staff; roadmap; patient-centeredness.

INTRODUCTION

medical institution efficiency

The modern development of the healthcare sphere actualises the issue of competition between institutions of different specialisation and subordination. This aspect requires institutions to review their service delivery systems, improve quality, develop and implement innovations. A separate challenge for institutions in the medical field, particularly municipal ones, is problems with limited financial resources and a shortage of medical personnel, necessitating the renewal of management methods and the development of modernised and improved strategies. The medical field in Ukraine has not been in the best condition lately. And despite some positive developments (in particular, in the primary and secondary chain of medical service provision), the service provision quality by medical institutions remains insufficient. However, the increase in population mortality and morbidity, insufficient infrastructural support, shortage of highly qualified specialists, and other problems in medical institutions reduce the national potential of medical and social population welfare.

Trends in the health care market after 2022 indicate that despite the fact that during the COVID-19 pandemic and hostilities, the Ukrainian health care system continued to function at the level adopted to meet the basic medical needs of the population, but at the same time both the crisis of an epidemic nature and the crisis of a politicalmilitary nature identified the presence of a number of problems in the health care system and existing and potential risks for the system of medical and social welfare of the population in the country. Demographic changes, migratory movements, financing issues, availability of medical services - all these pose significant threats and challenges to the Ukrainian health care system. As for trends in the volume of medical services, it is expected that in the first months of the war in 2022, their consumption will drop significantly. However, both outpatient and specialised medical care gradually recovered to pre-war levels already by the end of 2022. Downward trends in provision are observed in primary care, which is due to a number of objective and subjective factors (Healthcare at War, 2023). In 2023, health care expenditures amounted to UAH 217.4 billion, of which state budget expenditures together with transfers amounted to UAH 181.8 billion. UAH 139.4 billion was allocated to the implementation of the medical guarantee program (emergency, primary, specialised medical care, as well as reimbursement) (Ministry of Finance, 2024).

Unfortunately, the healthcare sector of Ukraine remains among those most affected by the terrorist acts of the aggressor country. Yes, just from February 2022 to February 2023, the health care sector suffered damage from the destruction of more than 2 billion U.S. dollars. dollars, as evidenced by the data visualisation in Figure 1.

Source: Generated by the authors using Stata (2024)

Total losses for Ukraine are estimated at 135 billion U.S. dollars and this is as of the beginning of 2023. The situation is exacerbated by losses of 35% of GDP. Negative economic and political-military trends naturally affect the physical and psychological state of the country's population, which, among other extremely negative effects, exacerbate the difficult situation in the health care system (Figure 2). The number of respondents for the survey amounted to more than 2,000 people. The study was carried out by the SATI method. Temporarily occupied territories were excluded from the sample.

Figure 2. The share of respondents who noted the specified problem in their lives (survey among the population of Ukraine, in which it was possible to choose more than one possible answer), 2023.

Source: Generated by the authors using Stata (2023)

The medical field continues to play a dominant role in ensuring the vital activities of society. Its infrastructural support, quality of functioning and efficiency of activity are key in the system of providing social guarantees to the population and increasing the level of well-being in the country. This actualises the issue of finding ways and forming a system of implementing measures and tools to increase the effectiveness and productivity of medical institutions of various levels and subordination in Ukraine.

LITERATURE REVIEW

The effectiveness of various participants in the medical service market has been investigated in many scientific works. Among the scientific works on the given topic, one should single out Changhee & Hyun Jung (2019). They analysed the effectiveness of players in the healthcare market and investigated the relationship between various types of effectiveness, achieving ways to optimise the supply chain of the healthcare sector.

Miura et al. (2022) investigated the effectiveness of over 400 medical institutions in Japan regarding the interaction between patients and medical staff. Benchmarking analysis is widely used to compare various financial indicators of the activity of medical institutions to determine the effectiveness of institution's management system and the level of activity of each department (Nakagawa et al., 2011).

Multi-vector models of research on the effectiveness of medical institution management are discussed by Soares et al. (2017). They provide an opportunity to reveal valuable insights into ways to improve the productivity of medical institutions.

The study of institutions of various specialisations with the search for a general efficiency index was carried out by Caballer-Tarazona et al. (2010) with the help of the Data Envelopment Analysis method and discriminant analysis. The efficiency level of public health facilities according to their types of subordination and the factors affecting it were investigated by Chiu et al. (2022). Here, a combination of comparative and regression analyses was used.

The medical market is the subject of research by Schneider et al. (2020). The authors define the resource use efficiency as the initial condition for high productivity of medical institutions. In particular, they pay special attention to solving issues of urgent medical conditions, including those caused by epidemic threats. The effectiveness of medical institutions is also considered in scientific works at the macrolevel, in particular by Sheliemina (2023). Changes in the medical system caused by reforms, in particular the effectiveness of medical service provision, are determined by such macroeconomic indicators as the dynamics of population's health, the ability to resist threats of destabilising factors, such as pandemics.

There are some works where the effectiveness of medical institution management is considered from the standpoint of the resulting operating system of providing resources and technical equipment at all levels of (Persona et al., 2008). A separate series of scientific papers in 2020-2023 is dedicated to the effectiveness of national medical systems in countering the COVID-19 impact and achieving resilience in the socio-economic state of countries (Heshmati et al., 2023; Rahmanov et al., 2021; Vasilyeva et al., 2020; Moiseenko et al., 2022).

The issue of improving the medical care effectiveness in specific areas of medical practice was investigated in the work by Liubchak et al. (2021). The role of the information provision factor in improving the efficiency of medical institution activities was studied by Janakiraman et al. (2022).

Technological factors in the activities of medical institutions, in particular, techno-innovations and digital tools for making management decisions, are studied (Basile et al., 2023; Gomes et al., 2023). All studies have their features of use at the macrolevel, as well as at the local level, or the level of individual medical institutions. However, the territorial features and specifics of activity of each institution and its patients, profile, etc., also determine the approach to its management and determination of critical effectiveness indicators. The bibliometric analysis based on the VOSviewer software (2023) made it possible to determine a list of key terminology related to the concept of the medical institution efficiency (Figure 3). The basis for the bibliometric analysis was scientific works from the Scopus scientometric database using keywords such as “medical institution efficiency” as well as the synonymous expression “healthcare institution efficiency” in the time period from 2008 to 2024. That confirmed the earlier statements that the definition of efficiency and the set of indicators that determine it are very diverse in different countries and scientific schools. The identified features allow us to form an approximate list of factors to consider when forming a management control system in healthcare institutions.

Figure 3. Results of bibliometric analysis of terminology by the search phrase “medical institution efficiency”

Source: Generated by the authors via VOSviewer (2023)

Keywords found in the analysis of medical institution efficiency can be divided into four distinct clusters. The red cluster describes interrelationships between concepts of factors directly determining the medical institution efficiency, such as decision-making, use of information technologies, effectiveness of solving patients' medical problems, etc. The green cluster describes a human-centred approach to determining the subject activity efficiency in the medical field. The yellow cluster describes characteristics of medical services that can, directly and indirectly, affect the institution's efficiency. The blue cluster indicates purely economic factors of the medical institution efficiency. Figure 4 shows the co-authorship analysis results of authors' relationships from different countries.

Figure 4. Results of bibliometric analysis of scientific schools in the medical efficiency study

Source: Generated by the authors via VOSviewer (2023)

The maximum number of works on the research topic belongs to authors from the USA, China, and the United Kingdom. It is these countries that form three clusters of geographical research regions. Gul & Karadayi- Ustra (2024) investigated the resource component of the efficiency of healthcare institutions, focusing in particular on the supply of medical personnel and bed stock, taking into account the seasonality factor of the demand for medical services. Research that determines the energy efficiency of medical institutions deserves special attention.

Figure 5. Results of bibliometric analysis of scientific schools in the medical efficiency study

Source: Generated by the authors via VOSviewer (2023)

Evolutionary analysis of categories in efficiency of healthcare institutions shows that until 2014, research on management of healthcare organizations was mostly popular. However, since 2016, in scientific research on the provision of human needs, a human-centric approach to medical services, prevails. After 2020, research on countering the coronavirus pandemic and improving the productivity of activities in conditions of limited resources in healthcare gained significant popularity.

Alotaiby & Krenyacz (2023) define the medical field as one of the most energy-consuming sectors of the national economy and explore a wide range of energy-saving technologies that can increase the efficiency and economy of these institutions using the example of Middle Eastern institutions.

Malhan et al. (2023) investigate the effectiveness of medical institutions from the point of view of their information provision, which is capable of levelling gaps in the management of a medical institution. The article is focused on the study of EHR systems of operational measures within the framework of the work of organisations of a medical profile. The authors emphasise that these systems are able to regulate the cost components of the institution's activities.

Part of the research is devoted to the indirect factors of the productivity of the medical institution. In particular, Wang et al. (2024) investigate how the use of social media is able to influence the effectiveness of the work of medical personnel and their psychological endurance, the quality of the performance of work tasks. That is decisive in forming the general opinion of patients about the provided medical services.

Wulandari et al. (2024) devoted their study to the study of the degree of patient satisfaction with the provision of services by medical institutions. From these positions, the effectiveness of the organisations of the health care system in performing their functions and their productivity is determined. They examine such performance indicators as physical environment, customer-oriented atmosphere, responsiveness, effective communication, privacy maintenance, and safety. Zhang & Yang (2023) investigated the efficiency of medical facilities at different regional levels over a period of 15 years using DEA analysis. The analysis includes such indicators as state subsidies, marketing to determine their impact on the activities of regional medical institutions.

Ong et al. (2023) set the goal of their research to analyse lean healthcare effectiveness and the factors determining this effectiveness. To do this, they analysed more than 200 responses of specialists in the field of health care. The conducted analysis made it possible to determine the key efficiency factors, which were corporate culture and personnel qualifications.

Piedra-Pena & Prior (2023) investigated whether state reforms had an effect on the performance of medical facilities in the analysed country. The novelty of their research and unconditional contribution is an attempt to analyse the relationship between the reform aimed at the universal coverage of medical services, the inclusiveness of social services and the efficiency of the health care system. Alharbi & Kundi (2023) investigated aspects of leadership in a medical profile institution and the impact of the effectiveness of this component of the institution on the quality of providing medical services, the quality of treatment and, in general, the formation of medical culture in society.

METHODOLOGY

The article uses the benchmarking analysis of improving the medical institution efficiency in foreign countries. Besides, it applies other methods and approaches to examine performance of medical institutions. As a research object, we chose a typical state hospital in Sumy Oblast. Also, the comparative analysis of efficiency of medical institution units is applied. The study hypothesis assumes that institution efficiency in medical service provision can increase via consideration of various aspects: personnel policy, service policy, and financing of activities. The study of healthcare indicators was carried out based on an analysis of the internal documentation of business entities.

The research comprised the following steps:

- substantiation of the theoretical and methodological principles of ensuring the effectiveness of the management of a medical institution;

- analysis of the effectiveness of the management of a medical institution on the example of a typical regional health care institution of the Konotop Central District Hospital;

- development of suggestions on ways to improve the effectiveness of activity management of the Konotop Central District Hospital.

In the article, as an information base, the research uses primary sources of information on performance of the analysed object of the medical industry. It comprises internal reporting, accounting, and secondary sources on medical development trends and the experience of measures to improve the efficiency of other healthcare institutions in Ukraine.

The research determines the trends, as well as successful and unsuccessful strategies and tools, which are already used in the practice of the analysed medical object and other typical institutions of the region. Based on the analysis results, it became possible to develop a road map for decision-making and implementation of measures to optimise management implementations in the health care institution. To control and verify the effectiveness of various performance management tools, it is suggested to use a mix of qualitative and quantitative methods. The results correlate with those obtained in previous studies of a similar nature, and appropriate conclusions are drawn based on such a comparison. An important component of the monitoring and methodology proposed by the authors is receiving feedback from hospital patients. This methodology allows to determine the effectiveness of applying each specific tool and evaluate the impact of the tools on attracting new patients and managing their diseases. The proposed set of road map tools makes it possible to understand the needs and preferences of patients, medical personnel and the urgent need to implement certain measures.

RESULTS

In Ukraine, due to the reforms, many changes took place. In particular, out-patient polyclinic care institutions (primary care) were rearranged as separate structures. A highly specialised care link (secondary and tertiary links) is now functioning separately. Family doctors have become leading performers and providers of primary medical care. These doctors serve patients with chronic diseases, diagnose and treat diseases that do not require highly specialised care, conduct preventive work, monitor immunisation issues, perform simple surgical operations, prescribe referrals for further treatment in in-patient departments, etc. Since the number of declarations concluded with one family doctor is limited, he has an opportunity to assess the social and physiological condition of patients more deeply due to the relief of workload. A more trusting relationship between the patient and the doctor is formed, costs for additional examinations are reduced. As a result, the economic efficiency of medical institutions increases. Improving doctors' qualifications is facilitated by the need to obtain points as a part of evaluations of specialised testing centres (Continuous Professional Development). Thanks to receiving points, doctors not only pass the planned certification, but it also motivates them to further self-improvement. In addition, introducing such an approach as continuous professional development stimulates development of medical education institutions. Free choice of disciplines and study formats form the demand for educational services. However, high price of education in public institutions encourages doctors to use offers of pharmaceutical company representatives. It provides an opportunity to take free courses with points while simultaneously advertising their products. During the calendar year, the doctor must score at least 50 points. There are different formats of activities for which you can get points, from attending a free online lecture to a costly internship at a specific clinic.

To ensure a high efficiency level in medical institution activities, in particular municipal non-commercial enterprises, some tasks have been defined in Ukraine. They provide for implementation of structural changes in the national health care field that national and local authorities must carry out. Considering the performed literature review and analysis of the medical care market, it can be concluded that the quality provision of medical services by the medical municipal non-commercial enterprises is achieved due to implementation of an effective personnel policy and a financial support policy of the institution.

By the medical institution efficiency, the authors understand its ability to accumulate resources effectively, which has a positive effect and is significant for the final result of institution's activity. This effect can be economic or social (medical) in nature. Specific performance indicators can characterise any medical facility (Table 1).

One of the main criteria used to analyse the healthcare institution efficiency is medical. This indicator is characterised by the qualitative and quantitative achievement of goals for improving the disease prevention, treatment or diagnosis. Health indices (performance indicators of a particular medical institution) include morbidity rates, death rates, surgery activity analysis, and primary morbidity rates. The introduction and use of new techniques and tools is an example of increasing medical efficiency, because it reduces the patient's stay period in the hospital, optimises duration of staff working hours, and improves service quality. Thanks to the development of medical care and the implementation of reforms in the medical sector in Ukraine, mortality rates are decreasing not only among adult population but also among infants (due to the management of pregnancy by family doctors, timely detection, and prevention of pathologies). Communal medical institutions modernise and enlarge equipment for receiving packages from the National Health Service, which makes it possible to increase the institution funding. In recent years, the number of nosologies for which medical care can be obtained in primary care institutions without hospitalisation has been increasing. Medical services are becoming more inclusive. To analyse management effectiveness for an individual patient, a different set of indicators is used, such as the patient's condition (deterioration, improvement, or no change) (Stefanyshyn, 2019).

Table 1. Efficiency indicators of medical institutions