Crucial key performance indicators for hospital evaluation: A scoping review

Abstract

Given limited resources, it is crucial to establish a concise set of performance indicators for evaluating and tracking a hospital’s performance. This study aimed to comprehensively investigate the existing evidence related to the identification, classification, and utilization of key performance indicators (KPIs) in the context of hospitals. This systematic scoping review was conducted following the Joanna Briggs Institute (JBI) methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SCR) extension. This review encompassed studies focusing on the evaluation of hospitals’ performance, including those that introduced and implemented key indicators. The search, covering published and unpublished studies, spanned from October 25, 2022 (updated in December 2023), using databases, such as MEDLINE (via PubMed), Scopus, Web of Science, Emerald, ProQuest, and Google Scholar. Of 2,316 records screened by titles and abstracts, 70 complete reports were assessed. Among them, 46 studies were found to be irrelevant, and eight were included in the review studies and thus omitted. Finally, 16 studies were included in this research. The 10 most frequently examined KPIs in these studies followed this order: Average length of stay, rate of nosocomial infections, patient satisfaction rate, mortality rate, bed occupancy rate, incidents/errors, accidents/adverse events, waiting time, readmission rate, and mean cost per patient. The average length of stay and the rate of nosocomial infections emerged as the most frequently scrutinized indicators. The findings also showed that there is a higher level of emphasis placed on the dimensions of effectiveness and efficiency.

Introduction

Demands for healthcare quality promotion, coverage, and outcomes are growing.[1] Healthcare decision-makers face challenges in managing resources effectively, aiming to maximize value for money and achieve desired outcomes or impacts.[2,3] That is why performance evaluation of healthcare providers, especially hospitals, is emphasized. It is considered one of the healthcare system’s main components and a significant consumer of health resources.[4,5] Performance evaluation has a key role in hospital management and can remarkably influence a healthcare management system’s operational efficiency.[6,7]

There are several methods for evaluating hospitals’ performance, such as the European Foundation of Quality Management (EFQM), balanced scorecard, and accreditation process. Each uses different criteria and indicators to evaluate performance.[8] Currently, key performance indicators (KPIs) are widely adopted in healthcare organizations for evaluating performance. KPIs serve to monitor, measure, and manage the effectiveness, efficiency, equity, and quality of healthcare systems.[9,10]

Identifying performance indicators that significantly impact the overall system is crucial for achieving high-quality performance.[11,12,13] While numerous indicators have been proposed for use in healthcare performance evaluation frameworks, not all are practical due to resource limitations.[14,15] Therefore, it is essential to narrow down the selection to a restricted number of performance indicators for assessing and monitoring the performance of a hospital.[16,17,18]

Many studies have been conducted to identify KPIs. The average length of stay and bed occupancy rate were most frequently used in hospital performance assessment.[19] Si et al., employing a decision-making trial and evaluation laboratory (DEMATEL) approach, concluded that accidents/adverse events, nosocomial infection, incidents/errors, number of operations/procedures, length of stay, bed occupancy, and financial measures play essential roles in the performance evaluation of healthcare organizations.[17] Some studies have classified KPIs into several dimensions. Khalifa and Khalid conducted a qualitative study and determined that KPIs can be divided into three areas: effectiveness or efficiency of healthcare provision, timeliness and safety, and patient-centeredness.[20] Zaboli et al. and Rasi et al. have classified KPIs into four dimensions: input, process, output, and impact, with various KPIs identified within these domains.[21,22]

After conducting a preliminary search in systematic review databases, such as the Joanna Briggs Institute (JBI) database, Campbell, and others, it appears that, despite numerous studies (including systematic reviews and original studies) aimed at determining KPIs, there is still no consensus on which key indicators are essential and sufficient for evaluating hospital performance. This study aimed to provide a detailed and comprehensive review of all the evidence related to the identification, classification, and application of KPIs in hospitals to identify the most important and frequently used KPIs.

Materials and Methods

This scoping review is underpinned by a conceptual framework that acknowledges the critical need for a concise set of performance indicators to evaluate hospital performance. In response to the increasing demands for healthcare quality and resource constraints, the study navigates through existing evidence to identify, classify, and utilize KPIs within the hospital context.

This systematic scoping review was conducted following the JBI methodology for scoping review[23] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR).[24,25]

Methodological procedures

The JBI’s suggested steps for scoping reviews were followed, including developing the title, objective, and underlying question; defining the inclusion and exclusion criteria for the studies; choosing data sources; gathering and organizing the results; and presenting the review.[26] We looked over the titles to make sure they fit the findings of the study. Two independent researchers conducted the review’s methods; in the event that they disagreed on which papers should be included or excluded, they convened to reach an agreement. A scoping review is an exploratory procedure that helps prepare the way for a systematic review by identifying and summarizing the scientific information related to new concepts.

Evidence Acquisition

All the techniques in the scoping review are guided by this research question. Thus, it defined the following underlying question using the abbreviation PCC (P = population; C = concept; C = context).

Inclusion criteria

Types of participants (Problems)

This review considered studies focusing on hospitals’ performance evaluation.

Concept

This review considered studies that introduced and implemented key indicators for hospitals’ performance.

Context

This review considered articles that were conducted in hospitals.

Types of sources of evidence

This review considered study designs, including primary research studies, systematic reviews, guidelines, and literature reviews. In addition, editorials, letter to editors, and text and opinions were excluded in this scoping systematic review.

All studies published in English and Persian covered by databases were included but publication dates were not considered in this review.

Search strategy

The search strategy was designed to include both published and unpublished studies. This review employed a three-step approach. At first, a preliminary search was conducted on PubMed, focusing on relevant information in the titles, abstracts, and index terms of articles. Then, a second search was performed using all the identified keywords and index terms on October 25, 2022 (updated in December 2023), across the following bibliographic citation databases: MEDLINE (via PubMed), Scopus, Web of Science, Embase, and Emerald. The search also included unpublished studies and gray literature, which were explored through ProQuest and Google Scholar. Finally, the reference lists of all selected reports and articles were searched for additional studies. Hand-searching and citation tracking also were conducted by researchers [Appendix 1].

Source of evidence screening and selection

After conducting the search, all identified citations were imported into EndNote X21, and any duplicates were removed. Two independent reviewers evaluated the titles and abstracts to determine their relevance to the review’s inclusion criteria. The full texts of potentially eligible studies were obtained and carefully assessed by the same two reviewers against the inclusion criteria. Any differences of opinion between the reviewers were resolved through discussion.

Data extraction

Two independent reviewers utilized the modified standardized JBI data extraction tool to extract data from the studies included in the review. The data extracted included specific details about the authors, publication year, type of study, context (setting), and concept information (KPIs, dimensions, and sub-dimensions). The final key indicators were extracted according to their frequency in the included studies.

Search results

A comprehensive search yielded a total of 3,740 studies from bibliographic databases and 1,105 studies from other sources. The retrieved citations were organized using EndNote X21, leading to the identification and removal of 1,424 duplicate records. Subsequently, a meticulous screening of 2,316 records based on titles and abstracts resulted in the assessment of 70 complete reports (59 from databases and 11 from alternative methods). Among these, 46 studies were deemed irrelevant, and eight were excluded because they had already been included in other review studies. Ultimately, 16 studies were selected for inclusion in this investigation [Figure 1].

Figure 1.

Search results and study selection and inclusion process. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools

These 16 studies comprised a diverse range of research designs, including seven descriptive studies, four mixed-methods studies, two systematic reviews, one umbrella review, one scoping review, one rapid review, and one case study.

Results

Following the screening process, a total of 16 studies that satisfied the inclusion criteria were subjected to a careful review. The key characteristics of these studies are summarized in Table 1 by authors, year, type of study, and objective.

Table 1.

Characteristics of the reviews included

Author		Year		Type of study		Objective
Carini, E		2020		Umbrella review		To identify and classify the dimensions of hospital performance indicators
Rahimi, H		2014		Systematic review		To identify the major indicators of hospital performance evaluation, as employed in performance assessment literature
Zaboli, R		2016		Systematic review		To determine key performance indicators in field hospital appraisal
Rasi, V		2020		Scoping review		To identify common evaluation indicators for hospitals
Jabari Beyrami, H		2013		Mixed method		To prioritize public-private partnership models in public hospitals of various countries based on key performance indicators
Arab, M		2014		Mixed method		To investigate the effect of the accreditation system on the key performance indicators of hospitals affiliated with the Tehran University of Medical Sciences
Pourmohammadi, K		2018		Mixed method		To synthesize the evidence relating to hospital performance indicators
Lin, C. Y		2022		Mixed method		To explore the application of the balanced scorecard (BSC) to service performance measurements of medical institutions
Si, Sh-Li		2017		Descriptive		To identify KPIs for holistic hospital management
Jiang, Sh		2019		Descriptive		To determine KPIs for hospital management
Zhang, L		2019		Descriptive		To identify KPIs in healthcare management
Hedayatipour, M		2020		Descriptive		To investigate the changes in the performance indicators of Shafa Academic Hospital in Kerman before and after the implementation of the accreditation plan during 11 years
Pishnamazzadeh, M		2020		Descriptive		To improve hospital performance is modeling the performance from resilience engineering perspective
Fabiano, G		2023		Descriptive		To describe available registry data and examine changes in KPIs
Armijos, J. C		2020		Case study		To design and implement a model of indicators to evaluate the performance of hospitals
Garrubba, M		2016		Rapid review		To identify the most common and current reported domains and indicators of performance in health care

The extracted key indicators for evaluating hospital performance, including their dimensions and sub-dimensions, are summarized in Table 2.

Table 2.

Extracted key performance indicators based on the studies

Author		Dimension		Sub-dimension		KPIs
Carini, E[32]		Process quality/efficiency				Therapeutic and interventional indicators
				Screening programs		Biennial hemoccult screening for colorectal/prostate cancer/cervical cancer
		Structural quality/efficiency				Implementation of guidelines, computer alert system for adverse drug events
				Antibiotic improvement intervention		Structured antibiotic order forms, academic detailing
		Clinical effectiveness and safety		Appropriateness of care		Cesarean section delivery
				Conformity of processes of care		Prophylactic antibiotic use for tracers
				Outcomes of care and safety processes		Mortality, readmission rate, admission after day surgery for selected tracer procedures, return to a higher level of care for selected tracer, conditions and procedures within 48 h, sentinel event
		Safety		Staff safety		Percutaneous injuries, staff excessive weekly working time
		Patient-centeredness		Client orientation, Respect for patients		The average score on overall perception/satisfaction/interpersonal aspect items/information and empowerment items/continuity of care items in patient surveys, last-minute canceled surgery
		Responsive governance		System integration and continuity		The average score on perceived continuity items in patient surveys
				Public health orientation		Breastfeeding at discharge
		Staff orientation		Perspective and recognition of individual needs		Training expenditures
				Health promotion and safety		Expenditures on health promotion activities
				Behavioral responses		Absenteeism: short-term absenteeism, absenteeism: long-term absenteeism
		Efficiency		Appropriateness of services		Day surgery for selected tracer procedures
				Productivity		Length of stay for selected tracers
				capacity		Inventory in stock, for pharmaceuticals, intensity of surgical theater use.
		Effectiveness				Mortality, readmission rate, cancer patients successfully surviving surgery/chemotherapy/transplant.
		Safety				In-hospital avoidable venous thromboembolism, hospital-acquired infections, medical errors, obstetric trauma, staff injury
		Patient-centeredness				Patient feedback management, pain control, satisfaction from personnel, explanation of procedures, treatment and discharge information, environment
		Staff orientation				Staff burnout/absenteeism/working overtime, satisfaction, clearly defined responsibilities in staff, continuous education
		Efficiency				Length of stay, hospital bed coverage, admission/discharge rate, cost of inpatient services, examinations ordered at the emergency room per patient, laparoscopic/open surgery rate, single-day stay for selected surgeries, cesarian section rate, surgery postponed or canceled
		Utilization				Patients visiting the emergency room department, admissions for acute conditions, usage of equipment/facilities, usage of laboratory examinations, surgical theater use
		Timeliness				The time needed for initial clinical examination/admission after arrival at the emergency room/selective surgical treatment, and patients leaving without being examined
		Resources and capacity				Permanent personnel, detached personnel, temporary personnel, personnel educational level, intra-sector nurses to physician’s ratio, computer application accessibility, use of electronic medical records, hospital webpage, telephone center, surgical theaters, beds per sector/room, short-term stay beds, space for patient baggage, toilet/intra-communication facilities/oxygen facilities/air-conditioning facilities in patients’ rooms, telephone facilities inwards, imaging facilities, ICU and HCU unit (s), hemodialysis facilities, management of hospital waste
Rahimi, H[19]						The average length of stay, the bed occupancy rate
Zaboli, R[22]				Input		Having a goal and transparent policy, the existence of the hospital coordination team, the state of being, deprived, and the number of staff per bed.
				Process		Implement the referral system, scenario planning for disaster
				Output		Number of surgical services, length of stay, the average time spent on patients in emergency resuscitation team, the time of hospital dispatch
				Outcome		Patient follow-up after discharge, satisfaction, hospital infections
Rasi, V[21]				Input		Number of beds, clinical and % administrative staff rate, total number of employees equivalent to full time, cost of resources, day case rates, managers’ salaries rate, gross margin, clothing and appearance of staff, parking for patients’ relatives and acquaintances, prescription rate of diagnostic procedures, staff salary and benefits, debtors, quality of medical equipment, hospital safety, the reputation of the hospital, wellness facilities for patient families and visitors, on-call physicians, patient safety culture, costs of staff training per capita, ratio of total staff costs to total hospital revenue, average overtime per employee, ratio of assets to debt, food quality
				Process		Length of stay, proportion of patients who have to use expensive medical equipment to total patients, survival rate, combined index of hospitalization adjusted days, number of visits/patients, number of correct diagnoses, number of surgeries, patient admitted ratio, the ratio of perfect nursing documentation, number of hours of nursing courses, appropriate prescriptions rate, rate of tests, average cost of patients/per bed/per day, hand hygiene practices, long stay rate, waiting time, operating expense per bed, duration of unused equipment, number of published articles, occupied day per bed, inpatient bed days per physician, bed occupancy rate, bed turnover rate, time and circulation of visits, the relevance of the tests prescribed to the diagnosed disease, physicians’ tolerance to hear details of patients’ problems, respectfully treat of all staff, number of discharge with personal consent.
				Output		Mortality rate, nosocomial infections, correct diagnosis rate, readmission rate, percentage of repeat surgical procedures, falling rate, medical errors, percentage of postoperative hematomas and hemorrhages, needle stick, prevalence of smoking among staff, percentage of costs due to medical neglect, error percentage in estimating bills correctly, hospital medical expenses relative to total hospital costs, ratio of private income to total hospital costs, sentinel event rate, total rejected bills, the rate of false tests, the rate of canceled surgeries, number of radiologic test rate, compensation rate
				Impact		Patient satisfaction, relocation of staff, absence of staff, employee sick leave rates, hospital success in obtaining credentials in quality management, complaint rate, staff satisfaction percentage, complaint patient percentage
Jabari Beyrami, H[37]		Quality-effectiveness				Rate of hospital infections, hospital incidents breakout rate, mortality, satisfaction
		Accessibility-equity				Average inpatient/outpatient waiting time
		Efficiency-financial				The average length of stay, bed occupation ratio, private income to total cost ratio
Arab, M[36]						Average length of stay, cesarean percent, turnover rate, satisfaction, bed occupancy rate, self-ordered discharge from the emergency room, and net death rate
Pourmohammadi, K[34]		Efficiency/utilization		Number of human resources		Number of clinical personnel, full-time equivalent interns/residents, administrative personnel, non-clinical personnel, full-time equivalent/adjusted admissions
				Number of hospital beds		Percentage of specialized beds and other beds, the ratio of active beds to fixed beds
				Cost		Cost of medical/operating supplies, wage, and salary payments to personnel engaged in patient/non-patient care, capital costs, adjusted depreciation charges for fixed and movable equipment, cost/adjusted admission, cost per inpatient
				Operation room (OR) utilization		The number of: OR cases booked, OR cases performed, OR cases canceled, percentage of OR cancelations, surgical operations to surgery beds, and day stay surgery rate.
				Emergency room (ER) utilization		Total number of ER visits, ER treatment time
				ICU utilization		Average ICU bed occupancy rate, average ICU length of stay
				Technology utilization		Use of electronic medical records, rate of the utilization of existing technology, number of high-tech services, number of medical supplies per bed, number of other operating supplies per bed, clinical integration, integrated database
				Radiology utilization		Total radiological procedures
				Laboratory utilization		Total laboratory investigations
				Other:		The bed occupancy rate, average length of stay, bed turnover interval, number of inpatients/outpatients, average number of drugs per encounter
		Financial		Profit		Total marginal profit, medical benefit-cost-per full-time equivalent
				Revenue		Operating revenue per adjusted patient days, non-operating revenue, current ratio, income to total revenues, revenue per physician full-time equivalent
				Cash flow		Cash to total debt
				Cost		Operating costs per adjusted patient days, unit cost performance, cost of outpatient visits, cost of salaries and overtime, emergency services expenses, personnel expenses, goods and services expenses, medicine expenses, average cost per day of hospitalization, pharmacy cost
				Investment		Return on investment
				Asset		Total asset turnover, tangible assets, return on assets
				Debt		Total debt/total assets, long-term debt to capitalization, debt ratio
				Liquidity		The current ratio, days revenue in net accounts receivable, days cash on hand, average payment period, replacement viability, acid test ratio, quick ratio, and budget flow compared to the approved budget
		Effectiveness		Accessibility (equity)		Waiting time, patients leaving without being examined, outpatient appointment waiting lists, satisfaction, ease of access, expected results achieved, coordination of care, involvement of family and friends, respect for values and preferences, amenities, comprehensiveness, continuity
				Safety		Rate of nosocomial infections, rate of accidents, rate of complications, failure to rescue, incidents/near misses, accidents/adverse events, hospital-acquired infections, medical errors, staff injury, ventilator pneumonia, technical difficulty with the procedure, patient falls, wrong surgery rate, hand hygiene compliance rate, postoperative respiratory failure, postoperative sepsis, prevalence of sentinel events
				Quality		Readmissions, mortality, cancer patients successfully surviving, quality certificates, appropriateness of care, surgery postponed or canceled, indicators of quality improvement programs, management of hospital waste, number of guidelines developed/using, staff training hours, a patient safety committee, a system for reviewing patient deaths, policies for handling dangerous chemicals, a credentialing committee, quality of life used to assess organizational performance, technical quality of care, appearance of facilities
				Responsiveness		Patient feedback management, pain control, staff burnout/absenteeism/working overtime/satisfaction, clearly defend responsibilities, average payment, diversity, working hours, frequency of night duty/shift, occupied position, average experience, staff safety/injuries, paid leave, number of staff per bed, continuous education, training budget rate, and social responsibility indicators
Lin, C. Y[53]						Complete and comfortable equipment, competitiveness of the medical profession, continuity of patient-to-hospital treatment, classification of medical profession according to customers (VIP system), complete medical service, complete salary, remuneration and policy, medical incomes of institutions
Si, Sh-Li[17]						Accidents/adverse events, nosocomial infection, incidents/errors, number of operations/procedures, length of stay, bed occupancy, financial measures
Jiang, Sh[11]						Incidents/errors, accidents/adverse events, nosocomial infection, nursing technology pass rate, length of stay
Zhang, L[35]						Incidents/errors, accidents/adverse events, nosocomial infection, length of stay
Hedayatipour, M[39]						The average length of stay, bed turnover interval, bed occupancy rate, net mortality rate, outpatient and hospitalization satisfaction
Pishnamazzadeh, M[33]						Patient satisfaction, waiting time, job satisfaction, burnout
Fabiano, G[48]						Percent of total and early surgeries, length of stay, pre-surgical stay, pressure ulcers, mortality
Armijos, J. C[31]		Time		Wait time		Average waiting time for: admission, triage, a medical procedure, per nursing procedure, outpatient clinic, internal and external transfers, medical discharge, first medical attention, diagnostic support activities, results of support activities,
				Processing time		Average time of: admission, resuscitation, triage, the medical procedure, diagnosis support activities, patient cycle, medical attention
		Quality		Mistakes		Percentage of hospital infections/pending surgeries/medication errors/adverse events, mortality rate, patient’s falls, readmission rate
				Compliance with standards		Existence of clinical protocols, the compliance rate of triage time standards, operation within 48 hours
				Satisfaction		People served outside the box, existence of information protocols for patients and families, rate of claims, patient/professional satisfaction rate, existence of training plans/procedures information to patients
		Efficiency		Productivity performance		Hourly productivity, operating room performance, average stay, percentage of outpatient surgeries, bed performance, percentage of counter-references, percentage of cesarean sections for deliveries attended/use of elective surgical wards.
				Compliance with standards		Existence of a patient classification or selection system, correct patient’s identification, number of patient registration per shift
		Capacity		Offer		The capacity of hospital beds, nurse/doctor relationship, number of beds per doctor, relationship between nurses and non-census beds, nurses/census beds ratio, absences of professionals, daily average number of beds available, rate of bed rotation
				Demand		Average days of stay, average daily census, patient rate, occupation rate, bed replacement interval
		Economic		Costs		Percentage of missed appointments, average cost per patient/service
				financial		Budget execution, execution percentage, budgetary spending
Garrubba, M[38]		Safety and effectiveness				Mortality, unplanned hospital readmission, hospital-acquired infections, the safety of maternity services, and cancer
		Equity and access				Emergency department wait length, specialist care wait length
		Efficiency/value for money				Cost and length of stay
		Patient-centered/experience				Maternity and inpatient personal needs

Finally, using the content analysis method, 10 indicators with the highest frequency in the literature were identified as the most common key indicators for evaluating hospitals’ performance. Figure 2 indicates the frequency of each KPI within the identified dimensions and sub-dimensions. Notably, the rate of nosocomial infections and the average length of stay demonstrated higher frequencies across the reviewed literature.

Figure 2.

Ten most frequently mentioned KPIs across the reviewed literature

Discussion

This study presented a detailed and comprehensive review of all evidence pertaining to the identification, classification, and application of KPIs. In this context, we have outlined a concise framework of KPIs designed for the purpose of facilitating efficient performance evaluation in hospital settings, particularly in light of constraints imposed by limited resources. Many studies have been conducted to identify KPIs using various models. Nikjoo et al. conducted a comprehensive mixed-method study to identify KPIs for hospitals, focusing on quality in three domains: quality of care, service delivery, and health system determinants. The study aimed to enhance the understanding of hospital performance evaluation indicators, contributing to assessing and improving overall performance in public hospitals.[27] Similarly, Heenan synthesized international approaches to indicator selection in health care, aiming to create a standardized process framework. This systematic approach enhances the understanding of indicator selection processes and their impact on healthcare quality, providing a relevant and applicable framework for real-world settings within healthcare systems.[28] Imani’s research contributed to hospital efficiency studies, proposing a conceptual framework for selecting variables to measure efficiency, particularly in Iranian public hospitals. This study aimed to enhance understanding by incorporating a broader set of variables in the context of Iran.[29] Overall, these studies collectively contribute to the development of frameworks for assessing and enhancing hospital performance. This review focuses on exploring and identifying KPIs for hospital evaluation, emphasizing the importance of establishing a concise set of indicators for effective performance evaluation, especially considering limited resources.

The findings showed that some studies had categorized indicators in terms of their central theme and nature and others in terms of their role in system performance (input, process, output, and impact). However, despite the variation in the type of classification of these indicators, common indicators form the core of all the reviewed models. The literature analysis reveals a significant focus on the dimensions of effectiveness and efficiency, based on the extracted data.

Effectiveness

Effectiveness refers to the ability in doing “the right” things. It measures the extent to which planned outcomes, goals, or objectives are achieved in ordinary circumstances through an activity, intervention, or initiative intended to produce the intended effect.[30] So, the effectiveness indicators measure the ability of health services to achieve the expected outcomes and the desired aims and objectives.

This study indicated that in 13 of 16 studies, the effectiveness indicators were mainly applied for hospital performance evaluation.[11,17,21,22,31,32,33,34,35,36,37,38,39] Based on the findings, several efficiency indicators were used in hospitals as KPIs; however, three of them were utilized more frequently than others. These indicators were length of stay, bed occupancy rate, and mean cost per patient, and they were categorized under the two sub-dimensions of productivity and financial performance. They include the rate of nosocomial infections, incidents/errors, accidents/adverse events, patient satisfaction rate, waiting time, readmissions rate, and mortality rate. These KPIs have been explored in various studies related to hospital performance evaluation.[17,34,40]

Nosocomial infections are defined by the World Health Organization (WHO) as a kind of infection that occurs in patients during the care process in a hospital or other healthcare settings, which was not present or incubating at the time of admission.[41] Nosocomial infection in the hospital includes surgical wound infection, infection of methicillin-resistant Staphylococcus aureus (MRSA), and incision-wound infection.[17] The results of this study demonstrated that the rate of nosocomial infections has been considered a hospital patient safety measure and plays a key role in evaluating hospital performance in terms of effectiveness.[11,17,21,22,31,32,34,35,37,38]

Incidents/Errors are defined as “action (s) by healthcare provider (s), omissions, decisions and systems that cause harm to or lead directly or indirectly to chronic disability, or impaired quality of life or death of patients as a result of medical treatment.”[42] Incidents/errors occur during the healthcare treatment process, including medication errors, errors in diagnosis and treatment, and blood transfusion errors.[17] Based on the results of this study, incidents/errors as another important indicator of patient safety have been repeatedly used in various studies for evaluating hospital performance.[11,17,21,31,32,34,35,37]

Accident/Adverse event is a harmful and negative outcome that happens when a patient has been provided with medical care.[17,35,43] Accidents/adverse events are another indicator of measuring patient safety in the field of hospital effectiveness, which have been mentioned in various studies as having a pivotal role in hospital’s performance evaluation.[11,17,31,32,34,35]

Patient satisfaction rate reflects the degree of satisfaction experienced by patients regarding the healthcare services they receive from their healthcare provider. Healthcare service satisfaction includes physicians, waiting time, and treatment.[17,44] Patient satisfaction is one of the leading indicators of responsiveness, which has been emphasized in several studies to measure hospitals’ effectiveness.[31,32,33,36,37,39]

Waiting time is recognized as a crucial indicator for measuring accessibility in healthcare settings, particularly clinical visits in hospitals.[45] Based on the findings, waiting time has been indicated in various studies as a KPI for hospitals.[21,31,33,34,37]

Readmission is defined as “a hospital admission that occurs within a specified time frame after discharge from the first admission.”[46] The readmission rate is one of the most important quality indicators and is used as one of the leading indicators for measuring hospital effectiveness. The findings of this study showed that several studies had used this indicator to measure hospital performance.[21,31,32,34,38]

Mortality rate (the proportion of patients who die during admission or shortly after that in hospital) can reflect the safety, effectiveness, and, in emergency medicine, timeliness of care as an essential and common indicator of quality.[47] Based on the results, some studies consider mortality as one of the essential quality indicators for evaluating hospital performance.[21,31,32,36,37,38,39,48]

Efficiency

Efficiency is one of the most critical challenges facing health system managers worldwide. Limited resources and, however, spending a large part of the expenditures of the health system in hospitals have made efficiency one of the essential factors in hospital performance.[34]

Efficiency indicators evaluate the effectiveness of resource utilization in generating outputs. These indicators can also assess the efficiency of work processes, including administrative tasks associated with operating specific programs or services. Such assessments prove beneficial for program managers and aid in program performance evaluation and determining funding needs. Efficiency as one of the six main dimensions of hospital performance evaluation has been emphasized by WHO.[49]

This study showed that 14 of 16 studies identified efficiency indicators in hospitals’ performance evaluation.[11,17,19,21,22,31,32,34,35,36,37,38,39,50] Also, the most critical indicators (KPIs) required to evaluate the hospital’s performance regarding efficiency have been identified.

Based on the findings, several efficiency indicators were used in hospitals as KPIs, but three have been used frequently compared to other indicators. These three indicators were categorized under two sub-dimensions of productivity, and financial while consisting of length of stay, bed occupancy rate, and mean cost per patient. Craig et al. have emphasized the significance of the average length of stay as a crucial KPI for hospital evaluation.[51] In parallel, Imani et al.’s research has underscored the importance of efficiency in hospital performance, aligning with our focus on key indicators, such as bed occupancy rate and mean cost per patient.[29]

Length of stay is “the time the patient passes in hospital from the entrance to the exit.”[35] The length of stay differs for each patient and depends on the rapidity of diagnosis, treatment process, availability, and appropriateness of alternative care after discharge. This indicator has been introduced in numerous studies as one of the most important key indicators in evaluating the performance of the hospital in terms of productivity and, in a broader view, terms of efficiency.[11,17,19,20,32,34,36,37,38,39,48,49]

The bed occupancy rate is defined as the ratio between the number of patients-day and the number of beds-day in a given period. It indicates the efficient use of hospital beds in a specified period.[50] Bed occupancy rate is helpful to indicate the capability of a hospital in planning and operational management of hospital beds and evaluating the ability of the hospital to provide appropriate care for patients.[20] Based on the results of this study, the bed occupancy rate, another important indicator of productivity, has been repeatedly used in various studies for evaluating hospital performance.[17,19,21,31,34,36,37,39]

Mean cost per patient is defined as “the total expenditure (expenditure for raw and auxiliary materials and consumables etc., excluding payroll) of a hospital, divided by the number of hospitalized patients.”[52] This indicator has been proposed as one of the critical financial indicators for measuring the efficiency of the hospital in various studies, which is essential to evaluate hospital performance.[21,31,32,34,38,52]

Limitations

Despite the significance of the findings covered here, it should be evaluated with primary limitations in mind. First, contrary to what the scoping review guidelines implied, the studies’ degree of evidence was not measured. Another limitation of this review was the unavailability of some articles due to publisher or journal rules.

Conclusions

With an exploratory approach, this scoping review was conducted to identify key indicators for hospital performance evaluation, revealing a predominant focus on effectiveness and efficiency dimensions. Effectiveness indicators in the field of safety, responsiveness, quality, and accessibility are very important in evaluating the performance of hospitals with specific indicators, such as rate of nosocomial infections, incidents/errors, accidents/adverse events, patient satisfaction rate, readmission rate mortality rate, and waiting time standing out. Efficiency indicators, addressing resource utilization and financial aspects, included length of stay, bed occupancy rate, and mean cost per patient. The synthesis emphasizes the significance of a balanced evaluation considering both effectiveness and efficiency, providing a comprehensive framework for continuous improvement in hospital performance and the delivery of high-quality healthcare services. Future research and applications can build upon these findings to adapt and refine indicators in response to the evolving landscape of healthcare systems.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Search Strategy (Last updated in December 2023)

PubMed
Search No.		Query		Results
1		“key”[Title/Abstract]		1,118,799
2		Hospital-related terms [Title/Abstract or MeSH Terms]		1,859,219
3		#1 AND #2 AND (humans[Filter])		40,374
4		Performance-related terms [Title/Abstract]		4,321,027
5		#4 AND #3		9,055
6		“indicator” OR “indicators” [Title/Abstract]		377,608
7		#5 AND #6		849
Scopus
Search No.		Query		Results
1		TITLE-ABS-KEY (hospital*) AND TITLE-ABS-KEY (key) AND TITLE-ABS-KEY (perform*) AND TITLE-ABS-KEY (indicator*)		2,009
2		TITLE-ABS (hospital*) AND TITLE-ABS (key) AND TITLE-ABS (perform*) AND TITLE-ABS (indicator*)		1,465
3		Filtered by DOCTYPE (ar, cp, re, cr) AND EXACTKEYWORD (Article, Hospitals)		837
Web of Science
Search No.		Query		Results
1		(“indicators” OR “indicator”) (Title/Abstract)		626,338
2		“perform” OR related terms (Title/Abstract)		7,621,061
3		“hospitalisation” OR “hospital” etc., (Title/Abstract)		1,396,804
4		Key terms in Title/Abstract		1,911,588
5		#1 AND #2 AND #3 AND #4		975
Embase
Search No.		Query		Results
1		‘hospital’/exp OR ‘hospital*’:ab, kw, ti		3,364,018
2		key: ab, ti, kw		1,410,253
3		‘indicator’/exp OR indicator*:ab, kw, ti		546,042
4		#2 AND #3		31,617
5		#1 AND #4		5,075
6		‘key performance indicator’:ab, kw, ti		565

Funding Statement

This work was part of a Ph.D. thesis funded and supported by Vice-Chancellor for Research and Technology, Tabriz University of Medical Sciences (Grant Award Number: 68604).