Performance in healthcare: a conceptual analysis

Abstract

Background

The concept of “performance” is widely used across disciplines, yet remains ambiguously defined, particularly in healthcare. This conceptual ambiguity poses challenges for researchers, managers, and policymakers in effectively evaluating and improving organisational outcomes in complex environments such as hospitals.

Methods

This study employed Rodgers’ evolutionary concept analysis method to clarify the concept of “performance” in healthcare. The process involved: (1) identifying the concept of interest; (2) determining surrogate terms and relevant uses; (3) selecting an appropriate realm for data collection through systematic literature searches in PubMed, Scopus, Web of Science, and Google Scholar; (4) identifying attributes of the concept; (5) determining antecedents and consequences; (6) analyzing related concepts; and (7) generating a model case. The analysis was further refined through multiple focus group discussions using brainstorming techniques with healthcare experts to consolidate performance-related dimensions.

Results

The analysis revealed significant inconsistencies in how performance is defined and measured in healthcare literature. We identified 21 distinct performance dimensions, which were integrated into a novel four-level framework termed the Umbrella Performance Model (UPM). This model positions performance as a conceptual-descriptive framework that integrates not only traditional elements such as productivity, efficiency, and effectiveness, but also 18 additional, healthcare-specific dimensions, that clarify performance boundaries and interrelationships.

Conclusion

The UPM provides a unified framework for understanding performance in healthcare organisations, particularly hospitals. By introducing this model, the study aims to reduce conceptual ambiguity and offer a holistic approach to performance evaluation that moves beyond traditional efficiency-based metrics. The model serves as a practical guide for health service researchers, managers, and policymakers to assess and improve organisational performance more comprehensively.

Background

Health is a fundamental human right and the cornerstone of sustainable development across social, economic, political, and cultural dimensions. Although it is a moral duty, it is also considered a social and economic issue [1]. In 2023, OECD countries have allocated an average of about 10% of their wealth to health [2]. The healthcare sector performance, as a key complex sector, owing to their advanced procedures and different resources, faces systemic challenges including cost inflation, operational inefficiencies, market competition, and persistent equity-accessibility dilemmas [3].

In recent decades, the concept of performance has gained increasing attention, being pervasive in almost all spheres of human activity [4, 5] in work, in business, in play [4], and even in management [6] as organizations have undergone dramatic changes, which have implications for conceptualizing and understanding the world of performance [7]. Therefore, we have come to think, often unconsciously, that everyone knows what the performance is [4]. Particularly, management scholars today agree that when considering the performance term, the focus should not be solely on the inputs and outputs produced by a single organization, but instead primarily on the broader outcome achieved in partnership with a comprehensive set of stakeholders for the benefit of the wider community [5, 8, 9]. However, different views of what constitutes good performance could lead to conflicting objectives and diverging policy aims [10].

Campbell (1990), describes the literature on the structure and content of performance as “a virtual desert” [7]^, and Lebas (1995), Whooley (1996), and Otley (1999) consider performance a term that varies based on individual perspectives and meanings with no identical or standardized definition [7, 11], while others consider it a disappointing term [4]. Some scholars emphasize the uncertainty inherent in the performance concept [11, 12]. At the same time, Bessire (1999), in his attempt to determine performance, admits how impossible it seems to find a consensus on a single definition of this concept. In 2001, Otley choses to use the term freely, as the word ‘performance’ is something of a weasel word in that it appears to mean very different things to different people [11].

In addition, there is confusion in understanding the words related to performance, including efficiency, effectiveness, and productivity. Sink & Tuttle (1989), Chew (1988), Koss & Lewis (1993), Sumanth, Thomas & Baron (1994), and Jackson & Petersson (1999) faced challenges in interpreting the terms performance, productivity and considered them interchangeable, as was the case with terms like efficiency and effectiveness [13–16]. Chew (1988) suggests that, despite the concept of productivity having a long history, it is remarkable that many individuals who make decisions every day about improving efficiency are unable to respond to the straightforward question of what productivity is [14]. Forrester (1993) and Tangen (2002) believe that performance is often misunderstood. Additionally, many researchers, such as Sink & Tuttle (1989), Singh et al. 2000), and Broman (2004), claim that productivity is relegated to a secondary position and is often overlooked or ignored by those who influence or control production operations [17].

Due to the complex internal environment of healthcare organizations and the simultaneous presence of two powerful institutional logics, “management” and “medicine”, these organizations require a more context-sensitive definition of performance than many other types of organizations, in order to minimize goal conflicts and clarify priorities [18].

While existing performance frameworks have provided valuable multidimensional perspectives, most were originally developed either for general organizational settings or for macro-level health system assessment. As performance is increasingly recognized as a vital indicator of health system functioning and a key driver of health policy formulation [19], it becomes essential to clarify how the concept of performance in healthcare organizations is defined, how it differs from related terms, and what dimensions it encompasses at the organizational level.

The Umbrella Performance Model (UPM) addresses these gaps by offering a context-specific and theoretically integrated framework for healthcare organizations. Unlike previous models, the UPM explicitly defines and hierarchically structures 21 core and additional healthcare-specific dimensions, clarifies their interrelationships, and provides operational guidance for their application in hospitals. Current conceptualizations often aggregate or overlap constructs such as efficiency, effectiveness, quality, and productivity, which may limit conceptual precision when applied to healthcare delivery organizations. By integrating contextual, professional, and organizational factors, the UPM enhances clarity, reduces ambiguity, and supports a more systematic understanding of organizational performance in healthcare settings.

Methods

The present study used a conceptual analysis method based on Rodgers’ (1989) evolutionary concept analysis approach (REF) [20]. Concept analysis is applied to dynamic, context-dependent concepts that lack a comprehensive definition. It involves decomposing a concept into simpler elements to enhance clarity and facilitate mutual understanding among researchers and professionals. Concept analysis can clarify the meaning of a concept in current use, helping future development. Rogers’ approach has seven steps including:

Identify and name the concept of interest

The concept under investigation was “performance” in the healthcare organizations. This term was chosen for its conceptual ambiguity and its varied uses in academic and research literature.

Identify the surrogate terms and relevant uses of the concept

An extensive list of alternative terms and related expressions used interchangeably or closely associated with “performance” was compiled. This was achieved through a a literature review and consultation with subject-matter experts to capture conceptual variation across disciplines.

Select an appropriate realm for data collection

The data collection domain included academic and grey literature from health administration, health economics, and health management. According to Rodgers’ (2000) evolutionary concept analysis, concept analysis studies do not require a comprehensive search of all sources. Instead, it emphasizes purposive selection of literature that defines, clarifies, or critically discusses the concept of interest [21]. Electronic databases such as PubMed, Scopus, Web of Science, and Google Scholar were consulted. The primary selection criterion was conceptual relevance—that is, whether a publication explicitly defined or critically examined the concept of performance performance or closely related constructs. Sources that mentioned performance only in passing or reported metrics without conceptual discussion were excluded. An initial review identified 12 core sources that directly addressed conceptual definitions of performance. In addition, a snowball sampling strategy (backward citation tracking) was applied. When relevant definitions or conceptual discussions were identified within the reference lists of the initially selected articles, the original cited sources were retrieved and reviewed in full. These sources were included if they met the inclusion criteria.

Keywords included the central concept and its alternative terms (e.g., “performance definition”, “performance concept”, “healthcare performance”, “hospital efficiency”, and organizational effectiveness”). The search was not limited to a date to capture the historical evolution of the concept. Studies included that explicitly defined or conceptually discussed “performance” or closely related constructs. Literature addressing healthcare or organizational performance and peer-reviewed articles or authoritative grey literature contributing to conceptual clarification. Empirical studies reporting performance metrics without conceptual discussion. Studies that focused solely on measurement tools without conceptual clarification and unrelated to healthcare or organizational contexts were excluded.

Recognise attributes of the concept

Key dimensions and core attributes associated with performance were identified through iterative content analysis. This revealed that performance is not a single, uniform construct but a multidimensional and relational concept. Essential characteristics, interrelationships and various manifestations in practice, were clarified.

Ascertain the references, antecedents, and consequences of the concept

Antecedents were identified as foundational organizational and contextual conditions necessary for performance. Consequences were defined as the observable organizational and system-level outcomes resulting from performance.

Identify concepts related to the idea of interest

Related but distinct concepts were critically examined to avoid conceptual redundancy. Extracted constructs were refined through focus group discussions using brainstorming techniques—where items were merged, removed, or modified based on relevance to the hospital context, feasibility for real-world application, and the avoidance of conceptual overlap.

Generate a model case of the concept

To demonstrate the practical application the Umbrella Performance Model (UPM) was developed as a model caseencompassing all identified features, antecedents, consequences, and interrelationships. The model was validated and refined through multiple research team meetings to ensure internal coherence and conceptual validity.

Results

From 1986 to the early 21st century, researchers have attempted to clarify the concept of performance. However, the term “productivity” was first used by Quesnay (1766), more than two centuries ago, while researchers from 1883 onward have begun to define it. Also, since 1950, researchers have expressed various views on the concept of efficiency; however, from 1980 onward, a more convergent view of the concept has emerged in the literature. In addition, since 1950, researchers have used the term effectiveness.

Surrogate terms and relevant concepts of the performance

Table 1 examines performance-related concepts from the perspectives of different researchers based on historical trends (performance, productivity, efficiency, and effectiveness).

Table 1.

The key performance concepts definitions

Concepts	Definition	Ref.
Performance	A purposeful task or action that is carried out or accomplished and can be scaled or measured	[7, 11, 12, 22–26]
	Accomplishment of specified targets within the specific constraints, appropriately	[27, 28]
	The result or consequence of the behavior by the outcome aspects	[7, 12, 17, 22, 24]
Productivity	Continuously improvement of things that already exist	[15, 17, 29]
	The inputs-outputs interaction	[15–17, 30–34]
Efficiency	Relationship between costs and benefits	[30, 34–37]
	Uses resources economically to reach the organizational goals	[11, 15, 43–47, 25, 35, 36, 38–42]
	Ratio between resources expected to be consumed and actually consumed in a standardized way	[16, 17, 30, 34, 36–38, 46, 48]
Effectiveness	The achievement of organizational goals, aims, and objectives	[11, 12, 17, 36, 48–52]
	How well a set of results is accomplished	[16, 38, 43, 46, 48, 53]
	The ratio between actual output to expected outcome	[16, 37, 39, 48, 51, 52]
	Ability to satisfy the markets and customer need for goods and services	[17, 25, 42]
	The degree of satisfaction of customer	[11, 12, 25, 42, 54]

Ascertain the references, antecedents, and consequences of the performance

Between 1880 and 1950, terms such as performance, productivity, effectiveness, and efficiency emerged [11, 17, 30, 36]. By the 1970s, productivity, effectiveness, and efficiency has been considered as the performance criteria [30].

Researchers have explored the relationships between these concepts, particularly distinguishing effectiveness and efficiency. Drucker (1963) emphasized effectiveness as a prerequisite for efficiency, prioritizing doing the right tasks over merely doing tasks well [36–38].

Kjurchiski (2014) noted that efficiency measures quality, while effectiveness pertains to achieving final goals [55]. Popa (2017) linked effectiveness to knowledge, competency, and the relationship between inputs, outputs, and expected results [36].

In 2005, Afonso et al. considered the relationship between efficiency and effectiveness and vulnerability to environmental factors that can affect production or outcomes [35]. Environmental factors and external influences, such as political choices, lifestyle and socioeconomic conditions, complicate the measurement of effectiveness compared to efficiency [29, 37, 52].

In healthcare, effectiveness is closely tied to treatment efficacy, which evaluates interventions under ideal conditions to meet evidence-based practice requirements. Effectiveness research utilizes real-world data to examine outcomes, costs, and variables that influence interventions, offering generalizable insights for clinical practice practice [56, 57].

KAO et al. (1994) differentiated productivity strategies: efficiency involves resource optimization, while effectiveness relies on advancements in technology or management [32]. The Asia Productivity Organization (2008) defines productivity as “efficiency plus effectiveness” [29].

Efficiency is easier to measure, often tied to resource utilization rates, while effectiveness relates to customer value and output generation [17]. Tangen (2005) clarified that efficient systems may still be ineffective, and vice versa [17]. Jackson (2000) argued that focusing solely on efficiency does not significantly boost productivity [46]. Productivity studies often emphasize efficiency due to challenges in measuring service-related productivity (such as heterogeneity, perishability, intangibility, and simultaneity) [50].

Researchers warn that over-prioritizing efficiency can limit organizational transformation and broader productivity goals [15]. Although productivity and performance are frequently discussed, their definitions remain unclear. Kirikal & Tallinna (2005) highlighted the importance of productivity in tracking organizational performance [58]. Andersen and Fagerhaug (2002) suggested that performance could substitute productivity due to its broad organizational scope [11].

Recognize attributes and generate model case (Umbrella performance model (UPM))

As mentioned earlier, studies have shown that performance is not an independent term and encompasses other concepts. Figure 1 presents our performance model; the Umbrella Performance Model (UPM) which consists of four levels. At a glance, at lower levels, the inputs, outputs, and outcomes of the organization are identified. At the second level, how to use the first-level concepts to calculate the efficiency and effectiveness of the organization is determined. At the third level, the concept of productivity is formed by combining efficiency and effectiveness, which is a broader concept than the concepts of the previous two levels. At the fourth level, the concept of performance is introduced with a focus on the fact that this concept alone cannot cover the last three levels and requires the use of other applied and functional concepts that help it to clarify its position better. Indeed, the Umbrella Performance Model shows that using an organization with high productivity, high efficiency, or high effectiveness alone cannot have positive performance.

Fig. 1.

Umbrella performance model (UPM). (Source; (Authors))

We consider the performance of an organization to be positive when it is not only productive, efficient, and effective, but also safe, equitable, flexible, profitable, etc. Therefore, performance cannot be considered simply by considering and relating to productivity, efficiency, and effectiveness. To show the real performance of an organization, managers, and politicians need to pay attention to all the concepts in the UPM (see Fig. 1). In this study, 21 performance-related concepts have been defined and these concepts have been re-categorized, and functional summarization has been performed. Then, some concepts have been merged (such as speed and time, innovation and creativity, capacity and sustainability, budget–ability and cost), some have been eliminated (such as relevance, delivery, dependability, and access), and the other has been replaced (such as growth with development). Finally, eighteen performance-related concepts under the performance dimensions have been finalized and introduced.

At its foundation, the model includes inputs, processes, outputs, and outcomes. These feed into measures of efficiency and effectiveness, which together form the broader construct of productivity. At the highest level, performance is defined as an inclusive concept that incorporates not only these operational elements but also 18 additional dimensions—such as equity, quality, safety, and patient-centredness. This layered structure highlights the complexity of performance. It emphasises that true organisational success in health systems cannot be measured by output alone, but by a multidimensional set of values and indicators.

In this model, the first level considers the transformation of inputs to outputs and outputs to outcomes. This process is directly or indirectly affected by internal or external factors. Internal factors include organizational structure and culture, employee competence, infrastructure, leadership style, management systems [59], or even organizational values, attitudes, communication structure, and employee morale. External or exogenous factors include various socioeconomic factors [29, 37], lifestyles [37], regulatory factors, competitive frameworks, organizational climates [29] as well as stakeholders, shareholders, suppliers, customers, unions, contractors, and media.

At the second level, the model considers organizational efficiency and effectiveness. Efficiency is defined as a quantitative approach that is tangible and measurable. This involves utilizing resources to achieve the expected results, with a focus on minimizing waste and maintaining a consistent level of quality. On the other hand, effectiveness is a ratio that indicates the achievement of final goals, meeting the needs of beneficiaries and creating added value for them at the right time, in the right way, and with the right quality.

At the third level, the model considers productivity, which is defined as a multidimensional concept that examines the relationship between effectiveness and efficiency by focusing on the organization’s strengths, weaknesses, opportunities, and threats, while spending minimal resources and achieving maximum quality. At the same time, it seeks continuous improvement of the services or products that are produced. This issue is also vital for organizational competition.

At the fourth level, the model considers performance, which is defined as a socioeconomic concept encompassing all lower levels, as well as other concepts, with 18 dimensions.

Practical example to shed light on the performance dimensions

In Table 2, each performance dimension is defined. For further clarification, in addition to addressing the core question, each dimension will also provide a corresponding example in the context of a hospital. For example, the performance dimension of “speed” indicates that if a hospital’s performance is not at the right pace, it will not only lead to patient dissatisfaction but also have direct and indirect effects on the processes of attracting patients, generating revenue, and even on the hospital’s reputation.

Table 2.

Performance dimensions

Performance dimension	Definition	The Core question in the hospital organization	Example from hospital patient/personnel view
Appropriateness	Appropriateness is ‘the quality of being suitable or proper in the circumstances’[60].	Is the performance in terms of quality, quantity, and time of providing services, appropriate to the demand of service receivers?	- Appropriateness between the number of emergency medical specialists with the number of patients referring to the emergency room in each shift. - Appropriateness between the ratio of the Intensive Care Unit (ICU) nurses to the ICU beds per shift.
Coherence	Coherence is based on the interaction between the main components, which is determined by the relationships and reactions between these components, as well as the results of these interactions. It links the components together and in the concerning organization [61].	Is there sufficient coherence between the components of the hospital? Are the processes carried out in a coherent and coordinated manner?	- Carry out the interdepartmental patient transfer process in a coherent manner with a focus on safe, correct, standardized, and coordinated transfer before patient transfer - Coordinating to carry out the purchase request for medical equipment needed by clinical departments to provide equipment with the right quality, on time, and in the necessary quantity
Cost	A cost is an expenditure that an organization incurs to deliver services or produce goods in the market [62].	Is the hospital manager aware of the cost of the services provided, and does the hospital monitor them?	- Is the standard cost price calculated for different diagnostic-therapeutic services, and is the standard cost price of each service compared with the actual cost price of that service? (For example, the standard cost of a laboratory test compared to the actual cost of that test)
Development	Deliberate efforts on the part of various agencies, aimed at improvement [63].	Are the possible deficiencies in the current processes being continuously improved, and is the performance improvement noticeable compared to the previous period?	- Improving the patient admission process in the elective operating room to reduce the number of cancellations of surgeries - Improving the process of the first visit of the patient by the doctor in the emergency room to speed up the assignment of emergency patients
Economy	An economy is a method for deciding how to allocate scarce resources for producing and consuming goods and services [64].	Is the performance such that it uses the hospital’s resources to provide optimal and cost-effective services?	- Organization of human resources in hospital departments (clinical, paraclinical, and support units) based on needs and based on the standards to optimally use and prevent human resource wastage. - Use quality medical equipment (like pediatric angiocatheter) to avoid additional costs and dissatisfaction of patients and medical staff.
Equity	Equity is typically defined as impartiality, fairness, and justice, which is closely related to equal opportunity (65). Two types of equity are vertical (different treatment of different people) and horizontal (similar treatment of similar people) [66].	Does the performance lead to fair relations and equal opportunities for clients and service recipients?	- Justice in paying benefits to employees with similar conditions and working hours by creating a transparent and fair scoring system. - Accepting all patients referred to the hospital based on the organization’s mission, regardless of the patient’s financial status, type of health insurance, racial status, and other socioeconomic conditions.
Evaluation	A process for assessing the worthiness, importance, merit, or value of a system [67].	Is the performance determined through periodic and detailed evaluation by an experienced team in various fields?	- Measuring the performance of the hospital’s medical staff in the field of timely attendance at the clinic, providing appropriate services to patients, appropriate behavior with patients, accurate diagnosis of the disease, and accurate prescription of medicine and para-clinical measures for the patient. - Measuring the performance of service workers regarding the correct use of detergent items
Flexibility	Economic reply to the systemic modifications [68].	Is the performance such that the hospital manager reacts flexibly and contingently to internal and external changes in different situations?	- The appropriate treatment of the hospital team with its employees in the condition of income deficit creates a sense of partnership between the employees and the organization to avoid the waste of employee resources due to the deficit of employee benefits. - The hospital complies with patients when a doctor is absent at the clinic by informing and calling patients before they go to the hospital clinic and reserving the patient’s appointment in future visits.
Innovation	The process that begins with the idea’s inception and continues until it is brought to the commercial stage in the form of production, exchange, consumption and consumption, and aims to attain innovation by integrating science, management, economics, and technology [69].	Is the performance such that it moves toward innovative goals and promotes creativity among its customers?	- Create a suggestion system among employees and patients who refer to the hospital to receive new, pure, and practical ideas from them. - Creating new technologies and providing services based on them in various diagnostic and therapeutic fields
Patient centeredness	It involves understanding patients’ illnesses within a broader biological, psychological, and social framework [70].	Does the performance emphasize the patient-centeredness? Are patients always at the center of attention of the management and executive teams of hospitals?	- Paying attention to the needs of patients before, during, and after the completion of the treatment process in the hospital - Listening to the patient and trying to solve his needs during hospitalization
Profitability	The ability of companies to make a profit depends on their sales, capital, and total assets. Therefore, long-term investors will be very interested in this profitability analysis. For example, shareholders will see profits received in the form of dividends [71].	Is the performance such that it has shown the long-term goals to overcome the costs and create reasonable and profitable incomes through authorized means?	- Check the hospital costs (such as personnel, medicine and equipment, energy, and depreciation) through reasonable income generation to create a reasonable profit. - Periodic monitoring of the balance of income and expenses of the hospital
Quality	Elshaer (2012): “A situation when a set of inherent characteristics consistently fulfill the continuously changing requirements of the organization’s customers and other stakeholders” [72].	Does the performance meet the necessary quality standards, and are they updated according to the standards for providing services to customers and beneficiaries?	- Creating a system for measuring the satisfaction of employees and patients - Observance of hand hygiene by clinical personnel by international standards
Quality of Work Life (QWL)	A set of valuable consequences of work life that affect individuals, organizations, and society [73].	Is the performance such that the quality of working life of internal and external customers is considered?	- Taking measures to identify and prevent employee burnout - Standardization of working environment conditions in line with the development and career enrichment of clinical and support staff
Relationship	Relationships are often taken to refer to human and interpersonal issues, between the system, other members of the organization, and the providers [74]	Is the performance such that it helps to create, facilitate, and accelerate effective relationships between internal and external customers?	- Establishing proper interaction between management and hospital personnel - Creating sincere and constructive relationships to strengthen the spirit of cooperation between nursing staff of different departments - Establishing appropriate communication with insurance organizations
Safety	The state of being away from the dangers caused by forces of nature or human errors accidentally [75].	Is the spirit and safe thinking that create a safety culture, offering customers both inside and outside the hospital, visible in performance?	- Providing safety measures away from any mistakes, adverse events, incidents, or near-misses events on the patient - Creating a safety culture to prevent physical, chemical, and biological injuries to hospital staff
Satisfaction	Rai (2013); “gratification, pleasure or fulfillment of desire. Satisfaction is an emotional state that results from achieving needs and desires [76].	Are internal and external customers satisfied with the performance?	- Patient’s satisfaction with the behavior of medical and nursing personnel - Employee’s satisfaction with superior performance
Speed	Speed is an attribute as elapsed time (i.e., minutes, hours, days, years), change in the rate of speed (i.e., velocity, acceleration), the duration of particular organizational events and processes relative to referent others (i.e., faster, slower, first, second, last), or the tempo, pace, or intensity with which organizational activities take place (i.e., rapid, slow, synchronous, rhythmic, syncopated) [77].	Does the performance have the appropriate speed to provide services to customers?	- The reasonableness of the patient’s waiting time to receive services in the outpatient clinic - The reasonableness of the patient’s waiting time for the first medical visit in the emergency room - The reasonableness of the waiting time to enter the inpatient operating room
Sustainability	Economic, environmental, and social issues are addressed in a balanced, comprehensive, and long-term manner that benefits both current and future generations of stakeholders [78].	Is compatibility with economic, environmental, and social issues with a long-term view evident in performance?	- Use of environmentally friendly energy in the hospital (solar panels for emergency power supply) - The continuous efforts of the hospital staff in order not to waste energy - Create a mechanism to prevent the provision of unnecessary services and the creation of induced demand.

In addition, the performance dimension of “Quality of Work Life (QWL)” indicates that if a hospitalfails to adequately address the QWL, personnel’s job satisfaction, motivation, health, job security, productivity, safety, and well-being will be negatively impacted. Quality of Work Life encompasses four principal axes: occupational health care, safe working environment, adequate working hour, and proper compensation (Pandey & Tripathi, 2018). Therefore, it is crucial to pay enough attention to the QWL as one of the performance dimensions in the UPM model.

Discussion

As emphasized in the literature, the term performance is multidimensional [7, 11, 12], with no single definition and a changeable nature depending on the context [11]. The forms of performance that a particular company tries to achieve are particular and case-specific [17]. Thus, performance measurement has evolved from solely focusing on an organization’s effectiveness, efficiency, or productivity to encompass a broader set of criteria.

In this study 21 different socioeconomic dimensions of performance are defined as specified in the UPM at the fourth level and for further clarity on these dimensions, their definition along with relevant questions and examples in an organization such as a hospital is provided. The UPM provides conceptual clarity lacking in previous frameworks by integrating and contextualizing performance dimensions specifically for healthcare organizations.

The focus on performance dimensions in this research is consistent with other studies. For example, Morin et al. (1984) present four dimensions; economic, social, political, and systemicfor performance. In later work by Villarmois (1998), these four dimensions have been reduced to two dimensions, objective and subjective [11]. Following this, Bessire (1999) presented a model of constructivism (Subject-Object-Project; a triadic perspective) to study performance by means of evaluation. According to Sink & Tuttle (1989), a complicated interrelationship exists between various perspectives of performance criteria and an organization’s performance. They present seven interrelated performance criteria, i.e., productivity, efficiency, effectiveness, profitability (or budget ability), quality, quality of work life and innovation [48]. Bessire (1999) and Otley (2001) present the three ‘E’s’ of performance in the field of management accounting and management control, i.e., effectiveness, efficiency, and economy [11]. Sink & Tuttle (1989) identified seven general performance criteria [48], whereas the UPM expands this umbrella to include 11 additional, healthcare-specific dimensions.

Most of these additional dimensions are specific to health care organizations. The OECD [79] has presented a model for measuring performance in health organizations. This model lists the following performance indicators: Health outcome indicators, Responsiveness indicators, Equity indicators, and Efficiency indicators. Although this framework can be highly effective for comparing health systems worldwide, it cannot serve as a substitute for the UPM model. In the UPM model, the focus is on defining organizational performance in health care, rather than on health systems. The World Health Organization framework for measuring performance [80] divides health system performance into three general categories: Functions and sub-functions (including governance, resource generation, service delivery, and financing), Intermediate objectives (including effectiveness, safety, user experience, access, and quality), and Final goals (including people-centeredness, health improvement, and financial protection). This framework also emphasizes measuring health system performance at the international level and across countries, but does not assess the performance of organizations that providesink health services, such as hospitals.

Although these frameworks have significantly advanced the understanding of performance, their application to healthcare organizations reveals important limitations. First, many classical models were developed for industrial or generic organizational settings and lack contextual sensitivity to the institutional complexity of healthcare, where clinical autonomy, ethical obligations, and regulatory constraints shape organizational functioning. Second, several influential frameworks—such as those proposed by OECD and WHO—primarily operate at the macro or health system level and are not designed to conceptualize performance within healthcare delivery organizations such as hospitals. Third, in a number of existing models, key constructs such as efficiency, effectiveness, quality, and productivity are either aggregated or insufficiently differentiated, which may generate conceptual ambiguity in healthcare contexts where these dimensions interact dynamically. These limitations highlight the need for a context-specific and conceptually integrated framework at the organizational level.

Additionally, according to Profiroiu (2001), public sector performance entails an interplay between objectives, means, and results. Hence, performance is the result of the simultaneous pursuit of efficiency, effectiveness, and a corresponding budget [37]. According to Van Ree (2002), in the modified form an organization’s performance criteria consist of productivity, efficiency, effectiveness, creativity, flexibility, and sustainability [81].

Tangen (2005) describes an umbrella term that contains the triple P model to define performance. He defines performance as the umbrella term for excellence, which includes cost factors, including profitability, productivity, and other non-cost factors such as quality, delivery, speed, and flexibility. In his model, productivity is defined by the relationshipbetween input and output. Profitability is fiscal association in which there is an effect of price factors (i.e., the difference between costs and incomes). The terms effectiveness and efficiency require collaboration across the other three terms. Effectiveness is defined as the extent to which the targeted results are accomplished, while efficiency is defined as how the resources involved in the transformation process are utilized [17]. However, this model does not explicitly consider healthcare organizations, highlighting the need for context-specific frameworks like the UPM. Beyond expanding the number of performance dimensions, the UPM’s primary conceptual contribution lies in integration at the organizational level, clarification of overlapping constructs, and hierarchical structuring of performance dimensions.

Also, Bartoli and Blatrix argue that by knowing evaluation, efficiency, effectiveness, quality and, piloting, the definition of performance could be realized [12]. Additionally, in 2016, Ghalem et al. suggest that performance is a combination of two terms, effectiveness and efficiency; however, depending on the context in which the performance might be used, other elements can be added to define the term, such as efficacy relevance, and economy [11].

Beyond expanding the number of performance dimensions, the primary conceptual contribution of the UPM lies in three areas. First, it integrates performance constructs specifically at the organizational level within healthcare, addressing a gap between generic management models and macro-level health system frameworks such as those of the OECD and WHO. Second, it clarifies and differentiates performance dimensions that are often treated as overlapping in prior models, thereby reducing conceptual ambiguity and strengthening the theoretical foundation for future operationalization. Third, the UPM introduces a hierarchical and relational structure, conceptualizing performance as an interdependent and layered construct rather than a flat aggregation of indicators. This structured integration distinguishes the UPM from previous frameworks and supports a more systematic understanding of organizational performance in healthcare settings.

While some general organizational performance models, such as those focusing on task and contextual performance, conceptually overlap with aspects of the UPM, our model explicitly addresses healthcare-specific and multidimensional performance. By integrating 21 core and additional healthcare-relevant dimensions, clarifying their interrelationships, and providing operational guidance, the UPM captures aspects of organizational performance that general models do not explicitly consider.

In summary, the UPM treats performance as an umbrella concept, encompassing productivity, efficiency, effectiveness, and eighteen additional dimensions, providing a comprehensive framework for evaluating organizational performance in healthcare.

Conclusion

This study aimed to clarify the concept of performance by reviewing its definitions and related constructs across the literature. We highlighted the lack of consensus and the overlapping use of terms such as productivity, efficiency, and effectiveness. Through this review, we introduced the Umbrella Performance Model (UPM) a four-level conceptual-descriptive framework that integrates these core elements with 18 additional healthcare-specific dimensions, offering a more holistic understanding of organisational performance. “The UPM focuses on organizational rather than individual performance, providing a structured tool for researchers, managers, and policymakers to evaluate and improve performance in healthcare settings. The UPM focuses on organizational rather than individual performance and provides a structured tool for researchers, managers, and policymakers to evaluate and improve performance in healthcare settings. Importantly, the model contributes not merely by expanding the number of dimensions, but by conceptually integrating and hierarchically structuring them within a healthcare-specific organizational context.

The UPM demonstrates that performance is not a standalone concept, but one that requires consideration of multiple, context-dependent factors particularly in complex environments such as hospitals. By applying this model, stakeholders can more effectively assess and enhance performance across at the organizational level Ultimately, the model aims to foster a shared language for performance and support more comprehensive evaluations that extend beyond traditional efficiency-based metrics.

Abbreviations

UPM

Umbrella Performance Model

APO

Asia Productivity Organization

ICU

Intensive Care Unit

QWL

Quality of Work Life

Author contributions

Study conceptualization and design: S. H. and R. R. Acquisition of data: S. H. and R. R. Modeling and interpretation of data: S. H. and R. R. N. S. M. J. Drafting of the manuscript: S. H. and M. A. J and M. R. Critical revision of the manuscript for important intellectual content: All athors.

Funding

The present article is part of the result of a doctoral thesis approved by Isfahan University of Medical Sciences with code 55657 (IR.MUI.NUREMA.REC.1401.005), without financial source.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.