Table 2.

Source of inefficiency in Eastern Mediterranean hospitals and strategies for improvement

Source of inefficiency		Common sources of inefficient performance	Proposed actions
Hospital products and services	overuse or supply of equipment, investigations, and procedures	- Inappropriate payment systems (fee-for-service payment mechanisms) - Misuse or inappropriate use of technology in patient treatment and diagnosis like imaging and lab services due to lack of knowledge and skills of health professional and lack of adopted evidenced-based guidelines. - Overuse or oversupply of equipment - Lack of or defective hospital equipment - Poor standards for use of technologies	-Reform incentive and payment structures, developing appropriate tariff and payment systems (e.g. use capitation or diagnosis-related group mechanism for reimbursement) -Raising workforce awareness and training workforce and managers about new information systems and technologies -Raising workforce awareness of energy management through frequent training -Develop and implement clinical guidelines
Hospital workforce	inappropriate or costly workforce mix	- Lack of or failure to use specialized managers in hospital administration - Suboptimal use of workforce capabilities, including those of physicians, nurses, paramedics, and support workforce, resulting in excess workforce in some departments - Inadequate management of hospital resources like workforce	-Recruiting workforce based on hospital needs (both in terms of numbers and specialties required) -Preventing the recruitment and maintenance of specialist workforce who are not significantly relevant to hospital and patient needs. -Using work measurement and time management techniques for optimal use of the workforce with respect to the volume of hospital operations
	unmotivated workforce	- Lack of motivation due to high workload - Lack of workforce motivation in the public sector because of inadequate salaries	-Introducing performance-based payments -Use appropriate incentive, reward and appraisal systems
Hospital services delivery	inappropriate hospital admissions and length of stay	- Inappropriate ALS*, unnecessary admissions, low BORs* and unnecessary referrals to specialists due to inadequate knowledge and training of workforce about best practice.	-Developing and implementing policies to accelerate admission and discharge processes and increase the quality of services -Developing strategies to reduce ALS*, including full-time presence of physicians and modification of hospital funding policies -Establishing a two-way electronic referral system, to provide physicians with feedback -Effective marketing using appropriate customer information, and improving communication and customer loyalty
	inappropriate hospital size (low use of infrastructure)	- Inefficient hospital size, lack of scale efficiency and too many hospitals and inpatient beds in some areas, not enough in others - Suboptimal use of available capacities such as infrastructure and active beds, resulting in excess beds in some departments (lack of planning)	-Modifying hospital size: selecting an efficient size and preventing hospital overdevelopment. if inefficient (downsizing or merging hospitals) -Making optimal use of hospital beds based on community needs. -Use of cost analysis and DEA model and other efficiency measurement models for incorporate inputs and output estimation into hospital planning. -Improving workforce, equipment, and beds based on evidence -Designing a basic framework for optimal resource allocation by health policymakers -Diversifying the outputs required for compensating hospital inefficiency -Redistributing hospital resources among regions -Training to raise knowledge about efficient admission practice
	medical errors and suboptimal quality of care	- Poor care management skills of physicians and other workforces. - Inadequate managerial skills and lack of training for hospital managers. - Inadequate skills and training of the hospital workforce.	-Designing on-the-job training courses tailored to workforce roles. -Using experienced and well-educated managers with management or healthcare management degrees, performance evaluation of hospital managers and provide feedback -Introducing managers to management techniques and methods of economic analysis -Improve hygiene standards in hospitals; provide more continuity of care; undertake more clinical audits; monitor hospital performance
Hospital system leakages	waste, corruption and fraud	- Inappropriate suboptimal allocation of funds among hospitals and unclear resource allocation guidance. - Hospital reliance on public funds and budgets, and lack of competition with other organizations.	-Modifying hospital budget structures -Improve regulation/governance, including strong sanction mechanisms; assess transparency/vulnerability to corruption; undertake public spending tracking surveys; promote codes of conduct

*BOR bed occupancy rate, BTR bed turnover rate, ALS average length of stay