Determinants of Health Service Efficiency in Hospital: A Systematic Review

One of the benchmarks for assessing service performance in hospitals is efficiency in medical services. Measurement of service efficiency will affect the quality of the hospital. Patients will consider the completeness of the service facilities they have and the quality of services to be obtained. This is due to the tendency of people to seek quality health services. Improving service quality standards in hospitals will have an impact on increasing income and getting recognition from the community for the quality of services in hospitals. This study aims to look at the determinant factors that affect hospital efficiency. This study uses a systematic review method based on the PRISMA protocol. Article searches were conducted through four online databases (PubMed, ProQuest, SAGE and SpingerLink). The initial search found 307 articles, filtered using inclusion criteria, so as many as 8 articles were analyzed with a time span of 2017-2021. The efficiency of health services in hospitals is the basis for obtaining a wider patient base and producing quality services. The results of the literature study show that there are 29 factors affecting hospital efficiency. The various factors obtained were categorized into organizational factors, health resource factors, and technical efficiency factors.


Introduction
The hospital as one of the complex health care facilities, because it involves various functions of service, education, and research, and covers various levels and types of disciplines so that hospitals are able to carry out professional functions both in the medical technical field and health administration to maintain and improve the quality of the home Hospitals must have a measure that ensures quality improvement at all levels [1]. A hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services [2]. One of the benchmarks for service in hospitals is efficiency in medical services. The implementation of hospital efficiency is not only related to aspects of medical administration, but also aspects of administrative management. The hospital efficiency assessment basically assesses the efficiency of medical services related to the utilization of available beds in the hospital and the efficiency of the utilization of hospital medical support. One of the hospital efficiency assessments can use the Barber Johnson chart. The Barber Johnson chart as an indicator of hospital management is a knowledge that has not been widely informed and seems to be needed by hospital managers in planning and policy making, in addition the Barber Johnson chart is one of the prerequisites for assessment by the Hospital Accreditation Team [3]. Quality health services are health services that can meet the needs felt by patients and are carried out in a good, timely, responsive and able to cure their complaints and prevent the development or spread of disease [4]. In addition, in choosing a hospital, patients will consider the completeness of the service facilities they have and the quality of service to be obtained. This is due to the tendency of people to seek quality medical services. Based on previous research conducted by Respati, related to the use of the Barber Johnson concept in developed countries it is used in hospital management to assess the efficiency of care management. This concept requires an orderly recording and reporting system as well as an attitude to assess his recovery. Based on the ideal standard of the four Barber-Johnson indicator parameters internationally, namely Bed Occupancy Rate (BOR) 75-85%, Length of Stay (LOS) 3-12 Days, Turn Over Interval (TOI) 1-3 days, and Bed Turn Over (BTO) 30 times a year. Meanwhile, according to the Ministry of Health in 2005, the efficiency of the use of beds if the BOR rate ranges from 65-85%, LOS 6-9 days, TOI 1-3 days, and BTO 40-50 times in a year [5]. BOR and BTO are indicators used to assess the service coverage of inpatient units, while LOS and TOI are indicators used to assess the efficiency of medical record unit services [6].
Based on the explanation above, researchers are interested in conducting a systematic review, through this method researchers can see and compare hospital efficiency through previous studies from various countries. This study aims to look at the determinant factors that affect hospital efficiency.

Literature Review
Hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services. Hospitals have the task of providing complete individual health services, which are related to health services which include promotive, preventive, curative and rehabilitative. One of the principles of service in hospitals is efficient service [7] Efficiency is one of the performance indicators that theoretically underlies all hospital performance. Efficiency can be used to allocate resources more precisely on target so that the resources that come from shareholders can be utilized optimally. Assessment of service efficiency is an assessment of managerial ability in the context of processing human resources, sources of funds, equipment, and technology, in order to provide health services to patients. Efficiency is related to 3 things, namely indicators and criteria, achievement of the assessment, and determining the level of efficiency [8]. Availability of hospital beds and efficiency in the management of health resources play an important role in determining the maneuvering room for health facilities in the event of an emergency [9]. Various studies identify factors to look at efficiency, such as hospital size, own-ership, bed occupancy rate, outpatient to inpatient ratio, average income of the population, technology, financing, and hospi-tal teaching status as determinants of hospital efficiency [10].

Methods
The method used in this study is a systematic review, in which several search strategies are used to identify relevant studies, carried out systematically consisting of identification, selection, assessment, and synthesis of the research results [11] [12]. The systematic review was based on PRISMA from the 2009 flow chart, and was selected according to the inclusion criteria of the study [13]. A systematic search was conducted to identify article eligible articles in electronic databases, including: PubMed, SAGE, SpingerLink, and ProQuest [14] [15].

Inclusion Criteria
The inclusion criteria consist of: restriction criteria related to the type of English, documents deemed appropriate are as follows: journals, articles, original studies, conference papers, full and free downloadable documents, published from (2017-2021), health disciplines, medicine & public health, health administration, and health informatics.

Document Selection Based on Keywords
The

Result and Discussion
Researchers identified 8 articles that met the inclusion criteria. Some of these studies were carried out in several countries, namely Iran, America, Palestinian, Tureky, Indonesia, Southeast Nigeria, and Uganda. The research design used in each of these articles is 2 articles using Data Envelopment Analysis (DEA) models, a longitudinal cross sectional study, cross-sectional study, descriptive, gray relational method (parametric statistical analysis methods), and descriptive method with a qualitative approach, and Tobit Regression Model. Table  1 is a table that describes the characteristics of the 8 articles analyzed, which are as follows: The hospital's bed utilization performance has a positive impact on the hospital's financial success. A significant portion of the cost of oper-tional analysis [19] ating in hospitals is due to unnecessary patient hospitalization. To reduce hospital costs, patient beds need to be used optimally. Hence, hospital managers should regularly audit bed utilization. 5 The Hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services. Hospitals are obliged to provide safe, quality, anti-discriminatory, and effective health services by prioritizing the interests of patients in accordance with hospital service standards [7] [22] [23] [24]. To assess the quality of hospital services, the National Health Services (NHS) introduces 6 (six) requirements in assessing the performance of hospital services, one of which is efficiency [25]. The efficiency of hospital management can be broadly seen from two aspects, namely the medical aspect, reviewing efficiency from the point of view of the quality of medical services, and from the economic perspective, reviewing efficiency from the point of view of the utilization of existing facilities. Assessment of service efficiency is an assessment of managerial ability in order to process sources of funds, personnel, equipment, and technology in order to provide services to patients, so in this sense it includes the notion of managerial ability, processing sources of funds, personnel, equipment and technology, and for patient care [8] [26]. The availability of hospital beds and efficiency in the management of health resources play an important role in determining the space for maneuvering health facilities in the event of an emergency situation, this is in line with the results of the analysis of the articles conducted [9] [17]. The hospital's bed utilization performance has a positive impact on the hospital's fi-nancial success. A significant portion of the cost of operating in hospitals is due to unnecessary patient hospitalization [19] [27]. Based on the systematic review conducted, various factors that can affect the efficiency of health services in hospitals are obtained, namely: Organizational factors , such as hospital-physicians integration level, teaching status, and market competition with hospital inefficiency, and status technology level. Manage the health resources factors, such us medical professionals, equipment, hospital beds, general practitioners, policies, management, proportion of qualified staff, training status. And then, technical efficiency factor that are hospi-tal ownership, Outpatientinpatient ratio (OPIPR), The average length of stay (ALOS), The ratio of administrative to health employees (ADHR), Hospital size (dummy) (SIZE), Hospital location (dummy) (LOC), The proportion of refugees living in the governorate (REFP), Number of hospital beds per 10,000 inhabitants (HPFP), The available primary care centers per 10,000 inhabitants (PRC), The percentage of public hospital beds (PPHB), bed occupancy rate (BOR), average length of stay (ALS), bed turnover rate (BTR) and turnover intervals (TI), Average Length Of Stay (AvLOS), Turnover Interval (TOI), Beds Turn Over (BTO).

Conclusion
The efficiency of health services in hospitals is the basis for obtaining a wider patient base and resulting in the quality of these services. Various factors obtained from the results of a systematic review are categorized into organizational factors, health resource factors, and technical efficiency factors.