Hospital Performance Analysis: A Tool for Effective Management in Times of Crisis

Introduction

Health-system reform and the global financial and economic crisis placed Bulgarian hospitals under simultaneous pressure to improve managerial and operational effectiveness. In such an environment, intuitive management is insufficient; decision-makers need systems that convert operational data into evidence for action.

The paper treats diagnostic performance analysis as part of organisational controlling and performance management: a structured approach for measuring, evaluating and managing the factors that determine hospital outcomes.

Aim

To critically compare leading theoretical and healthcare-specific performance frameworks with empirical Bulgarian hospital practice and develop an applied diagnostic-analysis model with key performance indicators suitable for management under resource constraints and crisis conditions.

Material and methods

The study combines a comparative review of general and healthcare-specific performance frameworks — including Balanced Scorecard, Performance Measurement Matrix, EVITA, Performance Prism, SMART Pyramid, EFQM and WHO PATH — with empirical survey evidence.

The survey covered 109 Bulgarian hospitals, approximately 38% of hospitals nationwide, and 412 respondents. The questionnaire contained 25 open, closed and semi-closed questions, including items used to derive weighting coefficients.

Respondent profile

The sample included 31% senior/managerial staff, 48% administrative staff and 21% medical staff, capturing perspectives from those who generate, process and use management information.

How diagnostic analysis was used

In 88% of cases, diagnostic analysis was performed to establish the hospital's current state. The decision to conduct analysis was most often driven by requirements from higher-level authorities — 70%.

Internal analysis focused primarily on medical activity — 21% and financial activity — 17%, while 98% of respondents also included indicators describing the external environment.

Three categories of hospital assessment approaches

1. External assessment — regulatory inspections, user/community surveys, third-party assessment, accreditation and statistical indicators.
2. General diagnostic-performance frameworks — corporate approaches such as Balanced Scorecard, Performance Prism, EVITA, SMART, EFQM, TQM, Six Sigma and benchmarking.
3. Healthcare-specific models — WHO PATH, Canadian, Danish, French and related systems.

The reviewed literature described nearly 100 performance methodologies and models used in healthcare, illustrating why framework selection is difficult for Bulgarian hospitals.

Theory versus practice: 11 indicator groups

Theoretical frameworks and Bulgarian practice were compared across 11 indicator groups. Frequency of use and weighting coefficients were then used to rank the groups and construct the proposed applied model.

Proposed model: internal environment

The model covers 11 internal dimensions:

• medical/clinical perspective;
• financial perspective;
• leadership, policy and strategy;
• employees and employee results;
• partners and suppliers;
• internal processes;
• key performance results;
• societal benefits/results;
• hospital information system;
• customers/patients and customer results;
• learning, innovation and adaptation.

Proposed model: external environment

External analysis includes customers, competitors/intermediaries, economic factors, the health system, demographic factors, population health, the medical labour market, social factors and information factors. This extends performance analysis beyond internal outcomes and connects hospital strategy to national, regional and local conditions.

Main contributions

• links diagnostic analysis with evidence-based management and controlling;
• compares international frameworks with practice in 109 Bulgarian hospitals;
• structures the comparison across 11 indicator groups;
• proposes an integrated internal/external environment model;
• shows that clinical and financial perspectives dominate practice but are insufficient for comprehensive management diagnosis;
• provides an empirical and conceptual basis for subsequent multidimensional hospital-analysis models.

Conclusions

Diagnostic performance analysis should be an integral component of hospital planning, control and strategic management. Its value lies not in accumulating metrics but in selecting measures that reflect strategy, convert data into management information and reveal deviations and opportunities for improvement.

Under crisis conditions, integrated analysis of the internal and external environment supports more defensible allocation of scarce resources and stronger alignment between hospital results and organisational objectives.

Scientific Key Terms