Parametric and non-parametric frontier applications are typical for measuring the efficiency and productivity of many healthcare units. Due to the current COVID-19 pandemic, hospital efficiency is the center of academic discussions and the most desired target for many public authorities under limited resources. Investigating the state of the art of such applications and methodologies in the healthcare sector, besides uncovering strategical managerial prospects, can expand the scientific knowledge on the fundamental differences among efficiency models, variables and applications, drag research attention to the most attractive and recurrent concepts, and broaden a discussion on the specific theoretical and empirical gaps still to be addressed in future research agendas. This work offers a systematic bibliometric review to explore this complex panorama. Hospital efficiency applications from 1996 to 2022 were investigated from the Web of Science base. We selected 65 from the 203 most prominent works based on the Core Publication methodology. We provide core and general classifications according to the clinical outcome, bibliographic coupling of concepts and keywords highlighting the most relevant perspectives and literature gaps, and a comprehensive discussion of the most attractive literature and insights for building a research agenda in the field.

Background: The objective of this study was to assess public hospital efficiency, including quality outputs, inefficiency determinants, and changes to efficiency over time, in an Italian region. To achieve this aim, the study used secondary data from the Veneto region for the years 2018 and 2019. Methods: A nonparametric approach—that is, multistage data envelopment analysis (DEA)—was applied to a sample of 43 hospitals. We identified three categories of input: capital investments (Beds), labor (FTE), operating expenses. We selected five efficiency outputs (outpatient visits, inpatients, outpatient visit revenue, inpatient revenue, bed occupancy rate) and two quality outputs (mortality rate and inappropriate admission rate). Efficiency scores were estimated and decomposed into two components. Slack analysis was then conducted. Further, DEA efficiency scores were regressed on internal and external variables using a Tobit model. Finally, the Malmquist Productivity Index was applied. Results: On average, the hospitals in the Veneto region operated at more than 95% efficiency. Technical and scale inefficiencies often occurred jointly, with 77% of inefficient hospitals needing a downsizing strategy to gain efficiency. The inputs identified as needing significant reductions were full-time employee (FTE) administrative staff and technicians. The size of the hospital in relation to the size of the population served and the length of patient stay were important factors for the efficiency score. The major cause of decreased efficiency over time was technical change (0.908) rather than efficiency change (0.974). Conclusions: The study reveals improvements that should be made from both the policy and managerial perspectives. Hospital size is an important feature of inefficiency. On average, the results show that it is advisable for hospitals to reorganize nonmedical staff to enhance efficiency. Further, increasing technology investment could enable higher efficiency levels.

The need for nonprofits to foster legitimacy within their communities has led to growing calls for mechanisms of sound governance based on the engagement of stakeholders in organizational activities. Previous studies have investigated the mix of governance mechanisms used by nonprofits to manage legitimacy, without paying attention to the different challenges of legitimacy these organizations face. Aiming to fill this gap, this article employs a multiple case study methodology to explore how mechanisms for engaging stakeholders in governance can be shaped by the need to gain, maintain, or repair legitimacy. The findings show that formal mechanisms based on the direct designation of board members by local stakeholders play a pivotal role in repairing legitimacy. Gaining legitimacy requires actual participation of stakeholders, while maintaining legitimacy calls for formal mechanisms that balance representativeness and competencies of the leadership.

Efficiency improvement is one of three patterns a public utility should follow in order to get funds for investments realization. The other two are recourse to bank loans or to private equity and tariff increase. Efficiency can be improved, for example, by growth and vertical integration and may be conditioned by environmental variables, such as customer and output density. Prior studies into the effects of these variables on the efficiency of water utilities do not agree on certain points (e.g., scale and economies of scope) and rarely consider others (e.g., density economies). This article aims to contribute to the literature by analysing the efficiency of water utilities in Denmark, observing the effects of operational and environmental variables. The method is based on two-stage Data Envelopment Analysis (DEA) applied to 101 water utilities. We found that the efficiency of the water sector was not affected by the observed variables, whereas that of wastewater was improved by smaller firm size, vertical integration strategy, and higher population density.

Efficient water management is a priority in the European Union, since the operational efficiency of many water utilities is very low compared to best practice. Several countries are restructuring the water industry to save costs. Larger-scale operations and vertical integration are promoted to achieve scale and scope economies; however, the literature is not unanimous that such economies exist. There is also little evidence of the effect of customer density on costs. This article offers some insights into this matter, analysing the Danish water industry by a two-stage Data Envelopment Analysis approach to investigate the effects of size, scope and density in the wastewater industry. The results show that the Danish wastewater industry is positively affected by vertical integration and higher population density: firms that serve more than 100 person per km of sewer and combine water and wastewater services achieve better efficiency. Size does not have any significant influence on global efficiency, although technical pure efficiency decreases statistically with firm size.