Key Characteristics of a Fragile Healthcare Supply Chain: Learning from a Pandemic.

The COVID-19 pandemic has highlighted the many challenges that provincial health systems have experienced while scaling health services to protect Canadians from viral transmission and support care for those who get infected. Supply chain capacity makes it possible for health systems to deliver care and implement public health initiatives safely. In this paper, we present emerging findings from a national research study that documents the key features of the fragility of the health supply chain evident across the seven Canadian provinces. Results suggest that the fragility of the health supply chain contributes to substantive challenges across health systems, thus limiting or precluding proactive and comprehensive responses to pandemic management. These findings inform strategies to strengthen supply chain capacity and performance in order to enable health systems to effectively respond to pandemic events.

Logistics of an advanced therapy medicinal product during COVID-19 pandemic in Italy: successful delivery of mesenchymal stromal cells in dry ice.

BACKGROUND: During the coronavirus disease-2019 (COVID-19) pandemic, Italian hospitals faced the most daunting challenges of their recent history, and only essential therapeutic interventions were feasible. From March to April 2020, the Laboratory of Advanced Cellular Therapies (Vicenza, Italy) received requests to treat a patient with severe COVID-19 and a patient with acute graft-versus-host disease with umbilical cord-derived mesenchymal stromal cells (UC-MSCs). Access to clinics was restricted due to the risk of contagion. Transport of UC-MSCs in liquid nitrogen was unmanageable, leaving shipment in dry ice as the only option. METHODS: We assessed effects of the transition from liquid nitrogen to dry ice on cell viability; apoptosis; phenotype; proliferation; immunomodulation; and clonogenesis; and validated dry ice-based transport of UC-MSCs to clinics. RESULTS: Our results showed no differences in cell functionality related to the two storage conditions, and demonstrated the preservation of immunomodulatory and clonogenic potentials in dry ice. UC-MSCs were successfully delivered to points-of-care, enabling favourable clinical outcomes. CONCLUSIONS: This experience underscores the flexibility of a public cell factory in its adaptation of the logistics of an advanced therapy medicinal product during a public health crisis. Alternative supply chains should be evaluated for other cell products to guarantee delivery during catastrophes.

Intermittent demand forecasting for medical consumables with short life cycle using a dynamic neural network during the COVID-19 epidemic.

Accurate demand forecasting is always critical to supply chain management. However, many uncertain factors in the market make this issue a huge challenge. Especially during the current COVID-19 outbreak, the shortage of certain types of medical consumables has become a global problem. The intermittent demand forecast of medical consumables with a short life cycle brings some new challenges, such as the demand occurring randomly in many time periods with zero demand. In this research, a seasonal adjustment method is introduced to deal with seasonal influences, and a dynamic neural network model with optimized model selection procedure and an appropriate model selection criterion are introduced as the main forecasting models. In addition, in order to reduce the impact of zero demand, it adds some input nodes to the neural network by preprocessing the original input data. Lastly, a modified error measurement method is proposed for performance evaluation. Experimental results show that the proposed forecasting framework is superior to other intermittent demand models.

Material deprivation and access to cancer care in a universal health care system.

BACKGROUND: The role of socioeconomic factors as determinants of oncology consultations for advanced cancers in public payer health care systems is unknown. This study examined the association between material deprivation and receipt of cancer care among patients with advanced gastrointestinal (GI) cancer. METHODS: This was a population-based, retrospective cohort study of noncuratively treated patients with GI cancer diagnosed from 2007 to 2017. Material deprivation, representing income, quality of housing, education, and family structure, was defined as quintiles on the basis of 2016 census data. The first consultation with a radiation oncologist or medical oncologist and the receipt of 1 or more instances of radiation and/or chemotherapy were measured in the year after diagnosis. Adjusted, cause-specific Cox proportional hazards competing risk analyses were used (competing event = death). RESULTS: This study included 34,022 noncuratively treated patients with GI cancer. Consultation rates ranged from 67.8% for those in the most materially deprived communities to 73.5% for those in the least materially deprived communities. Among those with a consult, rates of cancer-directed therapy ranged from 58.5% for patients in the most materially deprived communities to 62.3% for patients in the least materially deprived communities. Patients living in the most materially deprived communities were significantly less likely to see a radiation and/or medical oncologist after a diagnosis (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.92) and significantly less likely to receive radiation and/or chemotherapy (HR, 0.80; 95% CI, 0.76-0.85) than those living in the least materially deprived communities. CONCLUSIONS: This study identified socioeconomic disparities in accessing cancer care. Continued efforts at examining and developing evidence-based policies for interventions that begin before or at the time of oncologist consultation are required to address root causes of inequities.

[Construction of Quality Control System for Medical Equipment under the Model of County Medical Service Community].

The construction of county and district medical community is an important measure for high-quality medical resources to "double sink and improve". In this study, we have initially constructed a medical equipment quality control system for members of the regional medical community. The current situation of lack of professional medical equipment management personnel and quality control equipment in primary medical institutions has been alleviated, the quality control level of medical equipment in primary medical institutions has been improved, and a new management model for quality control of primary medical equipment has been explored.

Improving hospital pharmacy inventory management using data segmentation.

PURPOSE: This case study describes the development and empirical validation of an easy-to-implement practical framework for improving hospital pharmacy inventory management. SUMMARY: Research suggests various inventory optimization models, which can lead to cost reductions while maintaining adequate service levels; however, they are facing limited adoption in healthcare settings. The main barriers appear to be the high effort and complexity of implementation, the dependence on data that are not available or might not be in the right form, and the one-size-fits-all approach often followed without addressing healthcare sector-specific particularities. A research framework was developed by adapting relevant inventory models to the healthcare context using the concept of data segmentation on the basis of a three-dimensional classification of hospital pharmacy inventory items based on their relative importance, clinical criticality, and consumption pattern. Suitable replenishment policies were assigned to high-impact classes, and an integrated performance-measurement component assesses the framework's effectiveness. The suggested approach was implemented and empirically tested at the pharmacy of a large public hospital using longitudinal data. The results demonstrate substantial improvements with respect to all of the selected key performance indicators and translate into inventory cost savings due to reduced stockholding costs and better synchronization of inventories to demand. CONCLUSION: Use of standard software functionalities combined with targeted data segmentation efforts significantly improves hospital pharmacy inventory cost performance.

Construction of Quality Control System for Medical Equipment under the Model of County Medical Service Community / 中国医疗器械杂志

The construction of county and district medical community is an important measure for high-quality medical resources to "double sink and improve". In this study, we have initially constructed a medical equipment quality control system for members of the regional medical community. The current situation of lack of professional medical equipment management personnel and quality control equipment in primary medical institutions has been alleviated, the quality control level of medical equipment in primary medical institutions has been improved, and a new management model for quality control of primary medical equipment has been explored.

ABC, VED and lead time analysis in the surgical store of a public sector tertiary care hospital in Delhi.

BACKGROUND: An efficient inventory control system would help optimize the use of resources and eventually help improve patient care. OBJECTIVES: The study aimed to find out the surgical consumables using always, better, and control (ABC) and vital, essential, and desirable (VED) technique as well as calculating the lead time of specific category A and vital surgical consumables. METHODS: This was a descriptive, record-based study conducted from January to March 2016 in the surgical stores of the All India Institute of Medical Sciences, New Delhi. The study comprised all the surgical consumables which were procured during the financial year 2014-2015. Stores ledger containing details of the consumption of the items, supply orders, and procurement files of the items were studied for performing ABC analysis and calculating the lead time. A list of surgical consumables was distributed to the doctors, nursing staff, technical staff, and hospital stores personnel to categorize them into VED categories after explaining them the basis for the classification. RESULTS: ABC analysis revealed that 35 items (14%), 52 items (21%), and 171 items (69%) were categorized into A (70% annual consumption value [ACV]), B (20% ACV), and C (10% ACV) category, respectively. In the current study, vital items comprised the majority of the items, i.e., 73% of the total items and essential (E) category of items comprised 26% of all the items. The average internal, external, and total lead time was 17 days (range 3-30 days), 25 days (range 5-38) and 44 days (range 18-98 days), respectively. CONCLUSIONS: Hospitals stores need to implement inventory management techniques to reduce the number of stock-outs and internal lead time.

Analysis of Factors Influencing Hospitals' Implementation of a Green E-Procurement System Using a Cloud Model.

Currently, the green procurement activities of private hospitals in Taiwan follow the self-built green electronic-procurement (e-procurement) system. This requires professional personnel to take the time to regularly update the green specification and software and hardware of the e-procurement system, and the information system maintenance cost is high. In the case of a green e-procurement system crash, the efficiency of green procurement activities for hospitals is affected. If the green e-procurement can be moved to a convenient and trusty cloud computing model, this will enhance the efficiency of procurement activities and reduce the information maintenance cost for private hospitals. However, implementing a cloud model is an issue of technology innovation application and the technology-organization-environment (TOE) framework has been widely applied as the theoretical framework in technology innovation application. In addition, finding the weight of factors is a multi-criteria decision-making (MCDM) issue. Therefore, the present study first collected factors influencing implementation of the cloud mode together with the TOE as the theoretical framework, by reviewing the literature. Therefore, an expert questionnaire was designed and distributed to top managers of 20 private hospitals in southern Taiwan. The fuzzy analysis hierarchical process (FAHP), which is a MCDM tool, finds the weights of the factors influencing private hospitals in southern Taiwan when they implement a cloud green e-procurement system. The research results can enable private hospitals to successfully implement a green e-procurement system through a cloud model by optimizing resource allocation according to the weight of each factor. In addition, the results of this research can help cloud service providers of green e-procurement understand users' needs and develop relevant cloud solutions and marketing strategies.

Real-time location system-based asset tracking in the healthcare field: lessons learned from a feasibility study.

BACKGROUND: Numerous hospitals and organizations have recently endeavored to study the effects of real-time location systems. However, their experiences of system adoption or pilot testing via implementation were not shared with others or evaluated in a real environment. Therefore, we aimed to share our experiences and insight regarding a real-time location system, obtained via the implementation and operation of a real-time asset tracking system based on Bluetooth Low Energy/WiFi in a tertiary care hospital, which can be used to improve hospital efficiency and nursing workflow. METHODS: We developed tags that were attached to relevant assets paired with Bluetooth Low Energy sensor beacons, which served as the basis of the asset tracking system. Problems with the system were identified during implementation and operation, and the feasibility of introducing the system was evaluated via a satisfaction survey completed by end users after 3 months of use. RESULTS: The results showed that 117 nurses who had used the asset tracking system for 3 months were moderately satisfied (2.7 to 3.4 out of 5) with the system, rated it as helpful, and were willing to continue using it. In addition, we identified 4 factors (end users, target assets, tracking area, and type of sensor) that should be considered in the development of asset tracking systems, and 4 issues pertaining to usability (the active tag design, technical limitations, solution functions, and operational support). CONCLUSIONS: The successful introduction of asset tracking systems based on real-time location in hospitals requires the selection of clear targets (e.g., users and assets) via analysis of the user environment and implementation of appropriate technical improvements in the system as required (e.g., miniaturization of the tag size and improvement of the sensing accuracy).

Optimizing Endoscope Reprocessing Resources Via Process Flow Queuing Analysis.

The Massachusetts General Hospital (MGH) is merging its older endoscope processing facilities into a single new facility that will enable high-level disinfection of endoscopes for both the ORs and Endoscopy Suite, leveraging economies of scale for improved patient care and optimal use of resources. Finalized resource planning was necessary for the merging of facilities to optimize staffing and make final equipment selections to support the nearly 33,000 annual endoscopy cases. To accomplish this, we employed operations management methodologies, analyzing the physical process flow of scopes throughout the existing Endoscopy Suite and ORs and mapping the future state capacity of the new reprocessing facility. Further, our analysis required the incorporation of historical case and reprocessing volumes in a multi-server queuing model to identify any potential wait times as a result of the new reprocessing cycle. We also performed sensitivity analysis to understand the impact of future case volume growth. We found that our future-state reprocessing facility, given planned capital expenditures for automated endoscope reprocessors (AERs) and pre-processing sinks, could easily accommodate current scope volume well within the necessary pre-cleaning-to-sink reprocessing time limit recommended by manufacturers. Further, in its current planned state, our model suggested that the future endoscope reprocessing suite at MGH could support an increase in volume of at least 90% over the next several years. Our work suggests that with simple mathematical analysis of historic case data, significant changes to a complex perioperative environment can be made with ease while keeping patient safety as the top priority.

Case Study: Supply Chain Transformation in the Mercy Health System.

The Mercy case study documents evidence of a clinically integrated supply chain strategy implemented in the peri-operative programs in three of the 46 hospitals in the Mercy system. Mercy became the first US health system to achieve "the perfect order," a supply chain industry standard with end-to-end integration of supply chain best practice in the Mercy system. To date, the Mercy strategy has demonstrated revenue growth of $8 billion, a 70% reduction in Never Events, a 33.3% reduction in supplies cost/case and a 29.5% reduction in labour costs/case in the perioperative programs in three hospitals.

Análise das notificações em tecnovigilância em instituições hospitalares: diagnóstico de situação / Analysis of notifications in technovigilance in hospital institutions: situation diagnosis

Na área da saúde, principalmente a partir da década de 1970, verifica-se um desenvolvimento científico e tecnológico acelerado, com um aumento do consumo de diferentes tecnologias em todos os níveis de atendimento e consequente aumento dos custos. Muitas inquietações passaram a fazer parte do cotidiano das organizações de saúde diante dessa nova realidade, uma vez que o impasse de incorporar novas tecnologias à prática clínica conflita com a administração de recursos necessários. Em razão da grande diversidade tecnológica e de itens necessários para uma instituição de saúde de grande porte, evidências indicam a premência de mudanças importantes para um efetivo gerenciamento, com controles mais efetivos, exigindo dos gestores um desempenho pautado em eficiência e eficácia. Na atualidade, tem se constituído um desafio para as instituições implementar ações de monitoramento capazes de identificar precocemente possíveis problemas, pois, independentemente do tipo de produto médico-hospitalar utilizado, não há como garantir a ausência de riscos em sua utilização. Diante desta problemática, é de extrema relevância a implantação e o uso de sistemas de registros sistemáticos de avaliações de materiais, enquanto subsídio para uma gestão eficiente no que concerne à maximização de recursos econômicos. Nessa perspectiva, aliada ao interesse em oferecer ao paciente uma assistência isenta de danos e segura na atuação dos profissionais de enfermagem e da equipe multiprofissional é que se justifica a presente pesquisa, que teve como objetivo analisar as não conformidades relativas aos materiais médico-hospitalares notificados ao Gerenciamento de Risco das instituições hospitalares de Ribeirão Preto. Esse foi um estudo descritivo, retrospectivo, documental, com abordagem quantitativa, realizado na cidade de Ribeirão Preto nos serviços de saúde constantes do Cadastro Nacional de Estabelecimentos de Saúde (CNES) categorizados como hospitais públicos, privados ou filantrópicos, gerais ou especializados, nos anos de 2014, 2015 e 2016 e que tivessem serviço de gerenciamento de risco. Os dados foram obtidos do Serviço de Gerenciamento de Risco das instituições participantes. Foi construído um instrumento contendo as seguintes variáveis: produto (nome técnico); grupo de material (médico-hospitalar; higiene pessoal; esterilização); queixa técnica; categoria do problema (embalagem, estrutura e aspecto alterado); setor (unidade que registrou o problema). Foi utilizada estatística descritiva para análise dos dados, utilizando o software SPSS versão 24. Das oito Instituições de Saúde elegíveis para o estudo, cinco (62,5%) autorizaram a realização da pesquisa. A instituição 1 apresentou o maior número de notificações 950 (94%), representando quase a totalidade. Em relação ao ano, foram identificadas 357 (35%) em 2014, 283 (28%) em 2015 e 369 (37%) em 2016. Quanto ao grupo de materiais notificados, identificamos um predomínio dos materiais médico-hospitalares, em todos os anos da pesquisa, com um total de 991 (98,2%) notificações. Em relação ao tipo de material, houve variação dos principais itens durante os anos de estudo, porém, no total geral, identificamos que a seringa foi o principal tipo de material, com 172 (17,1%) notificações. O segundo material foram as luvas de procedimento, com um total de 79 (7,83%) eventos, seguidas dos equipos macrogotas, com 70 (6,94) notificações. Quanto à categorização das queixas que envolviam esses materiais em todos os anos, a principal queixa foi referente à rachadura ou quebra do produto ou de parte dele, com um total de 591 (58,6%) eventos. Os resultados desse estudo demonstraram a importância do monitoramento dos produtos utilizados na assistência à saúde na etapa de pós-comercialização, por meio das queixas técnicas. Identificamos um total de 1.009 notificações, sendo a maioria referente a produtos médico-hospitalares, como seringas e equipos, sendo a principal queixa referente a rachadura ou quebra do produto ou de parte dele. Ressalta-se que estes materiais têm contato direto com o paciente, o que pode ocasionar riscos à sua segurança

In the health area, especially since the 1970s, there has been an accelerated scientific and technological development, with an increase in the consumption of different technologies at all levels of care and consequent increase in costs. Many concerns started to be part of the daily life of health organizations in front of this new reality, since the impasse of incorporating new technologies into clinical practice conflicts with the administration of necessary resources. Due to the great technological diversity and the necessary items for a large health institution, evidences indicate the urgency of important changes for an effective management, with more effective controls, requiring from managers a perform based on efficiency and effectiveness. At present, it has become a challenge for institutions to implement monitoring actions capable of identifying possible problems early, since, regardless of the type of medical-hospital product used, there is no way to guarantee the absence of risks in their use. Faced with this problem, it is extremely important to implement and use systems of systematic records of material evaluations, as a subsidy for an efficient management in what concerns the maximization of economic resources. In this perspective, allied to the interest in offering the patient a harmless and safe assistance in the work of the nursing professionals and the multiprofessional team is that this research is justified, whose objective was to analyze the nonconformities related to the notified medical-hospital materials to Risk Management of the hospital institutions of Ribeirão Preto. This was a descriptive, retrospective, documental study, with a quantitative approach, carried out in the city of Ribeirão Preto in the health services included in the National Register of Health Establishments (CNES) categorized as public, private or philanthropic hospitals, general or specialized, in the years 2014, 2015 and 2016 and that had a risk management service. Data were obtained from the Risk Management Service of the participating institutions. An instrument was constructed containing the following variables: product (technical name); group of material (medical-hospital, personal hygiene, sterilization); technical complaint; category of the problem (packaging, structure and altered appearance); sector (the unit that registered the problem). Descriptive statistic was used for data analysis, using SPSS software version 24. Of the eight Health Institutions eligible for the study, five (62.5%) authorized the research. Institution 1 had the highest number of notifications 950 (94%), representing almost all of them. In relation to the year, 357 (35%) were identified in 2014, 283 (28%) in 2015 and 369 (37%) in 2016. Regarding the group of materials reported, we identified a predominance of medical and hospital materials in all years of the survey, with a total of 991 (98.2%) notifications. Regarding the type of material, there were variations of the main items during the study years, however, in the overall total, we identified that the syringe was the main type of material, with 172 (17.1%) notifications. The second material was the procedure gloves, with a total of 79 (7.83%) events, followed by macrogotes, with 70 (6.94) notifications. Regarding the categorization of complaints involving these materials in all years, the main complaint was about the cracking or breaking of the product or part of it, with a total of 591 (58.6%) events. The results of this study demonstrated the importance of the monitoring of products used in health care in the post-marketing stage, through technical complaints. We identified a total of 1,009 notifications, the majority of which refer to medical and hospital products, such as syringes and equipment, the main complaint being the cracking or breaking of the product or part of it. It is emphasized that these materials have direct contact with the patient, which can cause risks to their safety

Comparison through a prospective and randomized study of two replenishment methods at polyvalent hospitalization units with two-bin storage systems / Comparación mediante un estudio prospectivo y aleatorizado de dos métodos de reposición en unidades de enfermería en hospitalización polivalente de agudos con almacenamiento mediante doble cajetín.

OBJECTIVE: Two-bin storage systems increase nursing staff satisfaction and decrease inventories, but the implications that logistic staff would determine the needs of replenishment are unknown. This study aimed to evaluate whether entrust to logistics staff this responsibility at the polyvalent hospitalization units with two-bin storage is associated with higher risk of outstanding orders. METHODS: This was a prospective randomized experiment whit masking. Outstanding orders were considered variable response, those corresponding to assessments of the logistics staff were included in the control group and those corresponding to the nursing staff in the control group. Concordance between observers was analyzed using the Bland-Altman method; the difference between groups, with the U of Mann-Whitney and the cumulative incidence of outstanding orders and their relative risk was calculated. RESULTS: The mean amount requested by the logistic and nursing staff was 29.9 (SD:167.4) and 36 (SD:190) units respectively, the mean difference between observers was 6.11 (SD:128.95) units and no significant differences were found between groups (p = 0.430). The incidence of outstanding orders was 0.64% in the intervention group and 0.15% in the control group; the relative risk, 2.31 (0.83 - 6.48) and the number of cases required for an outstanding order, 516. CONCLUSIONS: Outstanding order relative risk is not associated with the category of the staff that identifies the replenishment needs at the polyvalent hospitalization units.

OBJETIVO: Los sistemas de almacenamiento mediante doble cajetín aumentan la satisfacción del personal de enfermería y disminuyen los inventarios, pero no se conocen las implicaciones de que sea el personal de logística quién determine la necesidad de reposición. El objetivo de este estudio fue evaluar si encomendar dicha responsabilidad a este personal en unidades de hospitalización polivalente de agudos entraña un mayor riesgo de pedidos extraordinarios. METODOS: Se realizó un estudio experimental, prospectivo aleatorizado con enmascaramiento. Los pedidos extraordinarios se consideraron variable de respuesta; los correspondientes a valoraciones del personal de logística se incluyeron en el grupo de intervención y los del personal de enfermería, en el de control. La concordancia entre observadores se analizó con el método de Bland-Altman; la diferencia entre grupos, con la U de Mann-Whitney y se calculó la incidencia acumulada de pedidos extraordinarios y su riesgo relativo. RESULTADOS: La cantidad media solicitada por el personal de logística y el de enfermería fue 29,9 (DE:167,4) y 36 (DE:190) unidades respectivamente, la diferencia media entre observadores fue 6,11 (DE:128,95) unidades y no se encontraron diferencias significativas entre los grupos (p =0,430). La incidencia de pedidos extraordinarios fue 0,64% en el grupo de intervención y 0,15% en el de control; el riesgo relativo, 2,31 (0,83 ­ 6,48) y el número de casos necesarios para un pedido extraordinario, 516. CONCLUSIONES: El riesgo de pedidos extraordinarios en unidades de hospitalización con almacenamiento mediante doble cajetín no está asociado con la categoría profesional del personal que identifica las necesidades de reposición.

Análisis de la eficiencia técnica en los hospitales del Sistema Nacional de Salud español / Analysis of the technical efficiency of hospitals in the Spanish National Health Service

Objetivo: Analizar la eficiencia técnica y la productividad de los hospitales generales del Sistema Nacional de Salud (SNS) español (2010-2012) e identificar variables hospitalarias y regionales explicativas. Métodos: Se estudian 230 hospitales del SNS mediante análisis envolvente de datos midiendo la eficiencia técnica global, pura, de escala, y el índice de Malmquist. La robustez del análisis se evalúa con modelos input-output alternativos. Se emplean modelos multinivel lineales transversales de efectos fijos para analizar las variables explicativas de eficiencia. Resultados: El índice medio de eficiencia técnica global (ETG) es de 0,736 en 2012, con una importante variabilidad por comunidades autónomas. El índice de Malmquist (2010-2012) es de 1,013. Un 23% de la variabilidad en ETG es atribuible a la comunidad autónoma. Las variables exógenas estadísticamente significativas (residentes por cada 100 facultativos, índice de envejecimiento, renta media anual por hogar, gasto en servicios públicos fundamentales y gasto público sanitario per cápita) explican el 42% de la variabilidad de ETG entre hospitales y el 64% entre comunidades autónomas. El número de residentes es estadísticamente significativo. En todas las comunidades autónomas existe una relación lineal directa significativa entre la ETG y la renta anual per cápita y el gasto en servicios públicos fundamentales, e indirecta con el índice de envejecimiento y el gasto público sanitario per cápita. Discusión El importante margen de mejora en eficiencia de los hospitales está condicionado por características específicas de cada comunidad autónoma, particularmente el envejecimiento, la riqueza y las políticas de gasto público de cada una (AU)

Objective: To analyse the technical efficiency and productivity of general hospitals in the Spanish National Health Service (NHS) (2010-2012) and identify explanatory hospital and regional variables. Methods: 230 NHS hospitals were analysed by data envelopment analysis for overall, technical and scale efficiency, and Malmquist index. The robustness of the analysis is contrasted with alternative input-output models. A fixed effects multilevel cross-sectional linear model was used to analyse the explanatory efficiency variables. Results: The average rate of overall technical efficiency (OTE) was 0.736 in 2012; there was considerable variability by region. Malmquist index (2010-2012) is 1.013. A 23% variability in OTE is attributable to the region in question. Statistically significant exogenous variables (residents per 100 physicians, aging index, average annual income per household, essential public service expenditure and public health expenditure per capita) explain 42% of the OTE variability between hospitals and 64% between regions. The number of residents showed a statistically significant relationship. As regards regions, there is a statistically significant direct linear association between OTE and annual income per capita and essential public service expenditure, and an indirect association with the aging index and annual public health expenditure per capita. Discussion: The significant room for improvement in the efficiency of hospitals is conditioned by region-specific characteristics, specifically aging, wealth and the public expenditure policies of each one (AU)