hospitals are complex organizations which face a unique challenge in this ever changing economic environment : they need to increase the quality of care offered to their patients , while still reducing the specific associated costs . in this respect , many countries have set multiple forms of future funding policies to pay for healthcare , whereby hospitals receive a certain amount for treating patients according to their number and type , and are unable to impact this price .
this system creates clear financial incentives to contain expenses , as hospitals that stay within the threshold will make a profit , while those delivering high - priced care will make a loss . for example , a drg ( diagnosis - related group ) system used to distinguish between patients with a certain diagnosis does not account for cost variability across disease progression .
thus , the main cause for cost variability even between hospital departments is attributed to the case mix index .
specialist or teaching hospitals ( secondary hospitals , respectively tertiary hospitals ) might make an argument that they treat relatively more severe patients due to their reputation for providing high quality care .
multi - hospital health systems have become the most popular administrative structure in the hospital industry , leading to both opportunities and challenges for hospital administrators . in government funded healthcare systems , a balance between costs and health services exists .
thus , pooling demand for specialized services can help contain healthcare expenses , but it can burden the patients as there will be increased travel distance .
one might be restraining operations to become more efficient , or to distinguish them from the competition , by offering enhanced products and services .
other possible reasons include increasing spending on public relations , or reinforcing their bargaining power with health plans .
specialized care units have the potential to increase the patient volume , reduce expenses , and increase quality .
thus , aggregative common tasks can help at reducing healthcare associated costs , while still improving patient outcomes .
research showed that quality increases when a high patient - volume for a specialized procedure allows medical personnel to develop their accumulative experience in managing the service and avoid a loss of learning between occasional procedures . in terms of multi - system hospitals , containing expenses for medical capacity
can be transmitted to the patients in forms of smaller hospital costs , or used by the network to offer additional services .
while some have found that multi - hospital systems have higher costs per case than freestanding hospitals , others have found the contrary .
for example , one accounting office might be in charge of all units with little appreciable increase in costs . moreover , hospital systems can scope economies on the production side by reducing identical equipment and efficiently managing employment and supply inventories .
research also shows that hospital systems help increase quality of care through better coordination and better tailoring of local needs .
they can also have an advantage with bargaining health plans , which can lead to higher prices and lower patient volumes .
multi - system hospitals are characterized by the consolidation of information processing and procuring functions , but also by increased access to capital , management expertise , and increased physician recruiting .
moreover , they also have improved market power and better capacity to participate in managed care contracting .
, merged with performance feedback are associated with enhanced acceptance of certain nonsurgical treatments . apart from these , hospital affiliations can impact on the treatment of patients through two channels .
firstly , multi - system hospitals may offer a wider array of health services , through service proliferation , by providing management expertise and funds to build new facilities and recruit medical personnel .
system affiliation also affects patient treatment patterns , as patients may need to be transferred from one hospital to another in order to receive a certain service .
secondly , multi - system hospitals have improved coordination and information transfer among facilities , which also impacts on patient treatment . therefore , system hospitals face lower transaction expenses in developing and implementing procedures and protocols .
having protocols in place means that hospitals may have quicker transfer times between facilities . to conclude
unfortunately , most of these data are business - oriented reports , ignoring one of the most vulnerable issues in such circumstances  healthcare - associated infections , with their tremendous burden ( medical , epidemiological , economical etc . ) .
thus , very few details were identified regarding expenses and expenditure control of multi - hospital systems .
the aim of the present study is to assess the efficiency in terms of costs of a multi - pavilion hospital from cluj county , romania .
hospitals are complex organizations which face a unique challenge in this ever changing economic environment : they need to increase the quality of care offered to their patients , while still reducing the specific associated costs . in this respect , many countries have set multiple forms of future funding policies to pay for healthcare , whereby hospitals receive a certain amount for treating patients according to their number and type , and are unable to impact this price .
this system creates clear financial incentives to contain expenses , as hospitals that stay within the threshold will make a profit , while those delivering high - priced care will make a loss . for example , a drg ( diagnosis - related group ) system used to distinguish between patients with a certain diagnosis does not account for cost variability across disease progression .
thus , the main cause for cost variability even between hospital departments is attributed to the case mix index .
specialist or teaching hospitals ( secondary hospitals , respectively tertiary hospitals ) might make an argument that they treat relatively more severe patients due to their reputation for providing high quality care .
multi - hospital health systems have become the most popular administrative structure in the hospital industry , leading to both opportunities and challenges for hospital administrators . in government funded healthcare systems , a balance between costs and health services exists .
thus , pooling demand for specialized services can help contain healthcare expenses , but it can burden the patients as there will be increased travel distance .
one might be restraining operations to become more efficient , or to distinguish them from the competition , by offering enhanced products and services .
other possible reasons include increasing spending on public relations , or reinforcing their bargaining power with health plans .
specialized care units have the potential to increase the patient volume , reduce expenses , and increase quality .
thus , aggregative common tasks can help at reducing healthcare associated costs , while still improving patient outcomes .
research showed that quality increases when a high patient - volume for a specialized procedure allows medical personnel to develop their accumulative experience in managing the service and avoid a loss of learning between occasional procedures . in terms of multi - system hospitals , containing expenses for medical capacity
can be transmitted to the patients in forms of smaller hospital costs , or used by the network to offer additional services .
while some have found that multi - hospital systems have higher costs per case than freestanding hospitals , others have found the contrary .
for example , one accounting office might be in charge of all units with little appreciable increase in costs . moreover , hospital systems can scope economies on the production side by reducing identical equipment and efficiently managing employment and supply inventories .
research also shows that hospital systems help increase quality of care through better coordination and better tailoring of local needs .
they can also have an advantage with bargaining health plans , which can lead to higher prices and lower patient volumes .
multi - system hospitals are characterized by the consolidation of information processing and procuring functions , but also by increased access to capital , management expertise , and increased physician recruiting .
moreover , they also have improved market power and better capacity to participate in managed care contracting .
, merged with performance feedback are associated with enhanced acceptance of certain nonsurgical treatments . apart from these , hospital affiliations can impact on the treatment of patients through two channels .
firstly , multi - system hospitals may offer a wider array of health services , through service proliferation , by providing management expertise and funds to build new facilities and recruit medical personnel .
system affiliation also affects patient treatment patterns , as patients may need to be transferred from one hospital to another in order to receive a certain service .
secondly , multi - system hospitals have improved coordination and information transfer among facilities , which also impacts on patient treatment . therefore , system hospitals face lower transaction expenses in developing and implementing procedures and protocols .
having protocols in place means that hospitals may have quicker transfer times between facilities . to conclude
unfortunately , most of these data are business - oriented reports , ignoring one of the most vulnerable issues in such circumstances  healthcare - associated infections , with their tremendous burden ( medical , epidemiological , economical etc . ) .
thus , very few details were identified regarding expenses and expenditure control of multi - hospital systems .
the aim of the present study is to assess the efficiency in terms of costs of a multi - pavilion hospital from cluj county , romania .
the institution analyzed in this article is the adults clinical hospital in cluj - napoca ( which , in the meantime , has been re - organized and is currently named professor octavian fodor institute of gastroenterology and hepatology cluj - napoca ) .
the hospital was comprised , in the studied period of 20042010 , of four pavilions , offering medical services pertaining to psychiatry , obstetrics - gynecology , orthopaedics - traumatology , and internal medicine , general surgery and gastroenterology .
the addressability of the hospital is high , over 30,000 patients from nearby counties benefitting annually from medical services .
the flowchart of the medical structure of the investigated multi - pavilion hospital during 2004  2010 is depicted in figure 1 .
it should be noted , however , that , starting with 2011 , the adults clinical hospital cluj - napoca is only comprised of the general surgery and internal medicine compartments ( m3-c3 ) .
a descriptive retrospective study was conducted from january 2004 to december 2010 to reach the aim of this study .
a set of indicators were compiled , divided into three main categories : personnel , statistics , and financial .
data related to these indicators was collected at a hospital level , from all four compartments pertaining to the adults clinical hospital cluj - napoca .
the main indicators assessed in this study are presented in table i. descriptive statistics were performed on the variables , such as frequencies , means and standard deviations , medians ( q1q3 ) .
inferential statistics were performed the check for significant differences between the means of the four hospitals , such as an anova test .
the institution analyzed in this article is the adults clinical hospital in cluj - napoca ( which , in the meantime , has been re - organized and is currently named professor octavian fodor institute of gastroenterology and hepatology cluj - napoca ) .
the hospital was comprised , in the studied period of 20042010 , of four pavilions , offering medical services pertaining to psychiatry , obstetrics - gynecology , orthopaedics - traumatology , and internal medicine , general surgery and gastroenterology .
the addressability of the hospital is high , over 30,000 patients from nearby counties benefitting annually from medical services .
the flowchart of the medical structure of the investigated multi - pavilion hospital during 2004  2010 is depicted in figure 1 .
it should be noted , however , that , starting with 2011 , the adults clinical hospital cluj - napoca is only comprised of the general surgery and internal medicine compartments ( m3-c3 ) .
a descriptive retrospective study was conducted from january 2004 to december 2010 to reach the aim of this study .
a set of indicators were compiled , divided into three main categories : personnel , statistics , and financial .
data related to these indicators was collected at a hospital level , from all four compartments pertaining to the adults clinical hospital cluj - napoca .
descriptive statistics were performed on the variables , such as frequencies , means and standard deviations , medians ( q1q3 ) .
inferential statistics were performed the check for significant differences between the means of the four hospitals , such as an anova test .
variability in the personnel indicators was observed for several indicators , such as number of filled md positions ( figure 2 ) , number of beds per filled md positions ( figure 3 ) , and number of beds per filled nurses positions ( figure 4 ) .
thus , even though the ergo pavilion has the lowest number of filled md positions overall for the investigated period , in 2010 its values for the number of beds per filled md positions were higher than for the m3-c3 pavilion .
the values were consistent for the m3-c3 pavilion . however , the lowest number of beds per filled nurses positions pertained to the orto pavilion .
even though from 2009 to 2010 the number of physician positions has increased from 34 to 53 , the number of doctors per number of beds has decreased , for the same time frame , from 62.05 to 38.63 , due to an increase in the number of beds .
m3-c3 had the highest values for the number of discharges per medical doctor , compared to the other pavilions . moreover , while the other pavilions had steady values for this indicator for the investigated period , we can observe the 2004 values dropped to almost half in 2010 .
the case mix index differs for each pavilion , with the highest values identified for m3-c3 , compared to the lowest for ergo .
moreover , while ergo has had consistent values for the investigated period , the values for m3-c3 have almost doubled in 2010 , compared to 2004 .
an interesting pattern was observed in terms of mortality , as the numbers inconsistent for the ergo , orto and stanca pavilions . by comparison ,
however , the m3-c3 pavilion had higher mortality indicators , being 13.76 in 2010 when compared to the other pavilions , which had values between 0.08 and 1.05 in 2010 . while the m3-c3 , orto and stanca pavilions have had relatively consistent values for the average hospitalization indicator within the observed timeframe , a drastic increase was observed from 2006 to 2007 for the ergo pavilion , from 24.52 to 47.40 .
heterogeneity between different years was observed for the continuous hospitalization indicator ( figure 10 ) and the wage budget indicator ( figure 11 ) .
the highest variability was observed between the budget and expenses indicators ( figure 12 ) , while a smaller variability was observed at the average costs per patient ( figure 13 ) .
the continuous hospitalization budget for m3-c3 was almost triple for 2010 ( 29,244,529 ron ) compared to 2004 ( 11,726,246 ron ) .
similarly , the continuous hospitalization budget for stanca for 2010 was almost four times higher than the 2004 budget ( 2,906,982 ron compared 12,400,112 ron ) . while the same budget increase was observed for orto pavilion as for stanca until 2008 , this budget dropped until 2010 , being similar to the ergo budget ( 4,978,232 ron for orto and 4,459,000 ron for ergo ) .
the budget - expenses rapport for m3-c3 has shown increased variability in the observed timeframe , varying between positive and negative from one year to another .
the ergo budget - expenses rapport showed a dropping tendency , from 3,201,208 ron in 2004 to minus 723,420 ron in 2010 . the orto budget - expenses rapport has also shown a dramatic drop tendency , being minus 962,754 ron in 2004 , culminating with minus 4,640,203 ron in 2010 .
the stanca pavilion is the only one showing a positive rapport between budget and expenses , being minus 617,377 ron , increasing until 3,971,397 ron in 2010 .
the costs per patient have increased at all pavilions in the observed time frame , the higher costs being at m3-c3 ( 10203 ron in 2010 ) .
however , the most dramatic increase was for the ergo pavilion , from 2006 ( 2368 ron ) to 2007 ( 6838 ron ) .
variability in the personnel indicators was observed for several indicators , such as number of filled md positions ( figure 2 ) , number of beds per filled md positions ( figure 3 ) , and number of beds per filled nurses positions ( figure 4 ) .
thus , even though the ergo pavilion has the lowest number of filled md positions overall for the investigated period , in 2010 its values for the number of beds per filled md positions were higher than for the m3-c3 pavilion .
the values were consistent for the m3-c3 pavilion . however , the lowest number of beds per filled nurses positions pertained to the orto pavilion .
even though from 2009 to 2010 the number of physician positions has increased from 34 to 53 , the number of doctors per number of beds has decreased , for the same time frame , from 62.05 to 38.63 , due to an increase in the number of beds .
m3-c3 had the highest values for the number of discharges per medical doctor , compared to the other pavilions . moreover , while the other pavilions had steady values for this indicator for the investigated period , we can observe the 2004 values dropped to almost half in 2010 .
the case mix index differs for each pavilion , with the highest values identified for m3-c3 , compared to the lowest for ergo .
moreover , while ergo has had consistent values for the investigated period , the values for m3-c3 have almost doubled in 2010 , compared to 2004 .
an interesting pattern was observed in terms of mortality , as the numbers inconsistent for the ergo , orto and stanca pavilions . by comparison ,
however , the m3-c3 pavilion had higher mortality indicators , being 13.76 in 2010 when compared to the other pavilions , which had values between 0.08 and 1.05 in 2010 .
while the m3-c3 , orto and stanca pavilions have had relatively consistent values for the average hospitalization indicator within the observed timeframe , a drastic increase was observed from 2006 to 2007 for the ergo pavilion , from 24.52 to 47.40 .
heterogeneity between different years was observed for the continuous hospitalization indicator ( figure 10 ) and the wage budget indicator ( figure 11 ) .
the highest variability was observed between the budget and expenses indicators ( figure 12 ) , while a smaller variability was observed at the average costs per patient ( figure 13 ) .
the continuous hospitalization budget for m3-c3 was almost triple for 2010 ( 29,244,529 ron ) compared to 2004 ( 11,726,246 ron ) .
similarly , the continuous hospitalization budget for stanca for 2010 was almost four times higher than the 2004 budget ( 2,906,982 ron compared 12,400,112 ron ) . while the same budget increase was observed for orto pavilion as for stanca until 2008 , this budget dropped until 2010 , being similar to the ergo budget ( 4,978,232 ron for orto and 4,459,000 ron for ergo ) .
the budget - expenses rapport for m3-c3 has shown increased variability in the observed timeframe , varying between positive and negative from one year to another .
the ergo budget - expenses rapport showed a dropping tendency , from 3,201,208 ron in 2004 to minus 723,420 ron in 2010 .
the orto budget - expenses rapport has also shown a dramatic drop tendency , being minus 962,754 ron in 2004 , culminating with minus 4,640,203 ron in 2010 .
the stanca pavilion is the only one showing a positive rapport between budget and expenses , being minus 617,377 ron , increasing until 3,971,397 ron in 2010 .
the costs per patient have increased at all pavilions in the observed time frame , the higher costs being at m3-c3 ( 10203 ron in 2010 ) . however , the most dramatic increase was for the ergo pavilion , from 2006 ( 2368 ron ) to 2007 ( 6838 ron ) .
efficient cost containment has been an important issue ; hospitals and healthcare facilities in general have been trying to resolve , without impacting the quality of services offered to their patients .
the aim of this study was to assess the efficiency in terms of costs of a multi - pavilion hospital from cluj county , romania .
the adults clinical hospital cluj - napoca was comprised of four pavilions , each having a different addressability . after comparing the pavilions in terms of personnel , financial and statistical indicators , our study identified several differences across the pavilions .
regarding personnel indicators , it was identified that the m3-c3 pavilion had the highest values in terms of number of filled md positions , number of beds per filled md positions and number of beds per filled nurses positions .
we believe this difference can be attributed to the higher number of beds the pavilion has , being thus able to capacitate a higher number of patients .
namely , m3-c3 pavilion had 341 beds in 2010 , compared to 120 , 126 , and 133 beds for ergo , orto and stanca respectively .
moreover , this is also a sign of the hospital s prestige in treating illnesses pertaining to internal medicine .
the higher case mix index for the m3-c3 , compared to the other three pavilions , can be attributed to the profile of each pavilion .
while psychiatry , obstetrics - gynecology , orthopaedics - traumatology , and gastroenterology are more disease - specific , internal medicine and general surgery imply a wider range of diseases treated and of procedures performed . moreover , the hospital is renowned at a regional level for its performance in diagnosing and treating gastroenterological diseases .
the mortality indicator showed a higher mortality for the m3-c3 pavilion , compared to the other three .
we can speculate that this increased mortality rate can be associated with the higher case mix index , as a higher case mix index also implies more severe cases as well .
on the other hand , a study found that a lower patient outcome can be correlated with lower staffing levels , especially for nurses , compared to the patient volume .
it was interesting to observe that while the continuous hospitalization budget for ergo , orto and stanca had had a relatively slow or steady increase or even decrease during the observed period , the continuous hospitalization budget for m3-c3 had increased significantly from 2004 to 2010 .
again , we can attribute this increased hospitalization to the more severe cases treated at the m3-c3 , which required prolonged hospital stay post - procedures .
moreover , more complex cases also require more complex procedures pre- and post - surgery , having an impact on expenses as well .
thus , one hospitalization day at m3-c3 cost on average 1728 ron , compared to 593 ron for stanca , 520 for orto , and only 281 ron for ergo . to further sustain this idea ,
the data also showed increased costs per patient for m3-c3 pavilion ( 10,203 ron ) , compared to 6308 ron for ergo , 5841 ron for orto , and 2792 ron for stanca .
research shows that gastrointestinal diseases impose a great burden in the united states in terms of mortality and expenses ; 32.4 billion dollars being spent in 2009 on endoscopy examinations .
moreover , at a global level , world health organization data place digestive diseases as a third cause of death for middle - income countries .
the budget vs expenses indicator provided a good insight into the financial situation of each pavilion . according to the data gathered from 2004 until 2010 , an interesting phenomenon occurred .
out of all pavilions , stanca was the only one whose budget was greater than its expenses .
contrarily , the orto pavilion was the only one whose expenses increased relatively high compared to its available budget .
few studies approached the issue of cost efficiency in healthcare , especially in the context of a multi - system hospital . in romania
, the cost efficiency was approached from the perspective of resource allocation to hospitals based on diagnosis - related groups .
a study identified new models for researching costs based on the diagnosis - related group system in the romanian health sector .
another study approached the issue of efficiency in terms of analyzing hospital s utility costs .
cost comparisons between hospitals , or , in this case , hospital pavilions , results in the identification of the most efficient hospitals , and their classification .
a precise definition of each service delivered and the identification every cost unit for delivering the service have been highlighted as essential in making comparisons across hospitals .
the institute of medicine has identified six dimensions important for a identifying a performing hospital : safety , effectiveness , patient - centeredness , timeliness , efficiency , and equity .
these dimensions are essential for determining if a hospital is providing quality care to its patients , and how efficient it is in cost - containment without jeopardizing care quality .
hospital systems are associated with increases in hospital market concentration , as their services respond to a wide array of procedure demand .
moreover , if these hospitals are located in the same area , they can rationalize care delivery more efficiently , as they can coordinate the procedures effectively .
however , the link between quality increase and expense containment is difficult to assess , as one might have to discern whether they are complementary or in competition one with the other .
to the best of our knowledge , this study is the first to approach the issue of cost - efficiency in the context of a multi - pavilion hospital in romania .
the pavilions included in the adults clinical hospital cluj - napoca have different expenses patterns , as each pavilion is focused on different specialties .
this in turn results in different expense patterns across each pavilion . we must study this trend more in depth , in order to gain a more comprehensive understanding of the phenomenon , so that effective expenditure containment strategies could be implemented .
future research can also focus on comparing the 20042010 timeframe with present times , so that we could identify other expenditure patterns that might have occurred .
 background and aimmulti - hospital health systems have become the most popular administrative structure in healthcare , leading to both opportunities and challenges for hospital administrators . in government - funded healthcare systems , there is a balance between costs and the provision of health services.the aim of the present study is to assess the efficiency in terms of costs of a multi - pavilion hospital from cluj county , romania.methodsthe institution analyzed in this article is the adults clinical hospital in cluj - napoca . a descriptive retrospective study collected data from january 2004 to december 2010 . 
 a set of indicators were compiled , divided into three main categories : personnel , statistics , and financial.resultstwenty-one financial indicators were investigated . 
 heterogeneity between different years was observed for the continuous hospitalization indicator and the wage budget indicator . 
 the highest variability was observed between the budget and expenses indicators , while a smaller variability was observed at the average costs per patient . 
 the costs per patient have increased at all pavilions in the studied time frame , the higher costs being at the internal medicine and surgery pavilions : 10,203 ron in 2010 ( 1 euro ~ 4.4 ron)conclusionthe pavilions included in the adults clinical hospital cluj - napoca have different expenses patterns , as each pavilion is focused on different specialties . 
 each pavilion serves different target groups , requiring different procedures . 
 this in turn results in different expense patterns across each pavilion . 
Introduction
Background
Purpose
Materials and Methods
Hospital description and served population
Statistical analysis
Results
Personnel indicators
Statistical indicators
Financial indicators
Discussion
Conclusions