Scale-Dependent Spatial Clustering of Hospital Operational Performance and Patient Safety Outcomes in East Java, Indonesia: A Spatial Autocorrelation Analysis

Understanding variations in hospital performance and patient safety is critical for improving health system efficiency, particularly in decentralized healthcare systems such as that of Indonesia. While geographic disparities in health outcomes are often emphasized in research, the relative contribution of spatial patterns remains underexplored. The aim of this study was to identify and visualize spatial clustering of hospital performance and mortality-oriented patient safety. Data from 428 hospitals in East Java, Indonesia, were used to develop standardized composite indices for measuring hospital performance and mortality-oriented patient safety outcomes. Spatial autocorrelation was assessed using global and local Moran’s I at both hospital and district scales. Subgroup spatial autocorrelation analyses were additionally conducted to examine whether hospitals with different institutional characteristics exhibit distinct spatial clustering patterns. The findings reveal no significant spatial clustering at the hospital level for either hospitals’ performance or patient safety outcomes. However, significant spatial clustering of patient safety outcomes emerged at the district level. Subgroup analyses revealed that class A and B hospitals show significant spatial clustering of patient safety outcomes. Local Moran's I identified high-high mortality clusters in Bondowoso and Jember districts for gross death rate, and in Madiun and Bojonegoro districts for net death rate. Low-low clusters representing districts with consistently favorable mortality outcomes were identified in Mojokerto and Bangkalan for both indicators. For policymakers, these findings highlight the need to prioritise governance and quality improvement efforts in high-risk districts while systematically learning from districts demonstrating consistently lower mortality outcomes.