هزینه یابی مبتنی بر فعالیت زمان محور در محیط درمانگاه : توسعه، ارتباط و تاثیر مدیریتی

Healthcare managers are continuously urged to provide better patient services at a lower cost. To cope with these cost pressures, healthcare management needs to improve its understanding of the relevant cost drivers. Through a case study, we show how to perform a time-driven activity-based costing of five outpatient clinic's departments and provide evidence of the benefits of such an analysis.

One of the key challenges to the continued viability of healthcare organizations is the development of relevant and accurate cost information on which to base strategic, pricing and management decisions [1], [2], [3], [4] and [5]. Recently, healthcare organizations have started to invest in more sophisticated cost-accounting systems, such as activity-based costing (ABC) [6], [7], [8], [9] and [10]. ABC is an advanced cost calculation technique that allocates resource cost to products based on resource consumption. Researchers have claimed that, since ABC may provide greater visibility into organizational processes and their cost drivers, it may allow managers to eliminate costs related to non-value added activities and improve the efficiencies of existing processes [7], [8], [11] and [12]. This process is also referred to as activity-based management. While several articles have advocated the use of ABC by service organizations in general and healthcare organizations in particular [6], [8], [9] and [10], there is, nevertheless, need for some degree of caution. Lievens et al. [7] and King et al. [13], for example, argue that a potential drawback of ABC systems lies in the time and resource consumption associated with the development and management of these systems. Kaplan and Anderson [14] note that the high time and cost to estimate an ABC model and to maintain it – through re-interviews and re-surveys – has been a major barrier to widespread ABC adoption. In a similar vein, Everaert et al. [15] claim that many managers who have tried to implement ABC in their organizations, including healthcare managers, have abandoned the attempt in the face of rising costs and employee irritation. In order to overcome the difficulties of ABC, Kaplan and Anderson [14] and [16], developed a new approach to ABC, called time-driven ABC (TDABC). A TDABC model can be estimated and installed quickly as estimates of only two parameters are required: (1) the unit cost of supplying capacity and (2) the time required to perform a transaction or an activity. The breakthrough of TDABC lies in the usage of time equations to estimate the time spent on each activity [17]. Through the inclusion of multiple time drivers, the time-driven approach to ABC can capture the complexities of organizations far more simply than the traditional ABC system could, which might well have had to account for varying transaction times by treating each variant of the process as a distinct activity [14]. Hence, TDABC seemingly provides many opportunities to design cost models in environments with complex activities, as in healthcare organizations, and service organizations, in general. This paper describes the development and application of a TDABC system for an outpatient clinic in Belgium. The outpatient clinic is a consultation department where physicians with different specializations have their office hours and where patients, after having an appointment, receive medical advice. Depending on this advice further medical treatment or hospitalisation takes place. By definition, all outpatient facilities are alike in having no overnight patients. While previous accounting studies have explored the development and the role of cost-accounting studies in more traditional hospital contexts [2], there has been relatively little analysis of the development and managerial impact of cost systems in an outpatient clinic. This lack of attention might be partly due to the absence of a legal framework to report and register all costs in an outpatient clinic environment [4]. Outpatient clinic services, however, are an important part of the healthcare services sector [18]. An increasing number of community-level outpatient clinics are satellites of larger medical centres or systems, and are thus part of a complex that can emphasize continuity of care. This trend toward increased outpatient health care corresponds with a growing workload at many outpatient clinics [18]. From an empirical standpoint, the outpatient clinic therefore offers an attractive context for this study. The remainder of this paper is organized as follows. In Section 2, we briefly address the technique of TDABC. In Section 3, we present the TDABC outpatient clinic case. In Section 4, we describe how the TDABC information induced improved decision making in this case. We end with concluding remarks.

In this paper we try to explain the development, the relevance and the managerial impact of TDABC in an outpatient clinic environment. The TDABC system seems to be well suited since it incorporates next to the advantages of the traditional ABC system some extra features like faster model adaptability, a simpler set-up and a higher reflection of the complexity of the real-world operations. The TDABC model in this paper was set up for five different departments: Urology, Gastroenterology, Plastic Surgery, Nose-Throat and Ears and Dermatology. Based on cost Table 4 and Table 5, the cost for a standard technical consultation appears to range from 5.19€ to 13.78€, while the cost for a non-technical consultation ranges from 4.50€ to 51.41€. The cost of a standard consultation shows already the influence of the specificity of the consultation, the differences in the usage of activities and machinery and the differences in the cost per time unit. Optional activities might then increase the cost between 0.13€ and 6.77€ for a technical consultation and 0.03€ and 48.83€ for a non-technical consultation. The TDABC system challenged healthcare managers and department heads to identify and analyze the underlying activities that drove the overhead costs. As such, the TDABC analysis allowed managerial recommendations concerning improvement opportunities [14], [15], [16], [17] and [20]. Secretaries were centralized, telephone accessibility was improved by putting head-sets available and voice recognition systems were introduced for all physicians to reduce the typing times of letters. Furthermore, we also saw the TDABC approach introduced a healthy competition and an open communication between the different departments concerning possible operational improvements. The introduction of interactive meetings on business and operational matters in that way promoted inter-hierarchical and more important inter-disciplinary (between physicians and managers) communication. Finally, while the interaction between cost-accounting systems and strategy has been frequently viewed as a passive one [21], in this study the TDABC information clearly improved the department heads and healthcare managers’ understanding of the different organizational processes. As such, the clinic's management was able to pursue strategic changes that increased the value and effectiveness of the current and future outpatient clinic.