Your scarcest resource

Most companies have elaborate procedures for managing capital. They require a compelling business case for any new capital investment. They set hurdle rates. They delegate authority carefully, prescribing spending limits for each level. An organization's time, by contrast, goes largely unmanaged. Bain & Company, with which all three authors are associated, used innovative people analytics tools to examine the time budgets of 17 large corporations. It discovered that companies are awash in e-communications; meeting time has skyrocketed; real collaboration is limited; dysfunctional meeting behavior is on the rise; formal controls are rare; and the consequences of all this are few. The authors outline eight practices for managing organizational time. Among them are: Make meeting agendas clear and selective; create a zero-based time budget; require business cases for all initiatives; and standardize the decision process. Some forward-thinking companies bring as much discipline to their time budgets as to their capital budgets. As a result, they have Liberated countless hours of previously unproductive time for executives and employees, fueling innovation and accelerating profitable growth.

Redesign of a pediatric pharmacotherapy elective course to accommodate budget reductions

OBJECTIVE

To redesign a pediatric elective pharmacotherapy course and determine whether the redesign resulted in changes in outcome measures.

DESIGN

Active learning activities were moved to an online format. Prerecorded lectures continued to be used. Peer evaluation was incorporated to give the students more feedback on their performance. ASSESSMENT; Presentation grades, average examination grades, course grades, and evaluation scores from each student who completed University course evaluations were documented for students during the 2 semesters before and the 2 semesters after the course redesign. Although for undetermined reasons a drop in examination grades occurred after the course redesign, no significant differences in presentation grades, final grades, or course evaluation grades occurred.

CONCLUSIONS

A strategic course redesign successfully reduced the costs and faculty time required to offer an elective course viewed as essential to the curriculum, allowing the course to be continued in the face of state budget cuts.

Working women households and time-saving consumption: empirical evidence from Kerala

This article explores the impact of labour force participation of Indian women on the consumption expenditure of their households. Field survey data were collected from working-wife and non-working wife households in Kerala, the state in India with the highest labour market participation of women in the organised sector. Differences in time-saving consumption expenditures of working and non-working wife households and different variables influencing consumption expenditures were researched. The study shows that among the variables which positively affect the time-saving consumption expenditure of the households, non-economic factors influence the time-saving consumption expenditure of the working-wife households more prominently than in non-working wife households.

[Patient classification systems. Nursing workload from the perspective of applied research (part 2)]

Building on the first part of the article, which described aims, forms and a new developed typology of Patient Classification Systems (PCS), the second part discusses three wrong assumptions that are often behind the application of common PCS. These assumptions deal mainly with indices of nursing care intensity for measuring of staff requirements and with patient characteristics (deficiencies and problems) in regard to the expenditure of time. Additional examinations show whether or not it is scientifically possible to express staff requirements on the basis of added up individual nursing activities. Data collected in several intensive care units by diagnosis related analysis of work activities (DTA) show that the distribution of expenditure of time for singular nursing activities does not result in meaningful arithmetic means usable for assessment instruments scheduling of personnel. Given these methodical constraints it should be examined with minuteness before the application of a PCS exactly which question should be answered by an instrument or method, and it should be examined whether the method is suitable for the question asked.

Consensus-based findings and recommendations for estimating the costs of health-related productivity loss from a company’s perspective

OBJECTIVES

There were two study objectives: (i) to identify, via consensus, a key set of items for estimating the costs of productivity loss from a company's perspective and (ii) to develop recommendations for the costs of estimating productivity loss on the basis of consensus findings.

METHODS

A modified Delphi procedure was utilized in which a predetermined set of 26 items formed the basis for inquiry in the first round. Thirty-six experts from five stakeholder groups in the Netherlands (employers, employees, policy makers and insurers, occupational health professionals, and researchers) participated in the panel. Opinions were sought regarding the relevance and retrievability of data on items related to the following three forms of work loss: work presenteeism (ie, decreased work performance while at work), short-term absenteeism (<2 weeks), and long-term absenteeism (>2 weeks). The data were analyzed quantitatively and qualitatively. The consensus for relevance was set at 70%.

RESULTS

After two rounds, 4 items were found relevant for estimating the costs of productivity loss due to work presenteeism, 6 items were relevant for short-term absenteeism, and 11 items remained for long-term absenteeism. The retrievability of data varied. Three sets of recommendations were formulated for estimating the costs of productivity loss from a company's perspective.

CONCLUSION

A streamlined set of relevant items has been identified via consensus and formulated into recommendations for estimating the costs of productivity loss from a company's perspective. Although not definitive, these recommendations represent an important step towards standardizing the way these costs are estimated, and, in turn, facilitate the comparability and utility of economic evaluations of occupational health interventions.

Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times

Anesthesiology groups that provide care for surgical procedures of longer-than-average duration are economically disadvantaged by both increased staffing costs and reduced revenue. Under the current billing system, anesthesia time is valued the same regardless of the total case duration. In this study, we evaluated the effect on four academic anesthesiology departments of two hypothetical scenarios by changing the anesthesia care billing system to make more valuable either 1) all time units or 2) just second-hour and subsequent time units. From the four departments, case-specific data (anesthesia Current Procedural Terminology code and minutes of care) were collected for all anesthesia cases billed for 1 yr. Basic units were determined from the American Society of Anesthesiologists (ASA) relative value guide. The average time for each case was defined as the average anesthesia time for that specific Current Procedural Terminology code, as published by the Center for Medicare and Medicaid Services (CMS). The actual total ASA units per hour (tASA/h) was determined by adding all the basic units and time units and dividing by hours of anesthesia care (minutes of anesthesia care divided by 60). We then calculated a hypothetical CMS tASA/h for each group by substituting the CMS average time for each anesthesia procedure time for the actual time reported by each group and using 15-min time units. For each group, the Actual (Act) tASA/h and CMS tASA/h were calculated for both options-changing the interval for all time units or only for second and subsequent hours. Intervals were 15, 12, 10, 7, 6, or 5 min. When changing all time units, Act tASA/h and CMS tASA/h were never equal for all groups. The two productivity measures became approximately equal if only time units after the first hour were changed to 6- to 7-min intervals. When changes were applied only to the Act tASA/h (with CMS tASA/h remaining at 15-min intervals), at the 12-min interval either option resulted in a similar or higher Act tASA/h than CMS tASA/h. Both options increase the value of time and help compensate for the lost economic opportunity of longer-than-average surgical durations.

IMPLICATIONS

Longer-than-average surgical durations result in less potential revenue per hour under current billing methodology. This study quantifies the increase in billing productivity when the value of time is increased, when evaluating the billing productivity of four academic anesthesiology groups.

Managing time

As you can see from these examples, there are many factors that must be considered in the relationship between time management and practice production. However, it is important to understand that there is a direct correlation among various factors--including how time is used, which services are provided, the volume of services provided and other factors--in establishing a practice with excellent financial results. As always, dentistry is about excellent patient care, but it still is important for the dentist and team to examine the day-to-day use of time and its effect on the business side of the practice.

Optimization of operating room allocation using linear programming techniques

BACKGROUND

New and innovative approaches must be used to rationally allocate scarce resources such as operating room time while simultaneously optimizing the associated financial return. In this article we use the technique of linear programming to optimize allocation of OR time among a group of surgeons based on professional fee generation.

STUDY DESIGN

For the period of December 1, 2000, to July 31, 2002, the following individualized data were obtained for the Division of General Surgery at Duke University Medical Center: allocated OR time (hours), case mix as determined by CPT codes, total OR time used, and normalized professional charges and receipts. Inpatient, outpatient, and emergency cases were included. The Solver linear programming routine in Microsoft Excel (Microsoft Corp.) was used to determine the optimal mix of surgical OR time allocation to maximize professional receipts.

RESULTS

Our model of optimized OR allocation would maximize weekly professional revenues at 237,523 US dollars, a potential increase of 15% over the historical value of 207,700 US dollars or an annualized increase of approximately 1.5 million US dollars.

CONCLUSIONS

Our results suggest that mathematical modeling techniques used in operations research, management science, or decision science may rationally optimize OR allocation to maximize revenue or to minimize costs. These techniques may optimize allocation of scarce resources in the context of the goals specific to individual academic departments of surgery.

Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians

BACKGROUND

Physicians' concerns with the health care system focus on having less time with their patients and needing to work harder to maintain incomes. We sought to determine whether physicians are working longer hours and whether their incomes are declining.

METHODS

Using survey data, we conducted a retrospective analysis of physician inputs, outputs, efficiency, and incomes for generalists, general internists, general surgeons, pediatricians, and obstetrician-gynecologists from 1987 to 1998.

RESULTS

Physician inputs (as measured by the average hours worked in professional activities) showed little absolute change across specialties over time. Outputs (as measured by the total number of patient visits per week) decreased between 9% and 28%, depending on the specialty. Efficiency (the proportion of time spent in direct patient care and the amount of time spent during a typical office visit) remained stable over the time examined. Consumer price index inflation-adjusted annual incomes increased considerably over the time period examined (42% for general internists, 28% for pediatricians, 13% for generalists, and 8% for general surgeons); only obstetricians-gynecologists showed a net loss of annual income when adjusting for inflation (a 6% loss).

CONCLUSIONS

Our findings do not confirm the prevailing concern that physicians are working harder or longer or that their incomes are declining, but they offer an explanation of how physicians are maintaining incomes without increasing work inputs. There is a great deal of dissatisfaction with the health care system among physicians; exploration of perceptual reasons for that dissatisfaction may outline a course of action needed to resolve it.

Impact of pager notification on report verification times

RATIONALE AND OBJECTIVES

The purpose of this study was to assess the impact on times of verification (TOVs) by a pager notification system (PNS) that informs physicians when reports are available for signature.

MATERIALS AND METHODS

An automated PNS was implemented in the authors' department in November 2000. Monthly report verification times of each physician were collected for 3 months in the years before and after initiation of the PNS. Radiologists enrolled in the PNS and those who were not were assigned into two groups for analysis. Mean TOVs for the two sets of 3 months and for the two groups were calculated and differences recorded. Two-tailed t tests were used to assess for statistical differences between the groups.

RESULTS

Twenty-nine of 37 radiologists voluntarily enrolled in the PNS (group 1). Mean TOV was 26.75 hours (standard deviation [SD] = 17.76) for these physicians before and 14.48 hours (SD = 11.86) after the PNS was employed (P < .01). For those physicians who did not enroll in the PNS, mean TOV was 11.53 hours (SD = 5.55) before and 9.77 hours (SD = 9.86) after the PNS was employed (P = .33). Both the absolute and percentage reductions in TOVs were significantly greater for those physicians enrolled in the PNS than for those who were not (P = .035). Twenty-three of 29 (79%) physicians who used the PNS showed a reduction in their report turnaround times.

CONCLUSION

Linking the PNS with the radiology information system to notify physicians of unsigned reports was effective in reducing report verification times.

Using technology to address recruitment issues in the clinical trial process

It takes nearly ten years to get a drug through the discovery and development pipeline and onto the market; most of this time is spent in the clinical phase. Clinical development times vary widely from drug to drug, but a drug typically spends just over 6 years going through clinical trials and regulatory processes. At least 3 years of this time is spent recruiting patients. Every month by which the development process can be shortened is worth US $25 million in additional income for the average drug. Can the recruitment time be shortened?

Time costs associated with cervical cancer screening

OBJECTIVES

Time costs borne by women when undergoing cervical cancer screening have rarely been elucidated, although such costs may pose substantial barriers to care. The purpose of this project was to quantify the opportunity costs associated with cervical cancer screening in young women attending Planned Parenthood Clinics.

METHODS

We conducted a self-report survey of 105 women from six clinics to measure travel, waiting, and exam times associated with cervical cancer screening. Respondents recorded their time of arrival and departure, length of time in the waiting room, age, income level, and hours per week they worked outside of the home. Time costs were valued three ways: through self-reported hourly wage, age- and gender-adjusted minimum earnings, and national age- and gender-adjusted hourly wages.

RESULTS

Respondents were on average 24 years old, worked 29 hours per week outside the home, and earned less than $20,000 per year. Mean time for one-way travel was 18.7 minutes; waiting room time was 16.9 minutes; and exam time was 50.8 minutes. Time costs were estimated to be $14.08 per visit based upon the self-reported hourly wage; $16.46 per visit based upon age- and gender-adjusted minimum earnings; and $19.63 per visit based upon age- and gender-adjusted national wage rates.

CONCLUSIONS

Time costs associated with cervical cancer screening represent an important opportunity cost and should be considered in studies attempting to identify barriers to screening adherence. Our results indicate that time costs accounted for up to 25% of cervical cancer screening costs. Time costs should be identified, measured, valued, and included in cost-effectiveness analyses of cervical cancer screening.

[The economic and labor impact of no staff replacement in primary care. Why and how we should measure it]

OBJECTIVES

To quantify the effect of not replacing staff in both job (mean overloads in time -MOT- and in users -MOU-) and economic terms. To calculate the effective real time worked (ERTW).

DESIGN

Cross-sectional descriptive study.

SETTING

Primary care, San Fernando Health Centre, Móstoles, Madrid.

PARTICIPANTS

The 41 people in the team.

MEASUREMENTS AND MAIN RESULTS

Records of time off in 1999, with economic and labour costs. Comparison of the mean patients per shift -MOU- with the gold standard: Royal Decree 1575/1993. 72.63% (14,227,538 pesetas) of the cost of time off (19,589,226 pesetas) was assumed by the team (negative cost, economic impact). The MOT per health professional was 6.6 weeks per year for doctors, 6.5 for nurses and 4.2 for paediatricians. The ERTW per professional was 44.1 weeks a year for paediatricians, 39.4 for doctors and 39.1 for nurses. The MOU on a professional being absent raises the lists to 2471 (medicine) and 2179 (paediatrics) on the morning shift; and to 2296 (medicine) and 1662 (paediatrics) on the afternoon one.

CONCLUSIONS

The team assumes most of the economic burden, with no counter-benefit. The MOT is high and exceeds the number of weeks per year of formally allowed time off. In practice, therefore, each professional covers for their full allowed time off. The ERTW is much below the 52 weeks on which the team was assessed. RD 1575/1993 is frequently broken by current MOU. It is suggested that coordinators use these indicators in negotiating the Contract of Care Management and the Portfolio of Services.

The transfer of resources from middle-aged children to functionally limited elderly parents: providing time, giving money, sharing space

The transfer of resources from middle-aged children to their functionally limited elderly parents is addressed from the perspective of the children who may allocate time to caregiving, share household space, and give money to parents. A simultaneous-equations model estimates the extent to which the three modes of transfer are interdependent, given the parents' needs for resources and the children's ability to provide them. Caregiving is the primary mode of resource transfer and is of overriding importance for individuals who depend daily on help from other persons. Coresidence and financial assistance complement direct human assistance and, at the margin, have a substantially large effect on caregiving time. It is, therefore, relevant to consider all modes of transfer in order to better understand how families accommodate the needs of their frail and disabled members.

[THe cost of radiotherapy. Piedmontese experience]

INTRODUCTION

An integrated task force of radiotherapists and administrators of the Piedmont region studied the estimated cost of radiotherapy (RT) to compare it with the figures in the 502/92 law modifying the financing of medical structures. This law changed the financing method from productive factors compensation to actually provided performances compensation.

MATERIAL AND METHODS

The RT departments of the Turin and Novara university hospitals, those of Ivrea and Asti and that of the Pinna Pintor Clinic (Turin) participated in the study, with 4889 examinations in the period of interest. The study consisted of 6 steps: 1) defining a nomenclator; 2) making a list of standard resources; 3) calculating the actual resource consumption; 4) relating 2) to 3); 5) calculating cost and times; 6) defining quality standards. A technical and/or a central group(s) carried out all the steps. The nomenclator indicates 13 main activities (e.g., irradiation, telecobalt therapy, brachytherapy, hyperthermia), each of them featuring some subactivities (e.g., telecobalt therapy: flash, a fixed beam, two opposing beams). The following productive factor were considered: a) personnel; b) material; c) investments; d) the service cost; e) general costs. The personnel cost (the main cost) was calculated as: A) routine activity; B) activity for other units; C) congress activity; D) research. The times for individual performances were estimated according to professional roles (e.g., medical doctor, physicist, technician, nurse, administrative) for each subactivity.

RESULTS

The estimated RT costs were as follows (please note that all figures are expressed in US $, at a rate of 1$ = ItL 1700). Irradiation: 15 (cost/session +/- 3%); telecobalt therapy: 30-55; Linac (energy < > 10 Mev): 38-60; special techniques: 931-2,314; HDR brachytherapy: 878-1,515; hyperthermia: 285; simulation: 50-92; dosimetry: 52-286; examination, treatment planning, follow-up, etc.: 24-59; immobilization devices, photographs, etc.: 3-66. The quality criteria are related to the personnel; high energy equipment; treatment planning; 3D dosimetry.

CONCLUSIONS

Our study led the Italian Ministry of Health to revise the estimated cost of RT examinations in July, 1996. We will further enquire into the new figures.

Time management: a review for physicians

This article reviews the basic concepts and techniques of time management as they relate to a medical lifestyle. Essential tools are described to help the physician reassess and sharpen skills for handling intensifying demands and constraints of juggling patient care, research, teaching, and family responsibilities. The historical background and principles of time management for three popular "best selling" techniques are critiqued. In addition, a fourth technique, or model, of time management is introduced for physician use.

Improving the efficiency and service of computed tomographic scanning

RATIONALE AND OBJECTIVES

This study quantified the impact on service and costs of operational changes in CT.

METHODS

Operational and financial analyses were performed in 1988 and 1991 after process flow and management changes were made.

RESULTS

The backlog decreased from about 6 weeks to 1 week. The cost per scan decreased 25%. Volume increased 50%. Two technologists were assigned per scanner doing some steps of the process in parallel rather than sequentially. Decreasing throughput time accounted for three fifths of the cost decrease. The reduction in number of scanners and hours of operation, change in radiologists' practice patterns, coordination of scheduling, CT priority for escort personnel, and personnel changes accounted for two fifths of the cost decrease.

CONCLUSIONS

It is possible to simultaneously decrease costs and improve the quality of service by careful operations analysis and management. Operational changes had synergistic effects that allowed more improvement than might be anticipated. Advisable management changes may be counterintuitive.

Private versus social opportunity cost of time: valuing time in the demand for health care

In this paper we examine whether the current method of valuing time within economic appraisals is appropriate. The cost to society of time taken to use health care may differ from the private opportunity cost of such time. However, demand for health care may be affected by the private opportunity time cost and not by the value of time to society. In this paper we show that the private opportunity cost of time is a better predictor of demand for a screening service than the societal approach. It is important, therefore, to use the private opportunity cost of time when assessing the demand for, and impact of, a health care intervention.

A cost utility analysis of treatment options for gallstone disease: methodological issues and results

The techniques of cost utility analysis (CUA) were used to evaluate the treatment of gallstone disease by open and laparoscopic cholecystectomy and by extracorporeal shockwave lithotripsy (ESWL). The application of the techniques in this context raised three methodological questions which are not satisfactorily resolved in the literature. The first is whether an ex ante or ex post perspective is best adopted for the measurement of quality of life (QoL). The second is the method for converting a short term deterioration in QoL followed by full health into QALYs and the reliability of the methods available. The third is the issue of indirect costs which, in the context of a temporary disease state, cannot be easily avoided. The economic evaluation found laparoscopic cholecystectomy to be generally superior than the competitor technologies (entailing lower costs and better outcomes). However, the results were sensitive to assumptions about the perspective for measuring benefits and the inclusion of indirect costs.