11 Introduction create insight into patient-important outcomes of care and 2) organize care services, evaluation, and continuous improvement around patients rather than providers. Time-driven activity-based costing has been proposed as the cost component of VBHC capable of addressing costing challenges. The traditional activity-based costing model has been difficult for many organizations to implement. One reason is that it is too resource-intensive in large or complex organizations. Time-driven activity-based costing has demonstrated some success in the production and service industries. The emphasis is on accuracy over precision, i.e., ‘approximately right rather than precisely wrong’.11 Accuracy is defined by how close a cost estimate is to the actual cost, and precision as the number of decimal places include in an estimation. Time-driven activity-based costing requires fewer resources than activity-based costing because it only needs two key parameters: the capacity cost rate and the time required to perform activities in service delivery – hence the name “time-driven” activity-based costing. In 2011, Robert Kaplan and Michael Porter presented a sevenstep approach (Table 1) for applying time-driven activity-based costing in healthcare settings to solve the cost crisis, and linked it to the VBHC agenda.12 Table 1: The seven steps of time-driven activity-based costing for health care organizations. Step 1 Select the medical condition. Step 2 Define the care delivery value chain, i.e., chart all the key activities performed within the entire care cycle. Step 3 Develop process maps that include each activity in patient care delivery and incorporate all direct and indirect capacity-supplying resources. Step 4 Obtain time estimates for each process, i.e., obtain time estimates for activities and resources used. Step 5 Estimate the cost of providing patient care resources, i.e., all direct and indirect resources involved in providing care. Step 6 Estimate the capacity of each resource and calculate the capacity cost rate. Step 7 Calculate the total cost of patient care. Insight into clinical outcomes, patient experiences, and costs can contribute to valuebased care at multiple levels. First, individual outcomes in the clinic are used for screening and monitoring symptoms and better informed shared decision-making. Second, through the evaluation of population outcomes, professionals can learn from the analysis of data and improve care for patients with certain conditions or diseases. Third, by benchmarking group outcomes, unwarranted variation and best practices can be identified. Organization of Maternity Care Variations in culture, history, politics, and healthcare policy have led to different ways of organizing maternity care in different countries.13 In the Netherlands, pregnant women at low risk of complications receive MLC from primary care midwives. In contrast, women at high risk of complications receive OLC from obstetricians, 1
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