O NLINE- ONLY

Using Time-Driven Activity-Based Costing

to Model the Costs of Various Process-
Improvement Strategies in Acute Pain
Management
Keyuri Popat, MD, medical director, acute pain medicine, Division of Anesthesiology and Critical
Care, The University of Texas MD Anderson Cancer Center, Houston; Kelly Ann Gracia, senior
research data coordinator, The University of Texas MD Anderson Cancer Center, Houston;
Alexis B. Guzman, project manager, reimbursement strategy, clinical revenue and reimbursement, The
University of Texas MD Anderson Cancer Center; and Thomas W. Feeley, MD, senior fellow, Harvard
Business School, and professor emeritus, The University of Texas MD Anderson Cancer Center
Downloaded from http://journals.lww.com/jhmonline by BhDMf5ePHKbH4TTImqenVDiEotxSR1UH0aQm8ky4rg6gf2QujsYA4fQ3+1SRTsen+hDjPNLb/Do= on 02/04/2019

EXECUTIVE SUMMARY

Pain control for patients undergoing thoracic surgery is essential for their comfort and for
improving their ability to function after surgery, but it can significantly increase costs. Here,
we demonstrate how time-driven activity-based costing (TDABC) can be used to assess per-
sonnel costs and create process-improvement strategies.
We used TDABC to evaluate the cost of providing pain control to patients undergoing
thoracic surgery and to estimate the impact of specific process improvements on cost. Retro-
spective healthcare utilization data, with a focus on personnel costs, were used to assess cost
across the entire cycle of acute pain medicine delivery for these patients. TDABC was used
to identify possible improvements in personnel allocation, workflow changes, and epidural
placement location and to model the cost savings of those improvements.
We found that the cost of placing epidurals in the preoperative holding room was less
than that of placing epidurals in the operating room. Personnel reallocation and workflow
changes resulted in mean cost reductions of 14% with epidurals in the holding room and 7%
cost reductions with epidurals in the operating room. Most cost savings were due to rede-
ploying anesthesiologists to duties that are more appropriate and reducing their unnecessary
duties by 30%. Furthermore, the change in epidural placement location alone in 80% of cases
reduced costs by 18%. These changes did not compromise quality of care.
TDABC can model personnel costs and process improvements in delivering specific
healthcare services and justify further investigation of process improvements.

For more information about the concepts in this article, contact Dr. Popat at
kupopat@mdanderson.org.
The authors declare no conflicts of interest.
© 2018 Foundation of the American College of Healthcare Executives
DOI: 10.1097/JHM-D-16-00040

e76 Volume 63, Number 4 • July/August 2018

© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
 Time-Driven Activity-Based Costing in Acute Pain Management
INTRODUCTION
Background
Epidural analgesia has been the modal-
ity of choice for pain control after tho-
racic surgery for many years because it
improves patient comfort and quality of
life. It also may help reduce pulmonary,
cardiac, and thromboembolic complica-
tions (Schuster, Gottschalk, Freitag, &
Standl, 2004). However, although it is
widely agreed that providing acute pain
services enhances postoperative out-
comes (Schuster, Gottschalk et al., 2004;
Schuster, Standl et al., 2004; Werner &
Nielsen, 2007), the delivery of acute pain
care significantly increases the cost of the
total perioperative care cycle (Schuster
& Standl, 2006). Reducing costs while
maintaining the standard of care would
require capturing healthcare costs and cost
drivers, but this assessment is a challenge
because of the complexity of healthcare
delivery and the masking of true costs
with charges.
Time-driven activity-based costing
(TDABC), introduced by Kaplan and
Anderson (2004), is a feasible solution to
this challenge (Kaplan et al., 2014). Various
healthcare settings and institutions have
implemented TDABC to capture the costs
of delivering healthcare services (French
et al., 2013; Öker & Özyapici, 2013).
TDABC is a cost-allocation methodology
that resolves the inaccuracy of overhead
allocation in traditional cost systems by
allocating indirect and support costs to
activities performed by shared resources.
The methodology requires an under-
standing of activities and processes and
the amount of time required to perform
certain tasks; then, costs are allocated
per resource performing each task. The
www.ache.org/journals e77
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
TDABC cost accounting approach pro-
vides managers with more accurate cost
information to better make decisions
regarding process improvement, profit-
ability, and pricing. TDABC was chosen
because of the collaborative process of
developing process maps to not only
understand the workflow in the acute pain
areas but also to understand the financial
impact of the decisions made (Kaplan &
Anderson, 2007).
TDABC has been documented in the
healthcare literature as an appropriate
costing methodology for process improve-
ment and as an alternative to healthcare’s
approach of using charges as surrogates for
cost (McLaughlin et al., 2014). It was used
at a comprehensive cancer center to reduce
process time by 16%, professional staff
costs by 67%, and technical staff costs by
12% when treating head and neck cancer
(Feeley, Fly, Albright, Walters, & Burke,
2010). Similarly, an international study
demonstrated the use of TDABC by hospi-
tal managers to measure unused capacity
among resources at a private hospital (Öker
& Özyapici, 2013). TDABC also has been
used in comparative effectiveness studies of
advanced proton versus photon radiation
therapies (Thaker, Frank, & Feeley, 2015).
Lastly, TDABC costs have been used to
evaluate alternative payment methods such
as bundled payments in healthcare (French
et al., 2013; French, Guzman, Rubio,
Frenzel, & Feeley, 2016; Öker & Özyapici,
2013; Thaker et al., 2015).
Providing value-based care requires
an understanding of cost. As the health-
care environment changes, hospitals
must compete for patients. In addition,
reimbursements are down, and thus it is
more important than ever to understand
 Journal of Healthcare Management
the costs of providing care and to identify
cost-saving strategies. Personnel accounts
for the largest portion of total costs, so
we used TDABC in an inpatient setting
to help assess the cost of a portion of the
care (pain management) provided to a
patient throughout a hospital stay, based
on the time each provider spends with
that patient. (Several studies suggest that
poorly controlled acute pain could lead
to higher chances of developing chronic
pain, and thus higher healthcare costs in
the future [(Lavand’homme, De Kock, &
Waterloos, 2005].) TDABC has been used
at a higher level to assess inpatient per-
sonnel cost by allocating provider costs
per staffed bed (Kaplan & Anderson,
2007). To the authors’ knowledge, this
is the first time a segment of inpatient
personnel cost has been calculated using
TDABC. As a hospital decides what kind
of services it can afford to offer, this type
of analysis for nonmainstream services is
useful.
We chose thoracic surgery as a model
because it constituted the majority of our
patient population requiring epidural
analgesia. The personnel and the processes
used for pain management for thoracic
surgery are similar to those required for
other acute pain management procedures.
Thus, the process-improvement strate-
gies identified in thoracic surgery can be
extrapolated to other acute pain manage-
ment procedures.
Study Aim and Objectives
The aim of this study is to demonstrate
how TDABC can model performance
improvement strategies and their effect
on cost. The objectives of this study are
(1) to measure baseline personnel costs of
e78 Volume 63, Number 4 • July/August 2018
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
placing epidurals in the operating room or
in another location (preoperative holding
room), and (2) to evaluate the cost savings
of process-improvement initiatives in pain
care delivery for patients undergoing tho-
racic surgery. We hypothesized that placing
epidurals outside the operating room and
reallocating personnel to perform at the
highest level of their qualifications would
save costs without compromising quality
and thus would increase value.
We retrospectively modeled the use of
healthcare resources by our set of thoracic
surgery patients to assess baseline costs and
the cost savings of process-improvement
initiatives. One technique for controlling
pain, epidural analgesia, was the center of
this analysis. The use of TDABC to study
acute pain care delivery for inpatient
services has not been reported. This case
study can be generalized to all hospitals
interested in improving their processes and
understanding their costs.
METHODS
Process Maps and Personnel Costs
A complete cycle of pain-management
delivery for patients undergoing thoracic
surgery was defined to determine which
activities and resources to include in the
cost analysis (see Figure 1 for a high-level
“blueprint” of inpatient surgery). The pro-
cess was color coded to identify activities
involving pain management resources and
thus to be included in the cost analysis.
Two pathways were identified for
patients receiving pain management with
epidural analgesia: epidural catheter place-
ment in the nonoperating area (i.e., pre-
operative holding room) and placement in
the operating room (OR). Care providers
involved in both pathways were interviewed
 Time-Driven Activity-Based Costing in Acute Pain Management

Figure 1
High-Level Blueprint of Processes Involved in Inpatient Surgery
Day of Surgery Post-Operative Day 0–1+

Surgery Holding Operating Post-

Surgery Preoperative Area Room Floor
Waiting Anesthesia Discharge
Check-In Area *Epidural *Epidural Nursing
Area Care Unit
Placement Placement

* Variation: Epidural placement in holding Acute Pain

area vs. operating room varies by resource
and space availability Medicine
Assessment

Note. Darker boxes indicate activities involved in pain management, which are included in the cost analysis.

Figure 2
Process Map Excerpt

Holding Area Day of Surgery 7

Resident
Signs in to
PICIS and
performs
positioning
prep
Start 5

1 2 3 4 5 7
Acute Pain Anes MD Acute Pain Acute Pain RN Acute Pain RN Does N 80% Anes MD
Coordinator Reviews patient Coordinator Gathers drugs Places patient need Signs in to
Gathers records; Escorts family monitors an IV? PICIS and A
surgery, blood, explains out and gathers 5 5 performs
and anesthesia procedure and equipment Y 20% positioning
consents; consents to prep
ensures history patient 10 6 5
and physical 12.5 4
Anes MD
have been Acute Pain RN
Places IV and
updated; Gathers drugs
portacath
pregnancy test 5 5
given; preop RN
assessment is
complete
52.5 6
PACU MD
Places IV and
portacath
5

Notes. Anes = anesthesiology; PACU = postanesthesia care unit; PICIS = electronic health record system. Process improvement
examples are shown in darker boxes. “A” (at right) is the first area identified by the authors to model an alternative, which is shown in
the topmost box. Resources are identified with the time estimates and probabilities of completing the activities involved in a process.

to create process maps. All finalized maps Cost estimates were obtained by multi-
were validated by direct observation and plying the cost-capacity rate (CCR) by the
by staff members from the Department amount of time required for each resource
of Pain Management, the Department of to perform the patient care processes
Thoracic and Cardiovascular Surgery, the (Kaplan & Anderson, 2004, 2007). CCRs
Division of Nursing, and the Department of were derived from staff members’ salaries
Anesthesiology. The process maps included plus fringe benefits and a percentage of
time estimates and probabilities of activ- institutional overhead costs. Each step in
ity occurrence (see Figure 2 for a detailed the process map was costed and aggre-
excerpt of one of the maps). gated to compute the total TDABC cost for

www.ache.org/journals e79

© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
 Journal of Healthcare Management
each thoracic surgery pain-management
pathway. There is consensus that time in
the operating room increases costs for any
patient procedure (Elixhauser & Andrews,
2010; Wright, Roche, & Khoury, 2010).
Therefore, it can be assumed that the
inclusion of facility costs (for the processes
that occurred in the operating room) in
our analysis would result in more inclu-
sive cost estimates for the epidural-in-OR
pathway. Because we did not have a cost
rate for operating room utilization at our
institution, we looked to the literature
and incorporated a rate of $20 per minute
for all activities that occurred in the OR
(Macario, 2010).
Process Improvements
For the first cycle of improvements, process
maps were analyzed for opportunities to
improve workflow efficiency. Two types
of changes were identified and evaluated:
personnel changes and workflow process
changes (see Table 1).
For the personnel process changes,
personnel were reallocated to perform
tasks at the highest level of their licensure,
and in Improvement A we suggested three
changes to our current workflow:
1. The registered nurse (RN) would
obtain the medications from the
pharmacy instead of the MD; the
RN would not need any additional
training to do this.
2. Instead of the MD writing the whole
procedure note, the resident would
write the note and the MD would
cosign it.
3. A midlevel provider, trained and
credentialed to see inpatients, and
supervised by the MD, would round
e80 Volume 63, Number 4 • July/August 2018
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
on the stable 70% of patients and
bill for them. This particular model
has been used in many U.S. hospi-
tals; at our institution, it is used by
other services, establishing a pre-
cedence (WOCN Society National
Public Policy Committee, 2012).
Improvement B featured a change in
OR scheduling. In our current workflow,
the acute pain coordinator spends a lot of
time asking the surgical team if they want
an epidural for their patient. With the
proposed change, this decision would be
part of the OR posting, thus saving time
communicating with the surgical team on
the day of the surgery.
The second part of Improvement B
limits the time taken to perform the epi-
dural, thus preventing delays in the operat-
ing room. To do this, we proposed setting
a cutoff at 30 minutes on an epidural
placement. If the epidural cannot be placed
within that time, providers would use an
alternative mode of analgesia. In our prac-
tice, 30 minutes was deemed to be enough
time to attempt to place an epidural.
For the second cycle, we examined
facility use for epidural placement. To
demonstrate the impact of shifting patients
from receiving epidurals in the operating
room to receiving epidurals in the preoper-
ative holding room, two alternative lower-
cost options were proposed that required
epidural placement in the holding room in
a higher percentage of cases (C-1 and C-2
in Table 1).
Performing epidural placement in the
OR or holding area is standard practice
around the United States. The physicians
performing these procedures are both
equally qualified anesthesiologists who
 Time-Driven Activity-Based Costing in Acute Pain Management

Table 1
Process Improvement Initiatives
Process
Improvement Time
Cycle Improvement Description Savings Cost Savings
Cycle 1 Improvement A Assign acute pain RN 11 minutes $76.02
Personnel change instead of anesthesia
MD
Assign resident instead of 5 minutes $37.06
anesthesia MD
Assign acute pain MLP 10 minutes $24.25
to follow up 70% of
the time in place of the
anesthesia MD
Improvement B OR schedule redesign: 48 minutes $70.56
Workflow change Reduce APM coordinator
effort by 48 minutes
Limit time to 30 minutes 10 minutes $92.88
for epidural placement
Cycle 2 Improvement C C-1a: Try to place Not $394.27 for
Facility/volume epidurals in holding applicable every epidural
change room for 50% and in placed in the
OR for 50% of epidural holding room
patient cases versus the OR
C-2a: Try to place epidurals Not
in holding room for 80% applicable
and in OR for 20% of
epidural patient cases
Note. APM = acute pain management; MD = personnel with MD; MLP = midlevel provider; OR = operating room; RN =
personnel with RN.
a
C-1 and C-2 are alternatives to each other.

often switch roles from the operating room
to the acute pain team. The monitoring of
the patients during the placement of the
epidural and the sedation given in both
locations is similar. After surgery, both
patient groups follow the same pathway.
Thus, the difference in placing the epi-
dural in the OR or the holding area is
essentially the location, and therefore the
difference in the facility cost. The OR is
much higher priced real estate per unit of
time compared to the holding area. In the
OR, there is also the consideration of lost
opportunity costs, as a surgical case could
be performed (and billed) in the time used
to perform an epidural.
TDABC methodology was used to
analyze results in a retrospective cohort
study of patients undergoing six thoracic
surgery procedures (chest wall resection,
esophagectomy, extrapleural pneumo-
nectomy, thoracotomy, pneumonectomy,

www.ache.org/journals e81

© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
 Journal of Healthcare Management
and video-assisted thoracoscopy), totaling
610 procedures, at a tertiary cancer hos-
pital. The mean length of stay according
to pathway was calculated and applied to
the TDABC totals, and the cost savings of
applying the process improvements were
estimated.
RESULTS
The three types of process-improvement
changes (personnel, workflow, and facil-
ity) each resulted in cost savings (see Table
1). Personnel change (Cycle 1-A) reflects a
reduction in time worked by more expen-
sive personnel. In workflow change (Cycle
1-B), scheduling was adjusted to limit
the time spent on specific tasks. All time
savings reported in Table 1 represent the
change in time between the previous aver-
ages and the new restricted times. Finally,
facility change (Cycle 2) showed that the
mean cost of placing the epidural in the
preoperative holding room was 33% less
than that of placing it in the OR.
Personnel (A) and workflow (B)
process changes resulted in mean cost
savings of 14% for the pathway with the
epidural placed in the holding room and
a mean cost savings of 7% for placing
the epidural in the OR. This percentage
savings is for the cost of pain care for the
six thoracic surgeries. Most cost savings
were due to redeploying anesthesiologists
to more appropriate duties and reduc-
ing their unnecessary duties by 30%. The
retrospective analysis showed that for the
six types of thoracic surgery performed at
the institution in 2013, 8%, or $125,781.90,
of the costs of pain care could have been
saved with these process-improvement
initiatives (see Process Improvement Cycle
1 in Figure 3).
e82 Volume 63, Number 4 • July/August 2018
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
Shifting epidural placement from the
OR to the preoperative holding room also
significantly decreased costs (see Pro-
cess Improvement Cycle 2 in Figure 3).
In 2013, institutional data showed that
most epidurals for the six thoracic surgery
procedures were placed in the operating
room (80%). Shifting patient volume so
that half the epidurals were placed in the
holding room and half were placed in the
OR (change C-1) resulted in cost savings
of 14%. Shifting patient volume so 80% of
epidurals were placed in the holding room
and 20% were placed in the OR (change
C-2) resulted in cost savings of 18%. The
length of stay and cardiac and pulmonary
complications were the same in all patients,
regardless of their location for epidural
placement.
DISCUSSION
By modeling and predicting the potential
impacts of personnel reallocation, work-
flow changes, and shifting patient volumes
to different locations for epidural place-
ment, TDABC helped identify cost driv-
ers that can be reduced. In recent years,
hospitals have been encouraged to contain
healthcare delivery costs and have since
called for costs to be included in proposals
for new medical interventions (Johnstone
& Martinec, 1993; Kaplan et al., 2014;
Schuster, Standl et al., 2004; Werner &
Nielsen, 2007). However, data on the costs
of delivering postoperative pain control in
clinical practice are still lacking (Schuster
& Standl, 2006; Werner & Nielsen, 2007),
and the cost of delivering adequate pain
control for patients undergoing thoracic
surgery remains unknown at our institu-
tion. It would be beneficial for healthcare
providers, especially those in surgery and
 Time-Driven Activity-Based Costing in Acute Pain Management

Figure 3
Cost Savings After Improvements Compared With Current Processes

Process Improvement Cycle TDABC Cost Savings Percentage Change

Process Improvement Cycle 1 $125,781.90 -8%
Process Improvement Cycle 2 C-1 $207,498.04 -14%
Process Improvement Cycle 2 C-2 $275,684.05 -18%

$300,000.00 0%
-2%
$250,000.00
-4%
-6%
$200,000.00
-8%
$150,000.00 -10%
-12%
$100,000.00
-14%
-16%
$50,000.00
-18%
$0.00 -20%
Process Improvement Process Improvement Process Improvement
Cycle 1 Cycle 2 C-1 Cycle 2 C-2

TDABC Cost Savings Percentage Change

anesthesiology, to quantify and evaluate
the costs of delivering skilled pain manage-
ment services over the course of a patient’s
complete cycle of care. Only then would
we be able to assess the costs and tradeoffs
of process-improvement initiatives in
delivering acute pain services (Johnstone
& Martinec, 1993; Kaplan et al., 2014;
Senagore et al., 2001). TDABC methodol-
ogy is advantageous because it provides a
feasible approach to determining the true
costs of delivering healthcare services and
facilitates the identification of process-
improvement opportunities (French et al.,
2013; Kaplan et al., 2014).
For our first improvement cycle,
TDABC methodology allowed us to
model the improvements in workflow
and the reallocation of personnel so they
could perform at the highest level of their
licensure. Together, these estimates showed
that the acute pain team at our institution
could reduce costs without compromising
quality, which is assessed by adequate pain
control for patients.
Our second improvement cycle mod-
eled a change in procedure location that
also did not compromise quality, as equally
qualified anesthesiologists performed the
epidural procedure regardless of the loca-
tion. Furthermore, from our review of the
retrospective data, the patient outcomes of
length of stay and pulmonary and cardiac
complications did not differ between the
groups that experienced and did not experi-
ence the changes of the second improve-
ment cycle. This supports the results of an
earlier study, which found that turnover
times were the same in the operating room
whether the epidural was administered in an
induction area outside the operating room
or in the operating room itself (Mulroy

www.ache.org/journals e83

© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
 Journal of Healthcare Management
et al., 2000). Thus, placing the epidural in
the preoperative holding room is more cost-
effective than placing the epidural in the OR
and maintains the same standard of care.
LIMITATIONS
A clear limitation of this study is that we
did not account for the use of medication,
equipment, and other supplies (i.e., mate-
rial costs). Obtaining the necessary cost
data for the materials proved difficult, and
considering that we could not influence
what materials were used (nor did the
study aim to do any sort of comparative
analysis of medications), we decided to
exclude material costs. Studies have consis-
tently shown that one half to two thirds of
the costs of pain care delivery are attrib-
utable to personnel (French et al., 2013;
Schuster & Standl, 2006; Schuster, Standl
et al., 2004); therefore, we focused on
assessing the personnel costs of managing
pain after thoracic surgery using TDABC.
Future studies of pain management costs
will need to include other cost drivers such
as facilities beyond our estimates of operat-
ing room costs and medication, equipment,
and supplies (Johnstone & Martinec, 1993).
Obtaining accurate facility costs for
use of the operating room is difficult, yet
essential. Future analyses should aim to
include all costs incurred by all processes
of interest. Although we did not know the
cost per minute of operating room use at
our institution, we were able to complete
our analysis using the costs available in
the literature. Besides the major limitation
of using a facility cost from the literature,
we also did not tackle the surgical pro-
cess times and surgical follow-up, as our
model could not affect process or person-
nel changes in those regards. An operating
e84 Volume 63, Number 4 • July/August 2018
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
room is most efficient when surgeries are
being performed in it; thus, we assessed the
cost of using the OR for epidural place-
ment instead of surgery. Another limitation
of this study is the use of an institutional
overhead rate for CCRs instead of a depart-
ment-specific overhead rate. Departments
with large amounts of depreciable capital,
such as equipment and technology, have
higher institutional support costs, leading
to higher costs overall.
CONCLUSION
Using TDABC methodology focused on
personnel costs enabled us to capture
complex processes and assess their costs
with manageable effort. We demonstrated
that TDABC helps identify process-
improvement opportunities and can model
and predict the financial impact of those
changes without actual implementation.
Our analysis provides justification for fur-
ther investigation of our proposed process-
improvement initiatives.
REFERENCES
Elixhauser, A., & Andrews, R. M. (2010). Profile
of inpatient operating room procedures in US
hospitals in 2007. Archives of Surgery, 145(12),
1201–1208. doi: 10.1001/archsurg.2010.269
Feeley, T. W., Fly, H. S., Albright, H., Walters, R., &
Burke, T. W. (2010). A method for defining value
in healthcare using cancer care as a model. Jour-
nal of Healthcare Management, 55(6), 399–411.
French, K. E., Albright, H. W., Frenzel, J. C.,
Incalcaterra, J. R., Rubio, A. C., Jones, J. F., &
Feeley, T. W. (2013). Measuring the value of pro-
cess improvement initiatives in a preoperative
assessment center using time-driven activity-
based costing. Healthcare, 1(3–4), 136–142. doi:
10.1016/j.hjdsi.2013.07.007
French, K. E., Guzman, A. B., Rubio, A. C., Frenzel,
J. C., & Feeley, T. W. (2016). Value based care
and bundled payments: Anesthesia care costs
 Time-Driven Activity-Based Costing in Acute Pain Management
for outpatient oncology surgery using time-
driven activity-based costing. Healthcare, 4(3),
173–180.
Johnstone, R. E., & Martinec, C. L. (1993). Costs of
anesthesia. Anesthesia and Analgesia, 76(4), 840–
848. doi: 10.1213/00000539-199304000-00028
Kaplan, R. S., & Anderson, S. R. (2004). Time-driven
activity-based costing. Harvard Business Review,
82(11), 131–138. doi: 10.2139/ssrn.485443
Kaplan, R. S., & Anderson, S. R. (2007). Time-driven
activity-based costing: A simpler and more power-
ful path to higher profits. Boston, MA: Harvard
Business School Press.
Kaplan, R. S., Witkowski, M., Abbott, M., Guzman,
A. B., Higgins, L. D., Meara, J. G., … Feeley,
T. W. (2014). Using time-driven activity-based
costing to identify value improvement oppor-
tunities in healthcare. Journal of Healthcare
Management, 59(6), 399–412.
Lavand’homme, P., De Kock, M., & Waterloos,
H. (2005). Intraoperative epidural analgesia
combined with ketamine provides effective
preventive analgesia in patients undergoing
major digestive surgery. Anesthesiology: The
Journal of the American Society of Anesthesiolo-
gists, 103(4), 813–820.
Macario, A. (2010). What does one minute of
operating room time cost? Journal of Clini-
cal Anesthesia, 22(4), 233–236. doi: 10.1016/j.
jclinane.2010.02.003
McLaughlin, N., Burke, M. A., Setlur, N. P.,
Niedzwiecki, D. R., Kaplan, A. L., Saigal,
C., … Kaplan, R. S. (2014). Time-driven
activity-based costing: A driver for provider
engagement in costing activities and redesign
initiatives. Neurosurgical Focus, 37(5), E3. doi:
10.3171/2014.8.FOCUS14381
Mulroy, M. F., Larkin, K. L., Hodgson, P. S., Helman,
J. D., Pollock, J. E., & Liu, S. S. (2000). A compar-
ison of spinal, epidural, and general anesthesia
for outpatient knee arthroscopy. Anesthesia and
Analgesia, 91(4), 860–864.
www.ache.org/journals e85
© 2018 Foundation of the American College of Healthcare Executives. All rights reserved.
Öker, F., & Özyapici, H. (2013). A new costing model
in hospital management: Time-driven activity-
based costing system. The Health Care Manager,
32(1), 23–36.
Schuster, M., Gottschalk, A., Freitag, M., & Standl,
T. (2004). Cost drivers in patient-controlled
epidural analgesia for postoperative pain man-
agement after major surgery. Anesthesia and
Analgesia, 98(3), 708–713.
Schuster, M., & Standl, T. (2006). Cost driv-
ers in anesthesia: Manpower, technique and
other factors. Current Opinion in Anesthe-
siology, 19(2), 177–184. doi: 10.1097/01.
aco.0000192790.78139.82
Schuster, M., Standl, T., Wagner, J. A., Berger, J.,
Reißmann, H., & Am Esch, J. S. (2004). Effect
of different cost drivers on cost per anesthesia
minute in different anesthesia subspecialties.
Anesthesiology: The Journal of the American Soci-
ety of Anesthesiologists, 101(6), 1435–1443.
Senagore, A. J., Whalley, D., Delaney, C. P., Mekhail,
N., Duepree, H. J., & Fazio, V. W. (2001). Epi-
dural anesthesia-analgesia shortens length of
stay after laparoscopic segmental colectomy for
benign pathology. Surgery, 129(6), 672–676.
Thaker, N. G., Frank, S. J., & Feeley, T. W. (2015).
Comparative costs of advanced proton and
photon radiation therapies: Lessons from time-
driven activity-based costing in head and neck
cancer. Journal of Comparative Effectiveness
Research, 4(4), 297–301.
Werner, M. U., & Nielsen, P. R. (2007). The acute
pain service: Present and future role. Current
Anaesthesia and Critical Care, 18(3), 135–139.
WOCN Society National Public Policy Committee.
(2012). Reimbursement of advanced practice
registered nurse services: A fact sheet. Journal of
Wound, Ostomy, and Continence Nursing, 39(2
Suppl), S7.
Wright, J. G., Roche, A., & Khoury, A. E. (2010).
Improving on-time surgical starts in an operating
room. Canadian Journal of Surgery, 53(3), 167.