A combined modelling of fuzzy logic and Time-Driven Activity-based Costing (TDABC) for hospital services costing under uncertainty

Hospital traditional cost accounting systems have inherent limitations that restrict their usefulness for measuring the exact cost of healthcare services. In this regard, new approaches such as Time Driven-Activity based Costing (TDABC) provide appropriate information on the activities needed to provide a quality service. However, TDABC is not flawless. This system is designed for conditions of relatively accurate information that can accurately estimate the cost of services provided to patients. In this study, the fuzzy logic in the TDABC model is used to resolve the inherent ambiguity and uncertainty and determine the best possible values for cost, capacity, and time parameters to provide accurate information on the costs of the healthcare services. This approach has not yet been tested and used in determining the costs of services of a healthcare setting. Therefore, the aim of this study is to present a new Fuzzy Logic-TDABC (FL-TDABC) model for estimating healthcare service costs based on uncertainty conditions in hospitals. The proposed model is implemented in a sample of the hospital laboratory section and the results are compared with the TDABC system. The TDABC model, by allocating the activity costs including fixed costs and not considering the uncertainty regarding the cost, capacity, and time required for each patient, often estimates the unused capacity and costs with a higher margin of error. The results show that the maximum difference in the prescribed costs was 4.75, 3.72, and 2.85 in blood bank, microbiology, and hematology tests, respectively, mostly due to uncertainty in the costs of consumables, equipment and manpower (on average 4.54, 3.8, and 3.59, respectively). Also, The TDABC system, in comparison with the proposed system, estimates the unused capacity of the resource with more error. Cost of unused capacity derived using FL-TDABC were 80 of costs derived using TDABC. In conditions where the information is ambiguous, using the new system in hospitals can lead to a more accurate estimate of the cost compared to the TDABC system. Moreover, it helps hospital managers to make appropriate decisions about the use of capacity, capital budgeting, cost control, and etc. © 2018 Elsevier Inc

Del ABC al TDABC. ¿Una herramienta efectiva en la gestión de costos para las pymes?

En los 80, surgió el sistema de costos ABC para satisfacer las necesidades de información que los sistemas tradicionales no proporcionaban y que las empresas requerían para tomar decisiones efectivas en un entorno empresarial competitivo. La implementación de este sistema presentaba ciertos problemas, los cuales hacían que no fuera aceptado universalmente a pesar de la atractiva propuesta de valor que ofrecía. Ante esta situación, Kaplan y Anderson proponen el TDABC para aminorar la complejidad y la subjetividad que implicaba el método ABC. El propósito de la presente investigación es mostrar evidencia disponible sobre la aplicación del TDABC en las pymes y conocer si este sistema de gestión de costos les ha otorgado los beneficios que estos académicos afirman en la teoría. La metodología utilizada es una revisión bibliográfica a treinta artículos para sintetizar la información relacionada a la fundamentación teórica del TDABC y mostrar las limitaciones y ventajas identificadas tras su aplicación en este tipo de organizaciones. Respecto a los resultados, los autores identificaron las siguientes ventajas: la facilidad de su aplicación, la flexibilidad del modelo y la medición de la capacidad inactiva. Sin embargo, estas ventajas no compensan la subjetividad generada. En conclusión, el TDABC no otorgó a las pymes seleccionadas todos los beneficios que Kaplan y Anderson sostienen en la teoría.Trabajo de investigaciónCampus Lima Centr

Cálculo de custos com base no tempo gasto por atividade para serviços de tomografia

A través del costeo basado en el tiempo invertido por actividad y de la asignación de costos se utiliza el tiempo como inductor de la actividad, y bajo la premisa de que la capacidad práctica no puede ser igual a la capacidad teórica, se desarrolla el presente estudio, con el objetivo de proponer un costeo basado en el tiempo invertido por actividad (TDABC), para un servicio de tomografía; a través de un estudio inductivo, descriptivo, de corte transeccional, utilizando la observación y el análisis de datos, el estudio se realizó en colaboración y coordinación con el área financiera y el personal del área de tomografía. Los resultados incorporan los análisis de procedimientos y subprocedimientos, actividades y comparaciones, así como los resultados del costeo a través del TDABC, como es el caso de un servicio en el que se invierte 38 minutos para su procesamiento y atención, de acuerdo al TDABC, el costo del servicio sería de S/ 597.47.Through the costing based on time spent per activity and cost allocation, time is used as an inductor of the activity, and under the premise that the practical capacity cannot be equal to the theoretical capacity, the present study is developed, with the objective of proposing a costing based on time spent per activity (TDABC), for a tomography service; through an inductive, descriptive, cross-sectional study, using observation and data analysis, the study was carried out in collaboration and coordination with the financial area and the staff of the tomography area. The results incorporate the analysis of procedures and sub-procedures, activities and comparisons, as well as the results of the costing through the TDABC, as is the case of a service in which 38 minutes are invested for processing and attention, according to the TDABC method, the cost of the service would be S/ 597.47.Á travers le chiffrage basé sur le temps investi par activité et la répartition des coûts, le temps est utilisé comme inducteur de l\u27activité, et sous le postulat que la capacité pratique ne peut être égale à la capacité théorique, la présente étude est développée. L\u27objectif de proposer une tarification au temps passé par activité (TDABC), pour une prestation de tomographie; Par le biais d\u27une étude inductive, descriptive, transversale, utilisant l\u27observation et l\u27analyse des données, l\u27étude a été réalisée en collaboration et en coordination avec le domaine financier et le personnel du domaine de la tomographie. Les résultats intègrent l\u27analyse des procédures et des sous-procédures, des activités et des comparaisons, ainsi que les résultats du chiffrage via le TDABC, comme c\u27est le cas d\u27un service dans lequel 38 minutes sont investies pour le traitement et l\u27attention, selon le TDABC., le coût du service serait de S/ 597,47.Através do sistema de custeio baseado no tempo investido por atividade e na alocação de custos, o tempo é utilizado como indutor da atividade, e sob a premissa de que a capacidade prática não pode ser igual à capacidade teórica, este estudo é desenvolvido, com o objetivo de propor um custeio baseado no tempo investido por atividade (TDABC), para o serviço de tomografia, da Clínica Adventista Ana Stahl; Através de um estudo indutivo, descritivo, transseccional, utilizando observação e análise de dados, o estudo foi realizado em colaboração e coordenação com a área financeira e o pessoal da secção de Imagens da Unidade de Análise. Os resultados reavaliam a importância da aplicação dos custos que correspondem a cada atividade, o que permitirá uma gestão adequada dos recursos financeiros, constituindo um contributo para as ciências contabilísticas.

Strategi Menentukan Harga Pokok Produksi yang Kompetitif Menggunakan Metode Activity Based Costing di PT. XYZ Food

PT XYZ Food realized the importance of accurate costing strategies to increase company profitability. The traditional method of determining the cost of goods manufactured led to undercosting or overcosting, which further resulted in a low selling price. Therefore, the company implemented the Activity Based Costing (ABC) method to calculate the cost of goods manufactured by identifying and classifying activities into four levels and setting cost targets for each activity level. The results of the ABC method showed that the cost of Snack Series 10 gr was Rp. 17,246 per kg and Mie Sedap Series 9 gr was Rp. 17,247 per kg. Through pricing structure simulations, the company could reach the Highest Retail Price of Rp. 500 without reducing margins, and even the margin of ABC was greater than the traditional method.  Thus, the use of ABC in determining the cost of goods manufactured can help companies increase profits and get accurate prices in a competitive market

The Realities and Expectations of Calculating Government Service Costs: An Analysis of Jordanian Hospitals

The goal of this study is to look at how government service expenses are calculated and analysed in Jordanian hospitals to direct health spending in the hospitals of the ministry of health of Jordan for 2021. ABC systems encourage hospitals to use, improve, and evolve in order to save government spending. The theoretical analysis's most significant conclusions were that the process of computing service costs was wrong and did not rely on the cost accounting system of activities or others. Furthermore, the calculation technique has resulted in a significant disparity in the cost of calculating each service from one hospital to the next, proving the inadequacies of the calculation approach. The study indicates that the Health Activity-Based Costing System (ABC) be activated to monitor expenditures, especially medical and healthcare disposables, in order to decrease waste costs; that pay-outs on the system be linked to high involvement files; and that an inventory is conducted at the close of every year to guarantee that the stock fits actual spending

Aplicação De Um Modelo Time-Driven Activity-Based Costing (TDABC) Numa Cirurgia Cardíaca de Substituição da Válvula Aórtica

A saúde tem um elevado impacto na economia portuguesa, sendo relevantes estudos para anali-sar os custos das organizações de saúde. A sua estabilidade é uma prioridade, e deve motivar o pessoal clínico e administrativo a custear as suas atividades com precisão para negociar um financiamento ade-quado. O financiamento dos hospitais do Serviço Nacional de Saúde (SNS) assenta em contratos-pro-grama estabelecidos com o Estado, colocando-se a questão se o pagamento das cirurgias reflete os seus custos reais. Assim, pretende-se estudar o custo de um serviço publico de cirurgia hospitalar, comparando-o com o preço de reembolso estabelecido pela Estado Português, com o objetivo de compreender se o preço de financiamento reflete ou não o custo do procedimento cirúrgico. Tendo em conta a complexidade inerente a atividades cirúrgicas, recorreu-se ao método de cus-teio Time-Driven Activity-Based Costing (TDABC). A sua acessibilidade e simplicidade, deve-se ao facto de, para calcular o custo de uma cadeia de processos é apenas necessário determinar a capacidade e o custo de cada recurso envolvido. Com o TDABC determina-se o custo por doente podendo ser o ponto de partida para um debate sobre o financiamento nos hospitais. A aplicação do TDABC iniciou-se com o mapeamento do percurso geral do doente, listagem das atividades de uma Cirurgia Cardíaca de Substituição da Válvula Aórtica (CCSVA) e dos recursos en-volvidos. Analisou-se uma amostra de 31 doentes para calcular o custo médio com custos diretos, ob-tendo-se o valor de 4 000,5€ (60,1%). Tendo em consideração a capacidade e os encargos associados a cada recurso, foram determinados os Capacity Cost Ratings dos RH, custos indiretos e equipamentos. Conforme a amostra em análise, foram calculados os custos destes recursos, obtendo-se os seguintes valores: RH: 778,7€ (11,7%), custos indiretos: 1 849,8€ (27,8%) e equipamentos: 28,7€ (0,4%). O TDABC foi apenas aplicado ao procedimento cirúrgico, isto é, o custo aferido não inclui o in-ternamento do doente nos sete dias seguintes à intervenção. Assim, considerou-se que o custo de um dia de internamento é o referido nas tabelas de Grupo Diagnostico Homogéneo (GDH): 3 123,01€, desta forma, tem-se que o custo total é de 28 518,81€. Considerando, os valores médios estipulados para este tipo de intervenção de 16 663,25€, conclui-se que a CCSVA está subfinanciada em 42%. De acordo com o estudo realizado, o preço estabelecido pelo GDH para a CCSVA, não reflete os custos reais do procedimento. O TDABC fornece informação detalhada sobre uma cirurgia, podendo ser uma ferramenta útil, não só para aferir os custos associados à mesma, como para identificar oportu-nidades de melhoria.The health sector has a great impact on the Portuguese economy and studies concerning the costs of health organizations are crucial. The financial stability of these organizations is a priority and there-fore clinical staff, and administrators should be encouraged to cost their activities with accuracy. The reimbursement of the National Health System (SNS) hospitals is based on contracts between the hospi-tals and the Government, and it is questionable if the established price for surgeries represents its actual cost. This study aims to analyse the cost of a public hospital surgical service and compare it with the reimbursement price set by the Portuguese government to determine if the reimbursement price reflects or not the actual cost of the procedure. The Time-Driven Activity-Based Costing (TDABC) is an appropriate costing method to deter-mine the cost of complex activities such as surgical procedures. This method has a simple application since it just requires the total cost and capacity of the resources involved in the process. With the TDABC it is possible to determine the cost per patient that might be the starting point for a discussion regarding reimbursement in the hospitals. The TDABC application began with the mapping of the overall patient care path, where it was established the Aortic Valve Replacement Heart Surgery (AVRHS) activities and the necessary re-sources. The average direct cost was calculated based on a sample of 31 patients and its value is 4 000.5€ (60.1%). According to the capacity and costs of the HR, indirect costs, and equipment it was calculated the respective Capacity Cost Ratings. Based on the same sample it was determined the cost of human resources: 778.7€ (11.7%), indirect costs: 1 849.8€ (27.8%) and equipment: 28.7€ (0.4%). The calculated cost is only related to the surgical procedure and therefore does not include the cost of the seven days patient's stay. For this reason, it was considered that each day that the patient spent recovering in the hospital represents 3 123.01€, this value was estimated according to the prices defined by the Diagnosis-Related Group (DRG). In conclusion the price for the procedure and patient stay is 28 518.81€, 42% higher than the price established. The application of the TDABC shows that the price set for reimbursement of the AVRHS does not reflect its actual cost. This method can provide detailed information concerning a surgery that might be a useful tool to determine its costs by activity and resource, as well as to identify improvement op-portunities

Book of abstracts of the ICIEOM-CIO-IIIE International Conference 2015

BOOK OF ABSTRACTS OF THE ICIEOM-CIO-IIIE INTERNATIONAL CONFERENCE 2015: ENGINEERING SYSTEMS AND NETWORKS: The way ahead for industrial engineering and operations managemen

Uso de sistemas multidimensionais e algoritmos de data mining para implantação do método Time Driven Activity Based Costing (TDABC) em organizações orientadas por projectos

JEL: M150 e M410Quando o método ABC (Activity Based Costing) foi apresentado para o rateio de custos de actividades de processos gerenciais, representou uma profunda modificação em relação aos métodos anteriormente utilizados. Logo ficaram patentes as enormes vantagens que trazia assim como os desafios em implementálo. O método TDABC (Time Driven Activity Based Costing) surgiu devido justamente às dificuldades operacionais do uso do ABC. Ao invés do uso de estimativas, normalmente dadas pelo corpo de funcionários da empresa, do percentual de tempo gasto em cada actividade, o TDABC propõe duas fundamentais mudanças em relação ao seu predecessor. A primeira é que se considera um tempo de inactividade em relação ao total de horas potencialmente trabalhadas (idle time). A segunda é que será calculado o tempo gasto por hora de trabalho. Nesse caso, o gasto em cada actividade será conduzido multiplicando-se esse valor por hora pelo total de horas requerido por ela. O método TDABC gera um resultado fundamental na hora que for implantado em uma empresa. São as chamadas equações de tempo para cada actividade. Nessas equações, é calculado o tempo gasto em cada actividade diante de diferentes níveis de complexidade na execução dessa. Todo esse trabalho só é possível diante da existência de sistemas de gestão integrada ERP (Enterprise Resource Planning) que registram cada acção na empresa. Nessa tese de doutoramento há duas propostas relativas a implantação do TDABC em empresas: A primeira é que o acompanhamento dos tempos de actividades seja feito por um sistema de ERP associado a um sistema de Business Intelligence (BI) ao invés de um sistema simples de ERP. A segunda proposta é decorrente da primeira. Sugere-se o uso de algoritmos de data mining (principalmente os algoritmos de árvore de indução e de análise de conglomerados), presentes nos sistemas de BI, para a detecção de níveis de complexidade nas equações de tempo. Como razão para a primeira proposta mostramos que sistemas de ERP jamais foram planejados para a detecção de padrões entre os dados neles armazenados. Portanto, sozinhos, eles não poderiam detectar os níveis de complexidade existentes na execução de uma mesma actividade. Para a segunda proposta mostramos que em organizações orientadas por projectos, ou que tenham departamentos que elaborem projectos e possam ser considerados como análogos a estas, a escala do número de actividades e seus dados gerados é tão ampla que gera a necessidade de um sistema automático de detecção de níveis de complexidade nessas actividades. A construção desses objectivos nessa tese segue a seguinte ordem: Primeiro é elaborada uma revisão do método ABC e as razões que levaram ao modelo subsequente TDABC. Em seguida apresenta-se também os conceitos de gerenciamento de projectos e Business Intelligence, notadamente a arquitectura multidimensional de dados e os algoritmos de data mining, introduzindo-se a maneira com que BI possibilita a diferenciação em níveis de complexidade nas equações de tempo. Para tanto faz-se uma introdução à linguagem MDX (Multidimensional Expression) de construção de relatórios em BI. Também se mostra, através de uma introdução aos sistemas de ERP, que esse tipo de sistema sozinho não viabilizaria esse tipo de resultado. Como forma de ilustrar todos esses conceitos é relatada a experiência de colecta de dados de actividades em projectos desenvolvidos em três organizações e a aplicação de BI para a geração das equações de tempo sobre esses dados.ABC (Activity Based Cost) method was introduced in order to organize the way costs should be partitioned among enterprise management activities, and caused a deep change in the way this division used to be made. Soon it became quite clear the huge advantages of employing such method and the challenges associated with it. The TDABC method (Time Driven Activity Based Cost) was designed to overcome the operational difficulties in using ABC. Rather than employing estimates provided by the company employees, concerning the time spent on each management activity, TDABC suggest two pivotal changes in comparison with its predecessor. First, TDABC considers an idle time regarding the potential total time available for work. Second, TDABC calculates the cost spent per work hour. Therefore, the overall activity cost is reached by simple multiplication of this cost per hour by the number of work hours required by the activity. TDABC produces a fundamental output when it is employed in a company. It is the set of time equations for the management activities. Through these equations, it is possible to calculate the time spent in each activity considering also their different levels of complexities. This result is possible only due to ERP (Enterprise Resource Planning) systems that record every action being performed within the company. In this thesis, it is suggested two main initiatives concerning the usage of TDABC in enterprises. The first one is to employ a Business Intelligence (BI) system associated with an ERP system in order to track the time spent on the management activities. The second initiative is a consequence of the first. It is suggested the usage of Data Mining algorithms (mainly the algorithms for cluster analysis), available in BI suites, for the detection of the complexities levels within the time equations. As justification for the first initiative, it is shown that ERP systems were never designed to detect patterns within their databases. Therefore, without a BI module, it would be quite cumbersome for an ERP system to detect complexity levels in executing a management activity. For the second initiative, it is shown that an average enterprise produces a large-scale number of management activities, and tracking these activities generates a huge amount of data. The volume of information makes impossible to realize the levels of complexities inside the time equations without an automatic procedure to support it. The first part of this work is oriented to introduce a revision of the ABC and TDABC methods. Later, it is introduced the concepts of projects and project management. It is also presented some concepts about Business Intelligence systems and the multidimensional data architecture. The work also introduces the data mining algorithms that make available the detection of the complexity levels in management activities. It is also introduced the MDX( Multidimensional Expression ) language for building reports in BI systems as way to generate the proper sets of data for such detection. It is then reinforced the difficulties to perform this type of analysis in pure ERP systems. In order to illustrate these results it is reported a case study performed in three project management companies and the BI generation of time equations

Desenvolvimento de um modelo de custeio numa lavandaria industrial

Mestrado em Engenharia e Gestão IndustrialExame público realizado em 30 de Maio de 2022O presente projeto de dissertação foi realizado em ambiente industrial, numa empresa recente no setor de lavandaria industrial, a Engomadinha Lavandarias. A Engomadinha Lavandarias há cerca de 3 anos apostou numa nova etapa e construiu um armazém industrial com o principal objetivo de integrar novos mercados no ramo têxtil. Foi definido como objetivo a criação de um modelo de custeio e respetiva ferramenta de orçamentação para uma empresa do ramo de lavandaria industrial, de forma a fomentar a sua competitividade e garantir uma sustentabilidade financeira. O desenvolvimento do projeto foca-se sobretudo em dois tipos de serviços, a lavagem industrial e os acabamentos têxteis. Foi efetuada a recolha de dados com a identificação dos recursos produtivos e dos processos associados. Com estes dados foram determinados os tempos das atividades e processos dosserviços prestados pela empresa, tal como todos os gastos associados a essas atividades. Com a determinação dos tempos e custos operacionais, foi possível calcular custos-padrão unitários, usados como base para o modelo de orçamentação desenvolvido. Pela análise dos dados verificou-se que os tempos de ciclo na lavagem industrial são superiores aos tempos de ciclo dos acabamentos têxteis, enquanto que os tempos de ciclo de secagem são semelhantes entre os dois serviços. Os tempos setup são bastante elevados, havendo a possibilidade de um futuro estudo de redução destes tempos. Apesar de os clientes de lavagens industriais representarem 84% dos clientes da empresa, estes representam 55% das receitas, enquanto que os clientes de acabamentos têxteis (uma percentagem de 16%) representam 45% das receitas. Em termos de ocupação das máquinas, os clientes de lavagens industriais representam uma ocupação de cerca de 68%. Por sua vez, os clientes de acabamentos têxteis ocupam cerca de 32% dos tempos de ciclo. Com a implementação da metodologia de cálculo implementada, foi criada uma ferramenta orçamentação em MS Excel para a empresa usar mediante a solicitação de serviços, quer por clientes do seu portfólio quer por novos clientes. Este projeto permitiu a realização de análises económico-financeiras para obter uma perspetiva sobre a real utilização dos recursos e de como são aplicados, possibilitando assim estudos de melhorias e adaptações a realizar na própria organização. Palavras-chave: Lavandaria Industrial; Custos Industriais; Modelo de OrçamentaçãoThe present dissertation was carried out in an industrial environment, in a recent company in the industrial laundry sector, the company Engomadinha Lavandarias. About 3 years ago, Engomadinha Lavandarias took a new challenge and built an industrial warehouse with the main objective of integrating new markets in the textile sector. The objective was to create a costing model and the respective budgeting tool, in order to promote its competitiveness and ensure the company’s financial sustainability. The development of the project focuses mainly on two types of services, industrial washing and textile finishing.Data was collected to carried out the identification of productive resources and their associated processes. With these data, the activities and processes times of the services provided by the company were determined, as well as, all the expenses associated with these activities. With the determination of operating times and costs, it was possible to calculate unitary standard costs, used as a basis for the budgeting model developed. By analysing the data, it was found that the cycle times in industrial washing are higher than the cycle times of textile finishes, while the drying cycle times are similar for bothservices. The setup times are considerable high, showing an opportunity of a future study to reduce these times. Although industrial washing customers represent 84% of the total company's customers, they represent 55% of revenues, while textile finishing customers (a percentage of 16%) represent 45% of revenues. In terms of machine occupancy, industrial washing customers represent an occupancy of around 68%. In turn, textile finishing customers occupy around 32% of cycle times. With the implementation of the calculation methodology implemented, a budgeting tool was created in MS Excel for the company to use upon request for services, either by clients in its portfolio or by new clients. The project outcome allowed to carry out economic and financial analyses to obtain a perspective on the actual use of resources and how they are applied, thus enabling studies of improvements and adaptations to be carried out in the organization itself. Keywords: Industrial Laundry; Industrial Costs; Budgeting Mode

The adoption, adaptation, and abandonment of value-based health care

Introduction: Value-based health care (VBHC) is a strategic framework designed to improve care in parallel with lowered or sustained costs. It was soon touted as “the strategy that will fix health care”, garnering increased attention in different countries. The contextual differences between and within health systems, in addition to the wide range of strategies employed by organizations adopting VBHC, create an opportunity for developing empirical evidence on the adoption, adaptation and potentially abandonment of VBHC. Aim: To explore the adoption, adaptation, and potential abandonment of VBHC. Methods: The empirical data has been collected from the contexts of the Karolinska University Hospital and the Hospital Israelita Albert Einstein. Study I is an observational, cross-section survey exploring physicians’ awareness on core concepts of VBHC in the context of Latin America. Study II is a mixedmethods study investigating how healthcare providers in Latin America are implementing VBHC. Study III is a comparative case-study of how VBHC was adopted in two contextually different hospitals – Karolinska and Einstein - and how its application was influenced by contextual factors at the system and organizational levels. Study IV is a longitudinal case-study exploring how VBHC management innovations were adopted, adapted, and abandoned at Karolinska. The Complex Innovation Framework was used to analyze the findings and suggest potential feedback loops driving adoption, adaptation, and abandonment of VBHC. Findings: Study I found that high cost of healthcare was identified as the key driver for VBHC discussions in Brazil, and that awareness on VBHC amongst clinical staff was low. Study II showed that healthcare organizations adopting VBHC failed to conceptually define it and adopt it as an integrative strategy – instead they identified management practices unrelated with the Value Agenda as VBHC. Study III showed that organizations adapted VBHC to emphasize components that best translated into their system, e.g. Karolinska focused on health outcomes and Einstein on costs. VBHC adoption challenged established business models - Karolinska had difficulties matching the new organizational model with the research and education missions; Einstein with aligning the new financing models with their independent physician staff. Study IV further shows that VBHC adoption was driven by a coalition of interests at Karolinska; adaptation was required early in the adoption process due to several misfit examples - between the specialization mandate and delivery of multidisciplinary care; the decentralization of management and the organization’s IT and data systems, financial model and cultural values; and the models of patient participation. In the end, abandonment was characterized by a return to previous practices – merger of flows resulting in larger units; re-center of outcomes improvement narrative around NQRs; - and the “silent death” of VBHC artifacts, such as the PFCs or outcomes steering cards. Discussion: VBHC adoption is largely influenced by contextual factors at the health system level, leading to a phenomenon of piece-meal adoption. Since systemic and organizational business model alignment with the components of VBHC is generally low, organizations emphasize those that are most aligned with their health system goals and contextual circumstances. Conclusion: If adopters of VBHC are able to focus attention on integrated understanding of both outcomes and costs (the hard core of VBHC), we may start to unpack the specific care-related processes that contribute to value creation for different patient populations