Optimal utilization of ultrasound equipment : a research into utilization of ultrasound equipment, increasing efficiency and possible post-merger cost savings

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Optimal Utilization of

Ultrasound Equipment.

A research into utilization of ultrasound

equipment, increasing efficiency and possible

post-merger cost savings.

Bachelor thesis

Nienke Eijsvogel

10381619

Supervisor: A. Hu

Faculty of Economics & Business,

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Statement of Originality

This document is written by Nienke Eijsvogel who declares to take full

responsibility for the contents of this document.

I declare that the text and the work presented in this document is original and

that no sources other than those mentioned in the text and its references have

been used in creating it.

The Faculty of Economics and Business is responsible solely for the supervision

of completion of the work, not for the contents.

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Optimal utilization of ultrasound equipment. 1. 1 Introduction

The health care system in the Netherlands was reformed in 2006. Within the new health care system, both hospitals and health insurance companies have become private and exposed to competition. The newly implemented care reform will have to undertake a transition from publicly provided care to more self-reliance on the part of the citizens. The new system presents a unique variant of a social health insurance. Insurance companies have been consolidating, and currently four insurance groups control 90% of the insurance market (Meijer, Douven, van den Berg 2010). These insurance groups are becoming stricter on paying claims to policyholders. Due to the entry of a substantial number of freestanding clinics, competition among hospitals has increased further (Schut, Sorbe, Hoj, 2013). One way for hospitals to cope with the reformed system is by increasing their market share. An increased market share can improve their bargaining position to suppliers and insurance companies (Fill, Baines, 2010). Since the implementation of the new health care system, the number of hospital mergers significantly increased (KPMG 2013). Between 2009 and 2012, the number of independent hospitals decreased from 116 to 89 (KPMG 2013).

Multiple studies have examined post-merger changes in cost efficiencies and the outcomes vary. Kjekhus and Hagen (2007) investigate the effects on cost efficiency of seven hospital mergers over an 8-year period in Norway. The results showed a negative effect of 2-2.8% on cost efficiency. They concluded that mergers on a larger scale, involving total restructuring of the treatment process, may improve efficiency but most mergers do not. Another study in the USA showed significant cost savings through economies of scale in the first year following a merger, but those decreased by the third year and were no longer significant. These findings indicate that it’s possible that other motivations, unrelated to cost savings, may be the largest

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catalyst for mergers (Harrison, 2011). Prior studies often do not isolate specific factors from mergers that are most likely to yield efficiency gains or losses. These factors are important to merging parties because they could support arguments for efficiency gains that would justify their merger to antitrust authorities.

1.2 Research Objective

Currently the two largest academic hospitals in Amsterdam, Amsterdam Medisch Centrum (AMC) and Vrije Universiteit Medisch Centrum (VUmc), are further intensifying their collaboration. They had already been exchanging knowledge on a regular basis and since February 2011 they have been discussing the possibilities of an alliance between them. In 2014 both boards of directors presented their future ambitions to centralize departments and relocate them at either Meibergdreef (AMC) or at Boelenlaan (VUmc). By centralizing the most capital-intensive departments, the boards expect to generate cost savings. In both hospitals, some of the most capital-intensive departments are the ones making use of ultrasound technology. To justify a merger between VUmc and AMC, both hospitals will have to prove that their alliance will enable cost savings that would otherwise be infeasible. This thesis investigates whether centralizing the ultrasound departments will generate cost savings on equipment.

First, an inventory will be made of ultrasound equipment for every department in both

hospitals. For each procedure carried out by ultrasound equipment, the average execution time is determined. Then yearly production numbers will be converted to time. Total execution time will be linked to available equipment to calculate average daily utilization rates. Equipment with a utilization rate below 50% is considered underutilized (Kaul 2014, Kumar 2015). Total cost pre-merger is then compared to total cost if departments were centralized and equipment would be utilized at a 50% rate at least.

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1.3 Practical and scientifical contribution

Since the health care system was reformed in 2006, the number of hospital mergers has increased significantly (ACM, 2016). The government stated their concern about this merger wave and demanded more clarity on the effect of mergers on healthcare quality (Ministerie van Volksgezondheid, Welzijn en Sport 2016). The Netherlands Authority for Consumers and Markets examined the post-merger quality of healthcare for hospitals merged between 2007 and 2014 (ACM, 2016). No evidence was found that the quality of healthcare had improved . Following this research, the ACM stated that arguments that will justify a merger have to be better supported and they will become more critical in approving healthcare mergers. This thesis aims to investigate the efficiency argument that would justify a merger between AMC and VUmc. Since the ACM wasn’t as strict in their assessment before, this argument has not been investigated well. The utilization rates of ultrasound equipment will be calculated by an adapted form of the ALOS formula, which is a traditional measure to assess hospital

utilization rates. Increased efficiency and thus optimal utilization of equipment would eventually improve quality of healthcare (Kumar 2014).

The possible efficiency gains within a horizontal hospital merger have been subject to some empirical studies. The results vary and so do the motivations behind those mergers (Kjekhus and Hagen 2007, Harrison 2011). Studies to post-merger costs often do not isolate specific factors that are most likely to yield assessed gains or losses. Furthermore, most of these empirical studies have been done in countries other than the Netherlands. In comparison to other healthcare systems, the Dutch system presents a unique and innovative variant of social health insurance (Kroneman 2016). International comparisons show a low number of

avoidable hospitalizations and the Euro Health Consumer Index ranks the Dutch health care as number 1 within Europe (Björnberg 2015). Nevertheless, the Netherlands still has one of

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the highest per capita health expenditures (Kroneman 2016). Research done in foreign healthcare systems doesn’t necessarily apply to the Dutch healthcare system.

1.4 Thesis outline

In order to determine whether centralizing the ultrasound departments will generate cost savings on equipment, this thesis will be arranged in the following manner; Chapter 1 is an introductory chapter that contains an introduction, the research objective and the practical and scientific contribution. Chapter 2 covers the available literature on the research objective. Chapter 3 describes the data and research approach. Chapter 4 describes the methodology. Chapter 5 presents the results. Finally, in chapter 6, conclusions from this thesis and recommendations for future research are drawn.

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2 Literature Study 2.1 Introduction

First we will look at the probability that the merger will succeed and more important, consolidation will be successful. The definition of consolidating is combining a number of things into a single more effective or coherent whole. If results show opportunities for cost savings due to underutilized equipment, those cost savings doesn’t necerassily have to be exploited. In order to reap the benefits of merging, consolidation has to be a main priority and shouldn’t be underestimated. Then prior studies to utilization rates will be discussed followed by the cost savings that could be generated by increasing those rates.

2.2 A review of the literature:

2.2.1 Probability of a successful consolidation

There are multiple factors that influence the success rate of consolidation.

The first factor is cultural difference. Both AMC and VUmc are aware of the fact there are cultural differences. To assess their organizational culture both hospitals make use of the Organizational Culture Assessment Instrument (OCAI), a valid method to examine organizational culture and the desire for change. VUmc is described as a more formal institution and their culture is defined as hierarchical. OCAI results further show that a shift towards an adhocracy culture, based on flexibility and more freedom of act, is desired

(Schaeffer, Schuler, Straatman 2008). AMC on the other hand is described as a more informal institution with more openness between boss and employees. OCAI results also show a desired shift to an adhocracy culture, based on more dynamic and innovation (Gunning, Burger 2008). So in both hospitals the same cultural shift, towards adhocracy, is desired but cultural differences are still present. The negative effect of cultural differences on

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consolidation is that it would require more time to overcome initial disparities (Carleton, Lineberry, 2010). A succesful post-Merger outcome is subject to effective management of cultural integration (Saunders, Altinay, Riordan, 2009).

The second factor is a sharing a unifying vision and goal (DePamphilis 2001). With difference in culture comes also difference in not only vision and goals, but also orientation and values. This negative effect of cultural differences would be diminished by the unification of the boards of directors, which is planned for 2017. While there are still cultural differences in lower layers of the companies, the board of directors will share a common vision and goal. Common goals would drive different units to cooperate, and would ease the process of deciding on reorganizational changes and implementing those (DePamphilis 2001). This reorganizational process and its quality is the base of the whole consolidation process.

The third factor that effects consolidation is not only sharing a goal, but also the content of it. There can be different motivations behind mergers. A possible motivation behind a merger is to create ‘critical mass’. Critical mass is defined as occupying a leading position in a market, with sufficient strength to counterbalance suppliers, competitors and customers (Jonker, Sluyterman 2001). Critical mass is created to attain the requisite management and investment base in order to acquire costly technology or attract specialized staff. If creating critical mass is the primary motivation, consolidation and improvement in operating efficiency are not necessarily expected. If consolidation itself is the primary motivation, improvement in operating efficiency and reduction in overall scale are expected (Alexander, Harpern, Lee 1996). One of the primary motivations for the merger between VUmc and AMC is reducing the yearly write-off on equipment and improving efficiency. To achieve this, consolidation is necessary and therefore expected.

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The fourth factor is the size of the merging hospitals. Alexander, Harpern and Lee (1996) examined the effect of similarity in size on consolidation and efficiencies. They found that mergers between similarly sized hospitals displayed greater opportunities for consolidation and increased efficiencies than mergers between dissimilarly sized hospitals. The number of beds categorized size. AMC (1002 beds) and VUmc (733 beds) would both fall into the last category (500+) and according to this research method could expect greater opportunities for consolidation. On the other hand empirical evidence is consistent that the optimal size of a hospital is between 200 and 400 beds and above that size cost increase (Posnett 1999). Research in Denmark between 2004-2006 show an optimal size of 275 beds but note they preclude drawing a conclusion about the consolidation of hospitals leading to sizes exceeding 1200 beds, because it is outside the range of data used. Effect of size is therefore ambiguous.

2.2.2 Hospital utilization rates

Within hospitals, there have been multiple studies examining utilization rates. Research to utilization rate of hospital beds resulted in ‘Roemers Law’. Roemer's Law is the notion that an increase in the number of hospital beds per capita increases hospital utilization rates. The research concludes that an increase of 10 percent in hospital bed per capita would increase hospital utilization by about 4 percent (Ginsburg, Koretz 1983). Roemers Law is one of the few accepted generalizations about hospital performance (Taroni 2001). Consistent empirical findings over 40 years and across different health care systems confirm that supply induces demand of hospital services (Delamater, Messina, Grady, WinklerPrins, 2013). A tool that is used to calculate bed utilization rates is the Average Length of Stay (ALOS) (Lewis,

McGrath, Seidel, 2011). The ALOS can be approached in multiple ways. Charge and

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formula:

𝐴𝐿𝑂𝑆 = 𝐼𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝐷𝑎𝑦𝑠 𝑜𝑓 𝐶𝑎𝑟𝑒 ÷ 𝐵𝑒𝑑 𝐷𝑎𝑦𝑠 𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒 𝑥100

Inpatient Days of Care is the accumulation of the length of stay for all patients. Bed Days Available is the accumulation of days beds were available for use. The ALOS is a traditional measure to calculate hospital activity and assess efficiency (Joumard, Hoeller, Andre, Nicq 2010).

Research to in particular ultrasound equipment has been done in India and the US. Kaul (2014) examined 30 cases and utilization rates were calculated by using an adapted form of the ALOS formula. The following formula:

𝑈𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝐶𝑜𝑒𝑓𝑓𝑖𝑐𝑖𝑒𝑛𝑡 = 𝐴×𝐵

𝐶×𝐷 ×100

A is the number of days equipment was used during the year. B is the number of hours the equipment was actually used during a working day. The average time for each procedure was asked and daily workload was observed from the log books of the whole year. (B = average time × average number of procedures performed on a working day). C is the number of days per year diagnostic equipment was available (working days). D is the number of hours

diagnostic equipment was available on a working day (opening hours). Kaul (2014) concluded the medical equipment had an average utilization rate of 60.2%. It was noted that delayed maintenance and breakdowns also affected utilization. Kumar (2015) examined 1993 cases for a period of 6 months. Utilization rates were also calculated using an adapted form of the ALOS formula. First, the workload was calculated by the number of treatments done daily over a 6-month period. The average time consumed for each scan was taken. The number of treatments done per day and total time the equipment was used were computed. Then the Utilization Index of equipment is derived with above data using the following formula:

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𝑈𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝐶𝑜𝑒𝑓𝑓𝑖𝑐𝑖𝑒𝑛𝑡 = _!! 𝑥 100

N is the average number of hours the equipment is used per day and M is the maximum number of hours the equipment can be used per day. Results show an average utilization rate of 50%. In the US, a RBMA data survey (2009) in the US analyzed 261 machines in 46 centers. The following formula was used to calculate utilization rates:

𝑈𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝐶𝑜𝑒𝑓𝑓𝑖𝑐𝑖𝑒𝑛𝑡 = 𝑊𝑒𝑒𝑘𝑙𝑦 𝑀𝑖𝑛𝑢𝑡𝑒𝑠 𝑈𝑠𝑒𝑑 ÷ 𝑊𝑒𝑒𝑘𝑙𝑦 𝑀𝑖𝑛𝑢𝑡𝑒𝑠 𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒 The survey concluded that ultrasound equipment in non-rural area’s has an average utilization rate of 56%. Significantly less than the 90% normative standard proposed by Med PAC.

2.2.3 Utilization rates and cost savings

Research to utilization rates and cost savings has been done to some extend. Andrade and Stafford (2000) found a significantly negative relation between own-industry mergers and utilization rates. Their findings were consistent with the contractionary motive for mergers to eliminate excess capacity. A more efficient use of equipment could increase utilization rates and eventually decrease scale and generate cost savings (Espen Eckbo 2010). Mergers with high levels of market overlap, as own-industry mergers, tend to have substantial opportunities for these sorts of cost savings. During the US debt ceiling negotiations between Joe Biden and Eric Cantor in 2011, increasing utilization rates of ultrasound equipment was proposed as a solution to lessen the federal debt. The Fiscal Year Budget (2013) cited possible savings of $800 million, if utilization rates would be increased to the 90% normative standard. Prior studies that focused on ultrasound utilization rates in India, recommend that valuable facilities, if underutilized, should be shared with other hospitals (Kaul 2014, Kumar 2015). Equipment is found underutilized when utilization rates are below 50%. These studies didn’t assess possible cost savings but noted under-utilized equipment will lead to major losses to

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stakeholders and utilizing equipment to their fullest is an important duty for hospital management.

3 Data

This section discusses the production and equipment data for each department. Production data were available in both hospitals. Dutch hospitals calculate the cost of treatment using a Diagnosis Treatment Combination (Diagnose Behandeling Combinatie (DBC)). This is an administrative code for a healthcare treatment that a patient with a given diagnosis undergoes. Once the treatment is completed, the hospital charges the health insurance company or

directly the patient, the DBC fee. For both hospitals the DBC code registration results in detailed ultrasound production data. Data on equipment were available within both hospitals but had to be validated and completed.

3.1 AMC Production and Ultrasound Inventory

AMC has 3 polyclinical departments that make use of ultrasound technology; Obstetrics, Gynaecology and a Fertility department. Obstetrics is the largest producer of ultrasound treatments. The departement not only performs ultrasound treatment on patients from the AMC, but also on patients that are referred tot hem by other hospitals. Obstetrics and

Gynaecology both are open from monday till friday. The Fertility department is open 7 days per week, because some treatments need specific timing and this could also be on weekends.

AMC Obstetrics Internal

Procedures Yearly

339486Y - PRENATALE SCREENING - COUNSELING 690

339486U - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - ELKE VOLGENDE

63 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I -

CONG. AFW.

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CONG.AFW.

339482A - ECHOGRAFIE A VUE IVW ZWANGERSCHAP - MET DOPPLER

3.451

339486B - ECHOGRAFIE - TRANSVAGINAAL 10

339486E - ECHOGRAFIE - GENITALIA INTERNA 133

339486G - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - ROUTINE - KLEIN

2.286 339486H - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - AT

INTAKE - UITGEBR.

2.475 339485M - ECHOGRAFIE A VUE IVM ZWANGERSCHAP -

MEERLING

496 339486W - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I -

ELKE VOLGENDE

117 339487A - PRENAT.SCREEN. - NUCHAL TRANSLUCEN.-NEKPL.-1LING-1E MEERL

476 339487B - PRENAT.SCREEN. -

STRUCT.ECHOSCOP.OND.-SEO-1LING-1E MEERL

876 339487C - PRENAT.SCREEN. - NUCHAL TRANSLUCEN.-NEKPL.-ELK VOLG.MEERL

23 339487D - PRENAT.SCREEN. -

STRUCT.ECHOSCOP.OND.-SEO-ELKE VOLG.MEERL

27

339486Y - PRENATALE SCREENING - COUNSELING 12

339486H - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - AT INTAKE - UITGEBR.

1

Total Internal 14406

Table 1. AMC Obstetrics production Internal

AMC Obstetrics Internal

Procedures Yearly

339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I -

CONG. AFW. 473

339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II -

CONG.AFW. 122

CONG. AFW. 373

CONG.AFW. 172

CONG. AFW. 133

CONG.AFW. 17

CONG. AFW. 254

CONG.AFW. 79

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CONG.AFW.

Total External 1656

Table 2. AMC External Obstetrics ultrasound production + Total Obstetrics

Gynaecology Procedures Yearly

339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP -

BEOORD.FOETALE VITAL. 83

339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 4699 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP -

339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1

Total Gynaecology 1773

Table 3. Gynaecology ultrasound production

Fertility Procedures Yearly

339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP -

339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 4699 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP -

339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1

Total Fertility 5866

Table 4. Fertility ultrasound production

AMC

Total Investment € 7.521.913,89 100% Ultrasound Poly. € 1.034.249,38 14% Table 5. Investment part Ultrasound AMC

Equipment Purchasing Year Purchasing Price Gynaecology Siemens Acuson X300 2008 € 30.250,00

Siemens Acuson X300 2008 € 30.250,00 Siemens Acuson X300 2016 € 30.250,00 Siemens Acuson X300 2016 € 30.250,00 Siemens Acuson X300 2016 € 30.250,00 Total € 151.250,00

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Obstetrics Voluson E8 2006 € 71.400,00 Voluson E8 2008 € 136.850,00 Voluson E8 2011 € 126.000,00 Voluson E10 2014 € 199.999,69 Voluson E10 2014 € 199.999,69 Total € 734.249,38

Fertility Siemens Acuson 2008 € 30.345,00

Siemens Acuson 2008 € 30.345,00

Philips HD 11 2011 € 44.030,00 Philips HD 11 2011 € 44.030,00 Total € 148.750,00

Total Value Polyclinical

Ultrasound Euipment € 1.034.249,38 Table 6. Ultrasound Equipment Inventory AMC

3.2 VUmc Production and Ultrasound Inventory

VUmc has 4 departments that make use of ultrasound technology; Gynaecology, Obstetrics the Fertility department and the Ferility Lab. All except the Fertility Lab are located in the same part of the hospital. Therefore CBV registration for Gynaecology, Obstetrics and the Fertility department are centralized and production data on ultrasound treatment is

accumulated. The 3 departments are open from Monday till Friday. The 4th department is the Fertility lab. The Fertility Lab is located in another part of the hospital and performs most fertility treatments. Unlike the polyclinic Fertility department, the Fertility Lab is open 7 days a week. Some treatments need specific timing and this could also be on weekends.

Fertility Lab

MONDAY-SUNDAY Procedures Yearly SATERDAY-SUNDAY

Procedures Yearly

339482 - ECHOGR.A VUE 8 339482 - ECHOGR.A VUE 0

339484F - FOLLIKELMET. 609 339484F - FOLLIKELMET. 178 339485G - ECHO GRAVIDI 968 339485G - ECHO GRAVIDI 0 339486B - ECHO TR.VAGI 589 339486B - ECHO TR.VAGI 0

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939481 - IUI PRE.ECHO 70 939481 - IUI PRE.ECHO 0

939485 - IVF PRE.ECHO 157 939485 - IVF PRE.ECHO 0

939486 - IVF ECHO 2546 939486 - IVF ECHO 711

939487 - IUI ECHO 2487 939487 - IUI ECHO 778

939490 - CRYO ECHO 1947 939490 - CRYO ECHO 695

939496 - OI VR.ECHO 17 939496 - OI VR.ECHO

Total Mon-Fri 9531 Total Sat-Sun 2362

Table 7. Fertility Lab ultrasound production Mon-Fri + Sat-Sun

Gyn + Obs + Fert Procedures Yearly

339486P - ECHO CONG.I 2371 339486Q - ECHO CONG.II 1430 339486U - ULTRAGELUID2 578 339421 - HYST.SALPING 277 339420 - SONOHYST.GR. 237 339482 - ECHOGR.A VUE 3564 339484C - FLOWMETING 1906 339485G - ECHO GRAVIDI 1961 339485X - ECHO CERVIXK 744 339487A - NT-METING 603 339487B - SEO 495 339487C - NT-METING 25 339487D - SEO 35 339492B - ECHO BUIKORG 1218

339486E - ECHO GEN.INT 1928

Total 17372

Table 8. Gynaecology, Obstetrics and Fertility ultrasound production

VUmc

Total Investments € 7.888.667 100%

Ultrasound Poly. € 968.381,00 12,28%

Table 9. Investment Part Ultrasound VUmc.

Equipment Purchasing Year Purchasing Price

Gynaecology Samsung WS80 2015 € 60.000,00 Samsung WS80 2015 € 60.000,00 Samsung H60 2015 € 40.000,00 Samsung H60 2015 € 40.000,00 Total € 200.000,00 Obstetrics Voluson E8 2006 € 100.000,00 Voluson E8 2010 € 150.000,00 Voluson E8 2013 € 167.356,00 Voluson E6 2015

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Total € 507.356,00 Fertility Prosound 6 2009 € 12.000,00 SSD-ALPHA-6 2015 € 39.675,00 _SSD-ALPHA-6 ₂₀₁₅ _{€ 39.675,00} Total € 91.350,00

Fertility Lab Aloka SSD-3500SX 2008 € 40.000,00

SSD-ALPHA-6 2010 € 50.000,00 Aloka 6 2013 € 40.000,00 SSD-ALPHA-6 2015 € 39.675,00 Total € 169.675,00

Total Value Polyclinical

Ultrasound Euipment € 968.381,00

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4 Methodology.

The utilization rates of equipment will be calculated using an adapted form of the ALOS formula. The average execution time of an ultrasound treatment is estimated to be 25 minutes. Production is then converted to total execution time:

𝑇𝑜𝑡𝑎𝑙 𝐸𝑥𝑒𝑐𝑢𝑡𝑖𝑜𝑛 𝑇𝑖𝑚𝑒 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑇𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡𝑠 𝑌𝑒𝑎𝑟𝑙𝑦 ∗ 𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝐸𝑥𝑒𝑐𝑢𝑡𝑖𝑜𝑛 𝑇𝑖𝑚𝑒

Time is then converted to working days (7,5 Hour) equipment is fully occupied by the following formula:

𝑊𝑜𝑟𝑘𝑖𝑛𝑔 𝐷𝑎𝑦𝑠 (𝐹𝑢𝑙𝑙𝑦 𝑂𝑐𝑐𝑢𝑝𝑖𝑒𝑑) =𝑇𝑜𝑡𝑎𝑙 𝐸𝑥𝑒𝑐𝑢𝑡𝑖𝑜𝑛 𝑇𝑖𝑚𝑒 7,5

Utilization rates per unit of equipment were then calculated by the following formula:

Utilization Rate = _{!"#$%& !" !"#$ !"#$ !"# !"#$%&#'%}!"#$%&' !"#$ !"##$ !""#$%&' ∗ _{!"#$%& !! !"#$%&'() !"#$%#&%'}!

Equipment with a utilization rate below 50% is considered underutilized (Kaul 2014, Kumar 2015). The value of equipment needed to perform at a 50% rate is calculated using the following formula:

𝑉𝑎𝑙𝑢𝑒 𝐼𝑛𝑣𝑒𝑛𝑡𝑜𝑟𝑦 𝑁𝑒𝑒𝑑𝑒𝑑 = 𝑈𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑅𝑎𝑡𝑒

0,5 𝑀𝑖𝑛𝑖𝑚𝑢𝑚 𝑅𝑎𝑡𝑒 ∗ 𝑉𝑎𝑙𝑢𝑒 𝑜𝑓 𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝐼𝑛𝑣𝑒𝑛𝑡𝑜𝑟𝑦

Then possible savings when equipment would be utilized at 50% are calculated by:

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5 Results.

5.1 Total Production

Department Procedures

Yearly Total Hours

Working days (7.5 hours) Fertility Lab VUmc 11893 4955,42 660,72 Gyn + Obs + Fert VUmc 17372 7238,33 965,11

Obstetrics AMC 16062 6692,50 892,33

Gynaecology AMC 1773 738,75 98,50

Fertility AMC 5866 2444,17 325,89

Table 11. Total Production converted to Time and Working days.

5.2.1 Utilization Rates VUmc

Procedures Yearly Execution Time Working days Open for Treatment

Gyn+Obs+Fer 17372 7238,33 965,11 260 Days a Year

Equipment Purchasing Year Purchasing Price Working Days Utilization Rate

Gynaecology Samsung WS80 2015 € 60.000,00 87,74 0,34 Samsung WS80 2015 € 60.000,00 87,74 0,34 Samsung H60 2015 € 40.000,00 87,74 0,34 Samsung H60 2015 € 40.000,00 87,74 0,34 Obstetrics Voluson E8 2006 € 100.000,00 87,74 0,34 Voluson E8 2010 € 150.000,00 87,74 0,34 Voluson E8 2013 € 167.356,00 87,74 0,34 Voluson E6 2015 € 90.000,00 87,74 0,34 Fertility Prosound 6 2009 € 12.000,00 87,74 0,34 SSD-ALPHA-6 2015 € 39.675,00 87,74 0,34 SSD-ALPHA-6 2015 € 39.675,00 87,74 0,34

Table 12. Utilization Rate Gynaecology + Obstetrics + Fertility VUmc

Fertility Lab 11893 4955,42 660,72 365 Days a Year

Equipment Purchasing Year Purchasing Price Utilization Rate

Aloka SSD-3500SX 2008 € 40.000,00 165,18 0,45

SSD-ALPHA-6 2010 € 50.000,00 165,18 0,45

Aloka 6 2013 € 40.000,00 165,18 0,45

SSD-ALPHA-6 2015 € 39.675,00 165,18 0,45

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5.2.2 Utilization Rates AMC

Procedures Yearly Exectution Time Working Days Open for Treatment

Obstetrics

Internal 14406 6002,5 800,33 260 Days a Year

External 1656 690 92 260 Days a Year

Total Obstetrics 16062 6692,5 892,33

Equipment Purchasing Year Purchasing Price

Working Days per Unit of

Equipment Utilization Rate

Voluson E8 2006 € 71.400,00 178,47 0,69

Voluson E8 2008 € 136.850,00 178,47 0,69

Voluson E8 2011 € 126.000,00 178,47 0,69

Voluson E10 2014 € 199.999,69 178,47 0,69

Table 14. Utilization Rates Obstetrics AMC

Procedures

Yearly Execution Time Working days

Open for Treatment

Gynaecologie 1773 738,75 98,5 260 Days a Year

Siemens Acuson X300 2008 € 30.250,00 19,7 0,08

Siemens Acuson X300 2016 € 30.250,00 19,7 0,08

Table 15. Utilization Rates Gynaecology AMC

Fertility 5866 2444,17 325,89 365 Days a Year

Siemens Acuson 2008 € 30.345,00 81,47 0,22

Philips HD 11 2011 € 44.030,00 81,47 0,22

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5.3.1

Department Value Equipment Inventory Utilization Rate

AMC Obstetrics € 734.249,38 0,69

AMC Gynaecology € 151.250,00 0,08

AMC Fertility € 148.750,00 0,22

Vumc Gyn+Obs+Fer € 798.706,00 0,34

Vumc Fertility Lab € 169.675,00 0,45

Table 17. Utilization Rates and Value Equipment Inventory AMC and VUmc

Optimal Utilization≥0,5 Ratio of Equipment Needed Value Equipment Needed Savings

AMC Gynaecology 0,08/0,5 € 24.200,00 € 127.050,00

AMC Fertility 0,22/0,5 € 65.450,00 € 83.300,00

Vumc Gyn+Obs+Fer 0,34/0,5 € 543.120,08 € 255.585,92

Vumc Fertility Lab 0,45/0,5 € 152.707,50 € 16.967,50

Total € 482.903,42

Table 18. Optimal Utilization and Savings AMC and VUmc

6 Conclusion

Utilization rates are different for every department. The AMC obstetrics department seems to outperform all others when it comes to utilization rates. The department does make use of expensive, high-end, equipment. 71% of the AMC ultrasound investments belong to the obstetrics department while they only store 5 out of the 14 numbers of equipment. However, with a 0,69 utilization rate they perform substantially above the 0,50 minimum. The second best performing department, when it comes to utilization rates, is the Fertility Lab from VUmc. With a 0,45 utilization rate they perform close to the 0,50 minimum. It should be noted that these utilization rates were calculated on a 365 years a day basis. Fertility

departments are also open for time specific treatments on weekends. They prefer however to perform other, not time-specific, treatments on weekdays. A 0,45 utilization rate reflects a higher utilization rate through weekdays, which is averaged down by a lower utilization rate on weekends. The same holds for the Fertility department at AMC. However, the AMC Fertility department shows a lower utilization rate of 0,22. This might reflect a higher

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Gynaecology, Obstetrics and Fertility from VUmc show an average utilization rate of 0,34. It’s unclear whether this average utilization rate reflects a same kind of distribution as the rates for AMC. The AMC Gynaecology department shows a utilization rate of only 0,08. The average of AMC Obstetrics and AMC Gynaecology would be around 0.385, which is close to the 0,34 rate for the 3 VUmc departments. If the departments at VUmc would perform at the 0,50 minimum, savings of approximately € 250.000,00 could be generated. It’s unclear which of the 3 departments has most room for improvement. The AMC Gynaecology department is the worst performing department when it comes to utilization rates. With a utilization rate of only 0,08, it could generate savings of approximately € 125.000,00 by increasing this rate to the 0,50 minimum.

In case the VUmc and AMC merge, most savings could be generated by a more efficient allocation of equipment in the AMC Gynaecology department and the VUmc Obstetrics, Gynaecology and Fertility departments. Since the AMC obstetrics department is already utilizing their equipment at a high level, merging this department with the VUmc Obstetrics department will probably not generate significant savings. If the VUmc Obstetrics department has a lower utilization rate then AMC, the post-merger utilization rate of Obstetrics could still be above the 0,50 minimum. The Gynaecology department of the AMC shows a very low utilization rate of equipment. Even when exact utilization rates for VUmc are unknown, most savings are expected by merging the two Gynaecology departments. Because it would take extremely high utilization rates for VUmc to bring the post-merger rate up to a level of 0,50. At last, the VUmc Fertility departments in both AMC and VUmc seem to have low utilization rates. The distribution of Fertility treatments is different between AMC and VUmc. While AMC centralized all their Fertility treatments in one department, VUmc divided them between a Fertility department, located next to other woman-related departments, and a Fertility Lab. The VUmc Fertility Lab shows a utilization rate of 0,45 which, as discussed

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before, probably is higher during weekdays. However, merging the AMC Fertility department and the VUmc Fertility department could probably generate savings. The AMC department is showing a 0,22 utilization rate and the VUmc department shows an (average) rate of 0,34. If only the AMC department would perform at the 0,50 minimum, already savings over € 80.000,00 could be generated. Overall there do seem to be opportunities for cost savings on equipment, most likely for the Gynaecology departments and the Fertility departments.

In order to seize these opportunities, post-merger consolidation has to succeed. While both hospitals aspire the same cultural shift and the two boards of directors have already been unified, there seems to be a good base for a successful consolidation process. On the other hand, both VUmc and AMC might have already exceeded the optimal size for hospitals. The probability consolidation will be succesfull is therefore ambigious. It will likely depend on the efficiency in decision making and the implementation of changes. Even more important, it depends on how eager both sides are in making this process work.

For further research other factors that might have effect on utilization rates could be

investigated. As there may be not enough FTE’s or ultrasound equipment might be located in a room that is occupied for other treatments as well.

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Appendix 1. 1.1 VUMC Fertility Lab MONDAY-SUNDAY Procedures Yearly Time

Indication(min) Total Hours

Working days (7.5 hours) 339482 - ECHOGR.A VUE 8 25 3,33 0,44 339484F - FOLLIKELMET. 609 25 253,75 33,83 339485G - ECHO GRAVIDI 968 25 403,33 53,78 339486B - ECHO TR.VAGI 589 25 245,42 32,72 339487A - NT-METING 1 25 0,42 0,06 939480 - CRYO VR.ECHO 132 25 55,00 7,33 939481 - IUI PRE.ECHO 70 25 29,17 3,89 939485 - IVF PRE.ECHO 157 25 65,42 8,72 939486 - IVF ECHO 2546 25 1060,83 141,44 939487 - IUI ECHO 2487 25 1036,25 138,17 939490 - CRYO ECHO 1947 25 811,25 108,17 939496 - OI VR.ECHO 17 25 7,08 0,94 Total 9531 3971,25 529,50 SATERDAY-SUNDAY Procedures Yearly Time

Working days (7.5 hours) 339482 - ECHOGR.A VUE 0 25 0 0 339484F - FOLLIKELMET. 178 25 74,17 9,89 339485G - ECHO GRAVIDI 0 25 0 0 339486B - ECHO TR.VAGI 0 25 0 0 339487A - NT-METING 0 25 0 0 939480 - CRYO VR.ECHO 0 25 0 0 939481 - IUI PRE.ECHO 0 25 0 0 939485 - IVF PRE.ECHO 0 25 0 0 939486 - IVF ECHO 711 25 296,25 39,50 939487 - IUI 778 25 324,17 43,22

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ECHO 939490 - CRYO ECHO 695 25 289,58 38,61 939496 - OI VR.ECHO 25 Total Sat-Sun 2362 984,17 131,22 Total Fertility Lab 11893 4955,42 660,72

Appendix Table 1. Fertility Lab Ultrasound Utilization Mon-Fri + Sat-Sun

Gyn + Obs + Fert

Procedures Yearly

Time

Indication(min) Total Hours

Working days (7.5 hours) 339486P - ECHO CONG.I 2371 25 987,92 131,72 339486Q - ECHO CONG.II 1430 25 595,83 79,44 339486U - ULTRAGELUID2 578 25 240,83 32,11 339421 - HYST.SALPING 277 25 115,42 15,39 339420 - SONOHYST.GR. 237 25 98,75 13,17 339482 - ECHOGR.A VUE 3564 25 1485,00 198,00 339484C - FLOWMETING 1906 25 794,17 105,89 339485G - ECHO GRAVIDI 1961 25 817,08 108,94 339485X - ECHO CERVIXK 744 25 310,00 41,33 339487A - NT-METING 603 25 251,25 33,50 339487B - SEO 495 25 206,25 27,50 339487C - NT-METING 25 25 10,42 1,39 339487D - SEO 35 25 14,58 1,94 339492B - ECHO BUIKORG 1218 25 507,50 67,67 339486E - ECHO GEN.INT 1928 25 803,33 107,11 Total 17372 7238,33 965,11

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1.2 AMC

AMC Obstetrics Procedures Yearly Time Indication(min) Total Hours Working Days (7.5H) 339486Y - PRENATALE SCREENING - COUNSELING 690 25 287,50 38,33 339486U - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - ELKE VOLGENDE 63 25 26,25 3,50 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 1.974 25 822,50 109,67 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 1.296 25 540,00 72,00 339482A - ECHOGRAFIE A VUE IVW ZWANGERSCHAP - MET DOPPLER 3.451 25 1437,92 191,72 339486B - ECHOGRAFIE - TRANSVAGINAAL 10 25 4,17 0,56 339486E - ECHOGRAFIE - GENITALIA INTERNA 133 25 55,42 7,39 339486G - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - ROUTINE - KLEIN 2.286 25 952,50 127,00 339486H - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - AT INTAKE - UITGEBR. 2.475 25 1031,25 137,50 339485M - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - MEERLING 496 25 206,67 27,56 339486W - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - ELKE VOLGENDE 117 25 48,75 6,50 339487A - PRENAT.SCREEN. - NUCHAL TRANSLUCEN.-NEKPL.-1LING-1E MEERL 476 25 198,33 26,44 339487B - PRENAT.SCREEN. - STRUCT.ECHOSCOP.OND.-SEO-1LING-1E MEERL 876 25 365,00 48,67 339487C - PRENAT.SCREEN. - 23 25 9,58 1,28

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NEKPL.-ELK VOLG.MEERL 339487D - PRENAT.SCREEN. - STRUCT.ECHOSCOP.OND.-SEO-ELKE VOLG.MEERL 27 25 11,25 1,50 339486Y - PRENATALE SCREENING - COUNSELING 12 25 5,00 0,67 339486H - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - AT INTAKE - UITGEBR. 1 25 0,42 0,06 Total Internal 14406 6002,50 800,33

Appendix Table 3. AMC Obstetrics Internal Ultrasound Utilization

AMC Obstetrics External Procedures Yearly Time Indication(min) Total Hours Working Days (7.5H) 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 473 25 197,08 26,28 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 122 25 50,83 6,78 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 373 25 155,42 20,72 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 172 25 71,67 9,56 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 133 25 55,42 7,39 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 17 25 7,08 0,94 339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 254 25 105,83 14,11 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 79 25 32,92 4,39

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339486P - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID I - CONG. AFW. 28 25 11,67 1,56 339486Q - ECHOGRAFIE - GEAVANCEERD ULTRAGELUID II - CONG.AFW. 5 25 2,08 0,28 Total 1656 690,00 92,00

Total Obstetrics (Internal +

External) 16062 6692,50 892,33

Appendix Table 4. AMC External Obstetrics ultrasound production + Total Obstetrics

Gynaecology Procedures Yearly

Time

Working days (7.5 hours) 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - BEOORD.FOETALE VITAL. 83 25 34,58 4,61 339486E - ECHOGRAFIE - GENITALIA INTERNA 157 25 65,42 8,72 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 4699 25 1957,92 261,06 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - BEOORD.FOETALE VITAL. 823 25 342,92 45,72 339486E - ECHOGRAFIE - GENITALIA INTERNA 102 25 42,50 5,67 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 25 0,42 0,06 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 25 0,42 0,06 Total Gynaecology 1773 738,75 98,50

Appendix Table 5. Gynaecology ultrasound production

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Fertility Procedures Yearly

Time

Indication(min) Total Hours

Working days (7.5 hours) 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - BEOORD.FOETALE VITAL. 83 25 34,58 4,61 339486E - ECHOGRAFIE - GENITALIA INTERNA 157 25 65,42 8,72 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 4699 25 1957,92 261,06 339485Z - ECHOGRAFIE A VUE IVM ZWANGERSCHAP - BEOORD.FOETALE VITAL. 823 25 342,92 45,72 339486E - ECHOGRAFIE - GENITALIA INTERNA 102 25 42,50 5,67 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 25 0,42 0,06 339489I - ECHOGRAFIE - TIJDENS OVULATIE INDUCTIE 1 25 0,42 0,06 Total Fertility 5866 2444,17 325,89