1

Jon Chilingerian, Ph.D

Email: chilinge@brandeis.edu

Managing Clinics, Care Processes and the

Physics of Patient Flow

September 20, 2013

Brandeis UniversityThe Heller School for

Social Policy & Management

LEUVEN CASE (B)

University Hospital Leuven, Belgium

Chilingerian 2013

2

Questions for Leuven Case

• What are the problems?

• What are the root causes?

• What percent of the time is their a

bottleneck?

• What tradeoffs exist?

Chilingerian 2013

Per capita expenditure on

healthcare (€)

0

500

1000

1500

2000

2500

3000

3500

Switzerla

nd

Germany

Belgiu

m UK

Sweden

Spain

Slovenia

Poland

Chilingerian 2013

3

University Medical Center Leuven, Belgium

• Annual budget: 450 million €

• 1.800 beds

• 7000 employees

– 5500 FTE

– 1000 physicians

• 500 consultants

• 500 residents

• Activities / year

– 63.000 admissions

– 540.000 in-hospital days

– 450.000 outpatients

– 50.000 emergencies

Chilingerian 2013

-30000

-25000

-20000

-15000

-10000

-5000

0

5000

1995 1996 1997 1998 1999 2000

year

profit / loss

forecast

Financial results (1000 €)

Chilingerian 2013

4

Flemish Hospital Network

DENDERMONDE

LEUVEN

BONHEIDEN

TURNHOUT

GENK

HASSELT

BRUGGE

OOSTENDE

Number of beds

LEUVEN UZ Leuven 1.800

BONHEIDEN Imeldaziekenhuis 453

BRUGGE AZ St-Lucas 415

DENDERMONDE AZ St-Blasius 382

GENK ZOL 822

HASSELT CAZ Midden Limburg 434

HASSELT Virga Jesse 567

OOSTENDE AZ Damiaan 534

TURNHOUT St-Elisabeth 369

TURNHOUT AZ St-Jozef 296

Total 7.872

AALST

KORTRIJK

AALST AZ OLV 800

KORTRIJK AZ Groeninge 1.000 Chilingerian 2013

1997 1998

Circumcision 131 180

Tooth extraction (general anesthesia) 44 558

Coronary Artery Bypass Surgery 465 560

Laparoscopic cholecystectomy 258 342

Inguinal Hernia 280 348

Appendectomy 202 235

Transtympanal draining using prothesis 246

Discus hernia 181 217

Adenoidectomy 281

Sample of Services

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5

1997

Liver 25

Heart

Lung

Kidney 125

Pancreas

Donor prelevation 65

Transplants

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Chronology

Events

Operational

Organisational

Strategic

Alliances,

Networking

Care Program

Choices

1998 - 1999

Change project

(McKinsey)

Change project

2000

Implementation phase

Implementation phase

2001 and on

Annual Department plan

Annual Department plan

Strategic Implementation

Chilingerian 2013

6

Scope of Change

Urgency

Low

High

Incremental change

aimed at financial crisis

Transformational

Change

Establish

Direction &

Incremental

Change

Create a Care

Programs

Set Corporate

and

Competitive

Strategy

1998-2000 2000-1 20001-now

STRATEGIC CHANGES - type• New Corporate Strategy: Networking/Alliances

– local level: general practitioners: e-health-LISA

– national level (Flanders): network protocol with 10 hospitals

– regional level: common government of regional hospitals

– international level (NAMCE)

• scientific exchange

• university network

• Leuven-Insead

• New Competitive Strategy:Choice in Care Programs

– Decrease length of stay

– Shift to outpatient activities

• Developing A New Medical Strategy

– Selection of pathology: increase in “academic” pathology

– Shift A � B � C-pathology

– Networking with Community Hospitals

7

INTEGRATE OPERATING STRATEGY WITH

SERVICE DELIVERY

• Develop a lean, non-bureaucratic organization

• Improve operating efficiency

• Decrease length of stay

• Shift to outpatient activities

• Selection of pathology severity: increase “academic” pathology

– Shift A � B � C-pathology

– Networking

• Choices in Care programs

– Based on patient needs, clinical expertise, academic profile, interaction between care programs, and financing...

1) Efficiency improvement• Example: Operation Room planning program

– Theory of constraints (Goldrath)

2) Optimisation or integration of existing services(system quality)• Example: Stroke unit

– efficiency increased– quality of care increased– major hurdle: physician professional sensitivities / ownership

3) Starting new forms of services• Example: wound care team

4) Cost reduction• Example: purchasing

– Sterile and non-sterile bandages: purchased separately (pharmacy vs. purchasing department)

EXAMPLES OF OPERATIONAL CHANGES (1351 ideas for all medical and non-medical

departments)

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8

Flemish Hospital Network

DENDERMONDE

LEUVEN

BONHEIDEN

TURNHOUT

GENK

HASSELT

BRUGGE

OOSTENDE

Number of beds

LEUVEN UZ Leuven 1.800

BONHEIDEN Imeldaziekenhuis 453

BRUGGE AZ St-Lucas 415

DENDERMONDE AZ St-Blasius 382

GENK ZOL 822

HASSELT CAZ Midden Limburg 434

HASSELT Virga Jesse 567

OOSTENDE AZ Damiaan 534

TURNHOUT St-Elisabeth 369

TURNHOUT AZ St-Jozef 296

Total 7.872

AALST

KORTRIJK

AALST AZ OLV 800

KORTRIJK AZ Groeninge 1.000 Chilingerian 2013

Ranking Faculty of medicine

K.U.LeuvenNarrow

P P (articles) CPP

(cit. per pub)

Univ. Oxford 8018 7.37

Univ. Cambridge 6249 7.23

Univ. Geneva 3399 7.15

Univ. Leiden 5101 6.03

Univ. London 35517 5.82

Univ. Leuven 3853 5.80

Univ. Strasbourg 1658 5.63

Univ. Edinburgh 5354 5.57

Univ. Heidelberg 4991 5.54

Univ. Zurich 5160 5.48

Karolinska 7795 5.46

Univ. Paris 19599 5.38

Univ. Helsinki 6348 5.16

Univ. Copenhagen 5691 4.84

FU Berlin 3861 4.76

Chilingerian 2013

9

League of European Research-

Intensive Universities

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NAMCE (network of academic

medical centers Europe)

• Collaboration with INSEAD

• getting new ideas on hospital management

• discussing, validating new evolutions

• scientific work on hospital management

• exchange of experiences with other European

centers

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10

What were the elements of

organizational change?

• Strategic Re-direction

• New Board of Directors

• Delayering

• Care Programs

• New management Practices– Yearly department plans

– New incentive scheme for MD’s

– Steering committee for Medical Decision Making

– Activity Based Budgets

– Limited Appointment of Medical Chairs: 5-year with evaluation

– Computer Aided Operating Room Scheduling

CULTURE CHANGE

� Basic idea: create a customer-oriented rather than a provider-oriented organisation

� 1) creation of medical-surgical divisions

� 2) creation of mixed management teams

� purpose: link the hospital domains in a structural way

� Method

� MD: clinical director

� nurse: nursing manager

� economic/administrative: administrative manager

� Implication: Separation of professional and organisational responsibility

Chilingerian 2013

11

1. Mental health care

2. Mother and child

3. General surgery

4. Rehabilitation

5. Thorax

6. General internal medicine

7. Abdomen

8. Oncology

9. Critical care

10. Head / neck / neuro

11. Medical diagnostical services

HOW? CLUSTER MEDICAL-SURGICAL DIVISIONS

Chilingerian 2013

Organization chart UMC Leuven

Division abdomenDivision general surgeryDivision rehabilitationDivision oncologyDivision head / neck / neuro

Clinical Director Director Finance/Admin.

Division mental health

Division medical diagnosticsDivision Mother and Child

Clinical Director Director HR

Division thorax

Division general internal medicineDivision Critical Care

Clinical Director Chief Medical Doctor Nursing Director

CEO

Board of Trustees, Hospital Dean, faculty of Medicine

Vice-ChancellorChairman of the Board

Chancellor University

Board of trustees, University

Chilingerian 2013

12

Care Program Concept

Chilingerian 2013

Strategy?

• Medical specialities (e.g., emergency services,

oncology, transplantation, hypertension, etc.) and

clinical activities (admission, investigation,

therapy, recovery, etc) are the sources of your

advantage.

• Most hospitals can perform similar activities better

than their rivals—

– this is called the operating strategy

• Few hospitals offer different services and few

perform different activities from rivals, or perform

them in unique ways—

– this is called strategic positioning

13

Clinical Activities

Admission

Investigation Therapy Recovery

How can these be done

differently? Can these become

positioned as better services?

Chilingerian 2013

250 CARE PROGRAMS

Hypertension

Inflammatory intestinal diseases

Abdominal wall hernia

Gastric-oesophageal reflux

Prostate tumour

...

C

a

r

e

p

r

o

g

r

a

m

A care program consists of the

coordinated delivery of all

services provided to a group of

patients with similar pathology

and similar care pattern

14

ACTIVITY CENTER

Hospitalisation

Operation

Quarters

Administration medical

staff

Financial

Division

Human

Resources

Ho

sp.

On

colo

gy

Ho

sp.

HK

-EN

T-S

tom

ato

Ho

sp.

IG-N

euro

-Der

mato

...

OK

A 1

OK

A 2

OK

A P

elle

nb

erg

OK

A M

ate

rn

ity Q

ua

rter

...

Ad

min

istr

ati

on

Med

ica

l S

taff

Acc

ou

nti

ng

An activity center is a provider of clinical* or non-clinical* services to a care program. They constitute the

operational units in which the means of the departments are concentrated.

* Medical, paramedical or nursing services

** Administrative or technical services

Sa

lary A

dm

inis

tra

tio

n

Pers

on

nel

Ad

min

istr

ati

on

Com

mu

nic

ati

on

Tra

inin

g

Operating Strategies: Alignment of

Activities/FunctionsTypes of Activity

Centers

Radiology SICU

• Physician

Services Nurse Beds• ...O.R.

C

a

r

e

P

r

o

g

r

a

m

Cardiovascular Disease

Transplantation

Orthopaedic disease

Labs

Patient

Management

Practice

Management

15

Concept of ‘Care Programs’

• Which care programs make us distinctive? Innovative, Effective, and Efficient

• Which care programs are most profitable?

• In which care programs are our patients extremely satisfied?

• In which care programs are our physicians, nurses, and other care providers extremely satisfied?

• Which activities in the care program add customer value?

• Which physicians are on the best practice frontier?

Chilingerian 2013

8

REFLECTIONS ABOUT CARE PROGRAMS

Source : McKinsey

High

Low

Profile

Financial

attractiveness

Non profitable

Profitable

?

?

?

?

?

X

For care program x, how can we :

• Increase financial attractiveness ? (i.e. decrease length-of-stay; decrease RX / lab utilisation)

• Increase the profile ?

• Attract more patients?

Chilingerian 2013

16

CARE PROGRAM - Profile Score

Score regional score in function of the distance to origin the hospital

+0.1 f(staff member assigned to care program)

0.1 f(written protocols)0.1 f(registration-database)

Score 0.1 f(yearbook)

Patient care 0.2 f(published outcome-indicator)

0.2 f(multidisciplinary discussions)

0.1 f(written patient information)0.1 f(staff member specifically authorised for

Total quality control)score +100 0.33 f(incidence pathology)

Score 0.33 f(exclusive technology and infrastructure)

relevance 0.33 f(exclusive personal expertise )

+

Score 0.66 f(peer review publications 1995-1997)

research 0.33 f(oral presentations 1995-1997)

40

15

15

30

Exhibit 21

Position of Clusters of Care Programs UMCL

TransplantationCongenital

Tumour

Functional Digestive

Miscellaneous

Degenerative / Functional Neural-Head-NeckFunctional

Urogenital

Degenerative Skin-muscle & skeleton

Degenerative / Functional Cardiovascular

Psychiatry

Infectious -Inflammatory -immunology Trauma-Toxic

Obstetric

Missing

Ambulatory

Non profitable

Low Profile

Profitable

High Profile

17

15

All care programs

0

25

50

75

100

-100% -90% -80% -70% -60% -50% -40% -30% -20% -10% 0% 10% 20% 30% 40% 50%

Financiële aantrekkelijkheid***

Pro

file

rin

g**

Eigen zorgprogramma's Top Klinisch Gedeelde zorgprogramma's Top Klinisch UZ exploitatie 1997Eigen zorgprogramma's Expert Gedeelde zorgprogramma's Expert Eigen zorgprogramma's niet bepaaldEigen zorgprogramma's Basis Gedeelde zorgprogramma's Bas is Gedeelde zorgprogramma's niet bepaald

h i

niet kostendekkend kostendekkend

Chilingerian 2013

Medical staff

Dept.-own AC’s (i.e..

endoscopy)

ii

Nursing manager

Administrative manager

Physician

(Clinical director, head of the Division)

Division Management

Gastroenterology

Physician (Head of the Dept.)

Nurses

Abdom. surgery Urology Hospitalisation Consultation

AC-Responsible

NursingStaff

”Departments" Department-specific - AC

...

Divisional Structure

18

RESULTS

EVOLUTION DEGREE OF SUBSTITUTION DAY CARE

31,7%

36,0%

47,5%

52,9%

0%

10%

20%

30%

40%

50%

60%

1996 1997 1998 1999

su

bs

titu

tie

gra

ad

Chilingerian 2013

19

STRATEGIC CHANGES – RESULTS: USED BEDS

1.000

1.100

1.200

1.300

1.400

1.500

1.600

1.700

1.800

1.900ja

n/9

6m

rt/9

6m

ei/9

6ju

l/9

6se

p/9

6n

ov/9

6ja

n/9

7m

rt/9

7m

ei/9

7ju

l/9

7se

p/9

7n

ov/9

7ja

n/9

8m

rt/9

8m

ei/9

8ju

l/9

8se

p/9

8n

ov/9

8ja

n/9

9m

rt/9

9m

ei/9

9ju

l/9

9se

p/9

9n

ov/9

9ja

n/0

0m

rt/0

0m

ei/0

0ju

l/0

0se

p/0

0n

ov/0

0ja

n/0

1

Chilingerian 2013

0

2

4

6

8

10

12

1996 1997 1998 1999 2000

Len

th o

f sta

y (

days)

EVOLUTION LENGTH OF STAY 1997-2000: -15-20 %

Chilingerian 2013

20

6 5 3

8 0 9

7 3 4

3 0 7 3 1 6

4 6 7

0

1 0 0

2 0 0

3 0 0

4 0 0

5 0 0

6 0 0

7 0 0

8 0 0

9 0 0

U Z L a l le p a t ië n te n 9 7 U Z L a l le p a t ië n te n 9 9

49 ,97%

57,33%

42,66%

36,67%

6,00%

7,3 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

U Z L a lle pa tiën ten 97 U Z L a lle pa tiën ten 99

1997 1999 1997 1999

EVOLUTION OF PATHOLOGY SEVERITY

(A, B, C-pathology)

Discharges Beds used

A

B

C

A

A

A

B

B

B

CC

C

0

ILLUSTRATION: N transplant patients

0

20

40

60

80

100

120

140

1995 1996 1997 1998 1999 2000 2001

Liver

Lung

Heart Lung

Heart

Chilingerian 2013

21

Financial results (1000 €)

-30000

-20000

-10000

0

10000

20000

30000

1997 1998 1999 2000 2001 2002 2003

year

profit / loss

forecast

Director

Finance/Admin.

Helmut

OR Coordinator

Division Abdomen

Peter

Clinical Director

Karin

Chair Cardiac Surgery

Chair Transplant

Committee

Christophe

MICU

Division General

Internal Medicine

Other Clinical

Directors

Dean, Faculty of

Medicine

Marcel

Chief Medical Doctor

Chair General

Internal Medicine

Karel

Chair Hepatology

Chief Internal Med.

Luc

Chair Transplant

Surgery

Transplant

Coordinator

Division Critical Care

Maria

Chair

Anesthesiology

Bart

Chair SICU

Division Thorax

Director HR

Nursing Director

Jan

CEO

Board of Trustees

Vice-Chancellor

Chairman of the

Board

Chancellor University

Partial Organization Chart – Leuven Medical Center

22

Unintended Consequences

• Selective Investment and Growth of Care Programs—based on patient needs, core expertise, academic profile, interaction between care programs, and payment and financing

– Capacity Problems: surgical cancellations

– Political Problems: inside and outside

– Increased Conflicts among physicians and caregivers

• Was this strategic shift financially sustainable in the Belgian Healthcare system?

Chilingerian 2013

Surgical Patient Flow

Flow of

ER

Patients

Flow of

Transplant

Patients

OR SICUGeneral

Beds

Average

daily

discharge

Flow of

Elective

Patients

Capacity 307 hrs/day 56 beds 1782 beds

Utilization 238 hrs 55 beds 1427 beds

Variability +/- 103 surgical hrs. +/- 4.1 days +/- 189 patient days

85%

.7%

100%

80%

14.3%

20%

23

Cardiac Surgery activities as influenced

by ICU capacity (2001)

April May June

• N beds 18.25 20.5 22.5

• N cardiac surgeries postponed 29 21 12

• N patients refused 69 59 27

Chilingerian 2013

In 2002, Bart, the Chair of the SICU requested 20 new SICU beds

at a cost of €3 million. Though an analysis revealed a 40% chance

of a bottleneck on any given day, the clinical leaders were reluctant

to add capacity because of an anomaly in the information.

Conclusion: More Beds

Chilingerian 2013

24

More Beds?

When the Chair of Internal Medicine

proposed the MICU (medical intensive care

unit) as a buffer, the chair of the SICU had

quipped, “You are messing up my strategy

to obtain more beds. I do not need your

MICU beds, let me handle this!”

Chilingerian 2013

Questions for Leuven Case

• What are the underlying problems?

– What are the root causes?

• Describe the best ways to schedule the OR?

• Explain these Tables:

7-9; 11; 18; 19; & 20

Chilingerian 2013

25

Solutions??

Chilingerian 2013

nursing days

0%5%

10%15%20%25%30%35%40%45%50%55%

19

97

A

19

98

A

19

99

A

20

00

A

19

97

B

19

98

B

19

99

B

20

00

B

19

97

C

19

98

C

19

99

C

20

00

C

* opsplitsing I-nI op basis van geëxtrapoleerd MVG-profiel 1997

SHIFT OF PATHOLOGY SEVERITY

(A, B, C- pathology)

A-care B-care C-care

26

0,0

2,0

4,0

6,0

8,0

10,0

12,0

14,0

16,0

A (gelijkgesteld aan 1) B C

Pathologiezwaarte

Mu

ltip

lic

ati

efa

cto

r

Kosten Inkomsten

Differential growth in cost and revenue with a shift from A to C

pathology: Medical Imaging

N nursing days in ICU by

transplant patients

0

200

400

600

800

1000

1200

1995 1996 1997 1998 1999 2000

Liver

Lung

Heart Lung

Heart

Chilingerian 2013

27

1997, UZL A-care C-care C vs A

Intensive care bed 0,1 7,9 79

Non-ITE bed 6,1 20,8 3,41

Total 6,2 28,7 4,63

Length of stay (days)

Unintended consequence 1: Cost increaseC-care requires more beds, especially ICU beds

Chilingerian 2013

Protracted Critical Illness (PCI) Patients in SICU (LOS > 21 days)

Year No. PCI patients

(%)

Capacity utilization

(%)

Mortality

(%)

1995 7.0 34 20

1996 7.7 40 26

1997 9.0 46 16

1998 9.9 47 19

1999 10.5 49 18

2000 10.0 47 18

Chilingerian 2013

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Hospital SICU Data on Patient Mix

1998 1999 2000

N patients admitted 2,296 2,221 2,196

N patients discharged 2,080 2,131 2,112

N nursing days 17,370 18,673 18,298

Bed occupancy rate (%) 91.1 % 98 % 95.6 %

Average length of stay (days) 8.2 d 8.6 d 8.5 d

Average care intensity

(MVG*)

12.9 13.4 13.9

Chilingerian 2013

What Happened?• The Chair of the ICU retired in Fall 2002.

• A new Chair who believes in evidence-based medicine,

believed that the transplant policy could be changed

without patient harm. So patients after a liver transplant no

longer get an isolation unit.

• By changing one person, the cultural system—(an old

versus new philosophy of care)– and the political system (a

new less powerful, new Chair of SICU) changed.

– Old Chair maximized patient safety, at the expense of other

patients waiting to get into SICU.

– New Chair says if a patient dies in the ER, waiting to get into the

SICU, that’s a quality issue, too

• The ICU capacity problem has been ‘solved’ in the short

termChilingerian 2013

29

Technical system (or current strategic

design)

• What is the mission, strategy, goals, and

constraints?

• Why are they doing this? values? Incentives

• Who is involved: people, roles, & responsibilities

• How is it being done? Key processes (decision

making, communication, etc)

• How are activities structured (differentiated, integrated

and coordinated) ?

Does this design work? Is there alignment or fit

between strategy and the parts?

Chilingerian 2013

Congruence Model

Executive

Leadership

Mission&

Strategy

Critical

Tasks

Culture &

Informal

Structure

People

Formal

Structure

ORGANIZATIONAL

PERFORMANCE

30

Strategic Design

• Critical Tasks

• Formal Structure

• Culture & Informal

• People

• Intrinsic satisfaction from meaningful work

– Direct Feedback/Autonomy—responsibility for outcomes

• Routine, predictable tasks

• Cohesive work groups– Explicit plans, goals, procedures

– Decentralized decision making/Balance of power

• Meritocracy/fair process

• Appetite for hard work & motivated

• Strong ability & willingness

• Capacity for self- management

Design Variables Characteristics

Political Perspectives

Who are the stakeholders? What are the relationships

among them?

What are their interests? Can the interests be aligned

for a coalition?

What are their sources of power?

Chilingerian 2013

31

What shared values, mindsets, beliefs and assumptions

do people have regarding what the organization is all

about? Are they consistent across people and areas?

What implications do these values and assumptions have?

Are they good or bad for performance?

Cultural Perspective

Chilingerian 2013

Where are the bottlenecks?

feedback

Technical System

Cultural System

Political SystemCapacity

constraintPhysician Behavior

AssumptionsLeadership

& decision

making

overload

overload

Chilingerian 2013

32

Explain capacity problems work

in the three systems

• Technical System

• Social & Cultural System

• Political System

Chilingerian 2013

33

Figure 4. Growth and Underinvestment:

A View of the Technical System

Chilingerian and Vandekerckhove 2002

Growth in

transplants and

complexity

Gain per

Surgeon’s

Activity

Quality:

cancellations,

transplants denied,

SICU readmits

OR Time, SICU

Bed and Staff

Capacity

Constraint

Investment in

Capacity

Perceived need

to invest

Policy

Environment

Medical Strategy:

Incentives to Attract

Complex Cases

Figure 5.Tragedy of the Commons:

A View of the The Cultural System

Surgeon A’s

Activity

Hospital Case Mix

Complexity

Surgeon B’s

Activity

OR Time,

SICU Bed and

Staff Capacity

Constraint

Surgeon A decides on medical

need and never questioned

Surgeon B decides on medical

need and never questioned Chilingerian and Vandekerckhove 2002

Beliefs of the

Chair of SICU

Quality:

cancellations,

transplants denied,

SICU readmits

Net Gains for B

Net Gains for A

Degree of Trust &

Cooperation

34

Figure 6. Shifting the Burden:

A View of the Political System

Delay

Surgical Cancellations,

and Queues

SICU

Availability

Develop More Service

Capacity

Deterioration of

Service Quality and

Physician Morale

Political Power

& Influence

Perceived

unfairness

Chilingerian and Vandekerckhove 2002

Demand for

SICU

• Dangers of arrogant leadership, an inability to challenge physician autonomy, bureaucratic silos, & a culture of finger pointing

• Need for a strategic service vision based on real strengths of care programs—

– identify a unique and valuable position, choose what not to do, choose a unique combination of activities

• Once strategy has been developed, the strategy must be aligned with the operations and embodied into everything the organization does

Takeaways: Leuven turnaround

Chilingerian 2013

35

• Think in terms of long-term relationships with physicians team members—align interests

– Avoid reliance on authority—build commitment to shared clinical goals

• Institute Fair process to deeply engage physicians & teach them develop their own strategic service vision

– How? Focus on diagnosing the strategic problems: separating facts from assumptions

• Invest in clinical agendas to build partnerships not to make deals

– value different perspectives, set high standards

– prevent them from making strategic mistakes

– Be honest in letting them know how things are going

Takeaways: Leuven turnaround

36

Thank you

The Heller School for

Social Policy &

Management

Chilingerian 2013

37

Care Program Activity System

RN Hiring

RN Cross Training

Multi-speciality wards

& Operational planners

REDUCED LOS &

UNNECESSARY

ANCILLARY

SERVICES

Technology

choices

Selection of Services

(Offered/Not Offered)

Standardized

OR Slots

Transfer PricesMD Hiring/Attitudes

MD

Incentive

Plan

Reward MD

Efficient Practices

Test

Turnaround

time

INCREASED

ADMISSIONS

Target Patient

Segments

Chilingerian 2013