Cost Hospital Uli

Journal of Management in Medicine
A model for calculating costs of hospital wards: an Italian experience

Livio Garattini, Giovanni Giuliani, Eva Pagano,
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A model for calculating costs A model for

calculating costs
of hospital wards: an Italian of hospital wards
experience
Livio Garattini, Giovanni Giuliani and Eva Pagano 71
Centre for Health Economics CESAV, Mario Negri Institute for
Pharmacological Research, Ranica (BG), Italy
Keywords Hospitals, Costs, Cost Allocation
Abstract Until recently Italian hospitals had no cost accounting or activity data collection
systems, being formally required only to do financial book-keeping. The cost analysis method
presented here might be used to set up detailed and complete hospital cost accounting, which
would permit a better understanding of patterns of resource distribution among departments,
better opportunities for cost saving and cost control for hospital managers and health authorities.
The study first identified a framework within which to assess the annual cost related to a hospital
ward, then calculated the mean bed day cost for each speciality. Cost data were collected over one
year in 1996 from manually compiled records, at one local hospital in Northern Italy. Costs were
estimated following a step-down allocation method. Wards requiring a major amount of
resources per day of stay are intensive cardio-coronary unit (US$650.689), and ophthalmology
(US$483.322). The less expensive ward is general medicine (US$148.645). The cost analysis
method presented in this study might be used to set a detailed and complete hospital cost
database, which is a necessary tool for hospital managers to realise cost control and cost recovery.
Introduction
Since the 1980s health services in Europe have been beset by spiralling costs, a
growing elderly population and the spread of new technologies. Consequently,
all have been taking measures to limit the growth of health care expenditures.
These include competition, increased autonomy for providers, and generation
of incentives to provide more cost-effective care (McKee et al., 1992).
A reform of the Italian National Health Service (INHS) was passed by the
government in November 1993 and introduced in January 1995. The INHS
continues offering universal coverage financed by social insurance contributions
and general taxation and most hospitals and primary care centres are owned by
public authorities. The main aim of the reform was to inject incentives for greater
efficiency at the regional and local tiers (Ferrera, 1995; European Parliament, 1995).
Before the reform public hospitals were managed by local health units (LHU),
and had no separate accounting system, so neither current nor capital costs could
be evaluated. This organisation produced a general lack of understanding on
cost accounting, and the adoption of financial accounting systems led to funds
being obtained on the basis of past expenditure (Garattini, 1992).
The study was made possible by the help of Massimo Brunetti, Duilio Vesconi and Ezio Zanelli
in data collection and model setting. The authors are grateful to Luciano Leoni and Cinzia Leoni
Journal of Management in Medicine,
for their valuable collaboration and to Giovanni Fattore for helpful comments. Special thanks go Vol. 13 No. 2, 1999, pp. 71-82.
to Judy Baggott for editing the manuscript. # MCB University Press, 0268-9235
13:36 ± 12/8/99 ± Total page(s) 12
JMM Now the major hospitals are becoming self-governing and are funded by
13,2 their regions, partly on past expenditure and partly on a fee-for-service
Diagnosis Related Groups (DRGs) like system (D. Lgs. 30.12, 1992; D. Lgs.
07.12, 1993). The introduction of a prospective payment system is expected to
increase efficiency and competition between health care providers.
Hospital management is starting to realise that a thorough understanding of
72 the costs of delivery of each hospital service is important with growing
competition (Johnson, 1987). A cost accounting system should replace the
present financial book-keeping, to enable management to assess unit costs of
services, so that the relationship between costs and productivity can be clearly
understood and integrated into governmental financial planning (Trisolini et
al., 1992; Cleverley, 1987). In Italy, the system historically lacks managerial
culture, competence and operational skills (Garattini, 1992). As long as
hospitals lack a cost-accounting system, reforms cannot succeed.

This article sets out a cost-accounting method to evaluate the actual costs
incurred by the different hospital departments. The study first identified a
framework within which to assess annual costs related to a hospital ward, then
calculated the mean bed day cost for each speciality.
Methods
The study tries to assess costs through a step-down allocation (Anthony and Young,
1988; Drummond et al., 1987; Finkler, 1982). This method, used in several other
studies (Anthony and Young, 1988; Berman et al., 1994; Doyle et al., 1996; Trisolini et
al., 1992; Vesconi et al., 1996; Young, 1984), is adapted here to the cost structure of the
hospital analysed. The framework was tested in the Bolognini hospital in Seriate
(Bergamo), a medium-sized local hospital ± 275 beds ± in Lombardy.
Bolognini hospital has 11 surgical and medical wards and provides inpatient
and outpatient services. Among the hospital units we distinguished between
cost, and cost and revenue centres (henceforth the definition is ``revenue
centre''). Surgery and medical wards are directly reimbursed for their services,
so they can be considered revenue centres. Those departments which are not
directly involved in treating patients, but support the production process, such
as reception, laundry, housekeeping, operating theatres, etc. are cost centres
only. Some departments are considered only as cost centres, even though their
outpatient activity is reimbursed (e.g. radiology, laboratory). The cost centres'
expenses must be assigned to the revenue centres. This leads to an estimate of
the full costs of the wards which are reimbursed and enables hospital managers
to verify the relations between costs and tariffs.
The specific goals of our cost analysis included:
. identifying the total financial costs;
. deciding on the cost allocation methods for each department;
. assessing the full cost of wards;
. separating admission costs per item;
. calculating a bed day cost in the different wards.
13:36 ± 12/8/99 ± Total page(s) 12
To assess department costs, wards and costs per day of stay for each ward, the A model for
following five steps were taken: calculating costs
(1) Data collection. of hospital wards
(2) Classification of items.
(3) Allocation of costs.
73
(4) Identification of the costs allocation bases.
(5) Calculation of average bed day costs.
Data collection
This local hospital has 11 wards and in 1996 recorded 87,476 Days of Stay (DS):
general medicine (17,118 DS), paediatrics (4,952 DS), general surgery (13,857 DS),
obstetrics and gynaecology (8,669 DS), orthopaedics (15,559 DS), cardiology
(4,645 DS) and intensive cardio-coronary unit (2,135 DS), neurology (7,665 DS),
neonatal pathology (6,775 DS), ENT (2,866 DS), ophthalmology (3,168 DS).
The hospital information system was not used to record real expenditures for
individual departments. Thus, we had to identify the different components of costs
and collect information on each item from different sources: personnel records,
pharmaceutical expenditures, stock, etc. We had a similar difficulty in collecting
activity data, i.e. measurements of the time spent in performing departmental
procedures. Activity data are crucial for allocating department costs on the basis of
their real utilisation by other departments or wards. To overcome this lack of
information on cost centres, the hospital organisation was analysed in depth.
Classification of items
A share of costs incurred by each department (direct costs) can be easily related to
its activity: most salaries and medical supplies are department-specific. However,
in order to assess the full cost of a department, costs related to other units must
also be considered (Anthony and Young, 1988). The full cost of a department
includes direct costs, overheads, and a share of costs indirectly incurred to provide
the service (indirect costs) (Johnson, 1987). Capital account funds are not included.
(1) Direct costs are traced directly to cost centres. They include medical and
non-medical staff's wages and goods imputable to a single operational
unit. The first item includes remuneration for physicians, paramedical
staff, technicians (e.g. in pathology or radiology services) and
administrative staff directly employed in the ward. The total costs
included overtime costs. Goods include: historical value of medical
(pharmaceuticals and medical devices, prostheses, reagents, etc.) and
technical products (stationery, cleaning, etc.), depreciation and ordinary
maintenance expenses for medical equipment.
(2) Overheads concern general services, e.g. administration, housekeeping,
power, heating. Overheads were allocated to cost and revenue centres
according to general parameters ± for instance, number of staff employed
in each department, number of beds or other appropriate bases.
13:36 ± 12/8/99 ± Total page(s) 12
JMM (3) Indirect costs regard the utilisation of other units by any department.
13,2 The cost evaluation of a ward must consider all the possible related
sources of expenditures, even if they are not directly related to its
product or service. For instance, in-patient full costs should include costs
related to pathology tests and ancillary services. We classified indirect
costs in two main categories: ancillary services (AS) and health care
74 services (HCS):
. Ancillary services are the canteen and kitchen, maintenance office,
wardrobe, laundry, reception and switchboard. Their burden on each
ward is unlikely to be evaluated on the grounds of real activity; they
were shared between the other departments on a proportional basis,
as number of beds and staff employed.
. Health care services play an intermediate role between AS and wards;

they receive general services from the former and provide medical
services to the latter. Specific productivity parameters were used for
their allocation, reflecting the real consumption of resources. HCSs
are anaesthesia and operating theatre, pharmacy, public health,
emergency, pathology, radiology and transfusion.
Allocation of costs
Indirect costs were allocated to the revenue centres (wards) using the step-
down procedure. First, we allocated overheads to all departments and wards.
Then, we allocated all expenditures from the first group of departments (AS) to
the remaining departments (HCS) and the wards. Finally, HCS departments
were allocated to final wards.
The example in Table I shows how this procedure leads to the total costs of
inpatient care (Drummond et al., 1987). Five services are listed: three cost
centres ± an overhead service, an AS department and a HCS department ± and
two revenue centres. The overhead cost ``Housekeeping'' incurs $100 direct
costs; the AS ``Wardrobe'' and the HCS ``Radiology'' incur $100 and $200 direct
costs; the two wards ``Psychiatry'' and ``Surgery'' incur respectively $250 and
Housekeeping Wardrobe Radiology Psychiatry Surgery Total
Department costs 100 100 200 250 300 950

Distribution of overheads 40 20 10 30
Subtotal 140 220 260 330 950
Distribution of AS
departments 35 35 70
Subtotal 255 295 400 950
Table I. Distribution of HCS
Allocation of costs (US departments 85 170
dollars: 1$ = lire 1,610
(average 1996 values)) Total 380 570 950
13:36 ± 12/8/99 ± Total page(s) 12
$300. Using an appropriate allocation basis, we establish that 40 per cent ($40) A model for
of ``Housekeeping'' is used by ``Wardrobe'', 20 per cent ($20) by ``Radiology'', 10 calculating costs
per cent ($10) by ``Psychiatry'' and 30 per cent ($30) by ``Surgery''. ``Wardrobe'', of hospital wards
which now costs $140 after this allocation, is shared between ``Radiology'',
``Psychiatry'' and ``Surgery'', in 25/25/50 per cent respectively. After allocating
HCS ``Radiology'' in this way, we find that the psychiatry and surgery wards
have full costs of respectively $380 and $570. 75
The final calculation of costs depends on the order followed in the ``cascade''.
The department which is allocated first does not receive any share of costs
from other departments. Usually, these are departments which provide their
services to others, but do not receive services. Here, for example, ``Wardrobe''
was allocated before ``Radiology'', since the former only provides services to the
latter. When departments provide services to each other, as between

``Housekeeping'' and ``Wardrobe'', the order of allocation is subjective. In
practice, however, the effects of different step down sequences on the total cost
are generally minimal (Young, 1984).
Identification of the cost allocation bases

The allocation is performed according to bases, which should estimate the
proportion of services provided by each overhead service/department to other
departments/wards. For example, canteen and kitchen costs were charged to
wards in proportion to the number of meals served.
Like the order of allocating departments, the choice of allocation bases
affects the final cost evaluation. However, there is usually a trade-off between
the degree of accuracy of allocation bases and the cost of collecting more
accurate information. For instance, the HCS `Òperating theatre'' is likely to use
more laundry services than the HCS ``Pharmacy''. A possible allocation scheme
could weigh the personnel of the Operating Theatre more heavily than that of
the Pharmacy, to allocate a larger share of ``Wardrobe-laundry'' costs to the
former. However, it might be better to collect this information after having
worked with cost accounting for some years.
The allocation scheme used in our study to assess full costs of direct services
was structured as follows:
. Overheads. Heating, housekeeping, power, water utilisation and
premises ordinary maintenance were allocated in proportion to
departments square footage.
Ordinary maintenance of technical-scientific medical equipment was
allocated in proportion to their historical value.
Telephone expenses and administrative overhead costs were allocated
in proportion to the number of staff.
. Ancillary services. Canteen and kitchen costs were allocated to AS
departments and to wards in proportion to the number of meals served.
Maintenance office costs were charged considering the disposition of
volumes of departments receiving this service.
13:36 ± 12/8/99 ± Total page(s) 12
JMM Wardrobe/laundry costs were charged on the basis of the number of

13,2 staff and beds.
Other support services (reception, conciergerie, purchasing office,
switchboard) were allocated in proportion to the number of personnel
employed in each departments the costs refer to.
76
. Health care services. Anaesthesia and operating theatre services costs
were allocated to surgical units in proportion to the real operating
theatre usage time. The average cost per hour refers exclusively to costs
related to the general cost of the service (personnel costs, heating,
telephone, power, etc.). Specific costs of each intervention (prosthesis,
pace-maker, etc.) were allocated directly to surgical units. This enabled
us to distinguish between general and specific cost per surgical

intervention, i.e. a hip replacement requires more expensive equipment
than a crossed ligament, but both absorb similar general surgical costs.
Pharmacy costs were allocated in proportion to the percentage of
wards pharmaceutical expenditures on the total.
Medical management costs were charged considering the number of
staff in the different departments.
Emergency service costs were assumed to have a fixed and a variable
component: the former was allocated to units in proportion to the
number of beds, the latter to the number of admissions coming from
emergency.
Pathology and radiology services were allocated in proportion to the
number and cost of tests required by units.
Transfusion centre costs were charged on the basis of the number of
blood sacks required.
Average bed day cost

To estimate the mean bed day cost for each speciality, the full cost of the ward
must be shared between the three different activities delivered in hospital
services: admissions, outpatient care and day hospital.
The first step consists of understanding how wards supply outpatient
activity. Usually, this care is delivered in the outpatients unit, which is an
independent revenue centre where ward consultants practice. This was the case
of our hospital, so indirect costs and overheads were allocated to the outpatient
department, except medical costs, which were allocated entirely to wards.
Therefore, the full cost of each ward includes inpatient activity costs and the
costs of medical staff employed in outpatient activities. To obtain the net cost
of a hospital stay, the latter share of personnel activity must be assessed.
To split the whole activity, we used the workloads referred to inpatient and
outpatient activities. Workloads were determined according to the guidelines
provided by the Lombardy Region for health services (Regione Lombardia,
Legge, 537/93).
13:36 ± 12/8/99 ± Total page(s) 12
A proportion was calculated for each activity, on the grounds of the working A model for
hours of medical and paramedical staff. By applying these proportions to the calculating costs
personnel costs (medical and nursing), we calculated the real net cost of each of hospital wards
ward, using the following formula:
CW CT PCo CT PCTM hOM =hTM PCTN hON =hTN
77
CW = ward net cost
CT = ward total cost
PCo = personnel cost related to outpatient activity
hOM, hON = number of outpatient medical (OM) and nursing (ON working
hours
hTM, hTN = number of total medical (TM) and nursing (TN) working
hours
PCTM , PCTN = total medical (TM) and total nursing (TN) personnel cost.
Finally, to estimate the bed day cost per ward we divided the annual ward cost
by the days of stay.
Results
Department costs
The first column of Table II shows the mapping of departments in Bolognini
Hospital and their direct costs. A total of 30 cost and revenue centres were
identified: five overhead services, 12 indirect departments (five auxiliary
services and seven health care services), 12 wards (general medicine, surgery,
neurology, etc.) and one cost centre including outpatient activity. The Table
shows how direct costs are shared. For example, the direct costs of HCS
(laboratory, transfusion centre, radiology, etc.), all together, amount to
$11,565,824, i.e. 36.5 per cent of total direct costs.
Total wards costs

Table III sets out the full costs of inpatient wards resulting from the step-
down procedure. By stripping the share of ward personnel costs related to
outpatient practice from the full cost, we obtained the yearly admission cost
of the ward.

The bed day cost in each ward is estimated by dividing annual admissions
cost by the number of days of stay. Results are shown in Table IV. The most
expensive wards were the Intensive Cardio-Coronary Unit (ICCU) and
ophthalmology, costing respectively $650.689 and $483.322 per day. The
least expensive ward was general medicine ($148.645).
13:36 ± 12/8/99 ± Total page(s) 12
JMM Departments Direct costs Percentage

13,2
Overhead services
Housekeeping 828,396
Telephone expenses 326,022
Power/heating/water 302,967
78 Hospital administration 844,197
Ordinary maintenance 1,196,277
Subtotal 3,497,859 11.0
Ancillary services
Wardrobe/laundry 170,512
Canteen and kitchen 556,676
Maintenance office 351,516

Reception 237,313
Other services 183,512
Subtotal 1,499,529 4.7
Health care services
Laboratory 3,308,701
Transfusion centre 426,922
Radiology 2,281,016
Anaesthesia and
operating theatre 3,436,232
Emergency 719,632
Pharmacy 472,465
Public health 920,856
Subtotal 11,565,824 36.5
Wards
General medicine 1,734,025
Paediatrics 855,113
General surgery 1,886,683
Obstetrics and
gynaecology 1,458,355
Orthopaedics 1,581,071
Cardiology 1,263,400
Intensive cardio-
coronary unit 1,136,900
Neurology 1,258,685
Neonatal pathology 1,710,877
ENT 540,204
Table II. Ophthalmology 1,177,683
Allocation of direct Nursery 294,049
costs to hospital Outpatients services 253,191
departments (US Subtotal 15,150,237 47.8
dollars: 1$ = Lire 1,610
(average 1996 values)) Total 31,713,449 100.0
13:36 ± 12/8/99 ± Total page(s) 12
Personnel costs to Wards inpatient A model for

Wards Full cost outpatients total costs calculating costs
of hospital wards
1. General medicine 2,732,815 177,900 2,554,916
2. Paediatrics 1,269,239 94,359 1,174,881
3. General surgery 4,116,114 283,085 3,833,029
4. Obstetrics and gynaecology 2,775,247 252,355 2,522,892 79
5. Orthopaedics 4,049,072 104,382 3,944,690
6. Cardiology 1,697,938 265,422 1,432,516
7. ICCU 1,389,222 ± 1,389,222
8. Neurology 1,901,223 127,026 1,774,197 Table III.
Total cost of inpatient
9. Neonatal pathology 2,171,283 828,959 1,342,324

wards (US dollars: 1$
10. ENT 1,105,116 168,721 936,394 = Lire 1,610 (average
11. Ophthalmology 1,765,636 234,472 1,531,165 1996 values))
Bed day cost at

Days in 80 per cent
Wards Full cost hospital Bed day cost occupancy ratea
1. General medicine 4,113,414,230 17,188 149 153

2. Paediatrics 1,891,557,670 4,952 237 268
3. General surgery 6,171,176,830 13,857 277 285
4. Obstetrics and gynaecology 4,061,856,775 8,669 291 265
5. Orthopaedics 6,350,950,284 15,559 254 265
6. Cardiology 2,306,350,930 4,645 308 350
7. ICCU 2,236,647,945 2,135 651 680
8. Neurology 2,856,457,540 7,662 232 217
9. Neonatal pathology 2,161,141,391 6,775 198 184 Table IV.
11. ENT 1,507,594,557 2,866 327 344 Average bed day cost
12. Ophthalmology 2,465,175,068 3,168 483 524 (US dollars: 1$ = Lire
1,610 (average 1996
Note: aData regarding highest occupancy are not available values))
Discussion
In recent years changes in the funding of INHS have made cost accounting a
subject of considerable interest to health care managers. Government have
started up strategies for controlling and constraining reimbursements to
hospitals, by introducing a DRG-like tariff system, even though the first results
are not so encouraging (Krueger and Davidson, 1987). The need for rational
cost management calls for new cost accounting systems (Farmindustria, 1998).
The analysis discussed in our study aims at assessing the full cost of a
hospital ward. Since the figures refer only to one local hospital, they have no
national relevance. Nevertheless, they seem to be in line with other Italian
13:36 ± 12/8/99 ± Total page(s) 12
JMM data. Differences between bed day costs of wards are proportional to those
13,2 set out in a national report (Mediobanca, 1997). The average bed day cost
depends on the occupancy rate beds, the fixed costs per unit being inversely
related to the number of hospital beds actually used. We have calculated
bed day costs in each ward at an occupancy rate of 80 per cent, considered a
good level (Figure 1). Cardiology and paediatrics show the highest variance
80 from the base case ± 14 per cent and 13 per cent ± while the others are quite
close.
The study suffers some general limits. First, cost allocations could have been
related to specific diseases, since the new Italian reimbursement system is
based on DRG. At the time of the study, however, DRG records had not yet
been validated, and the information system was still experimental. Still, only
few Italian regions have applied the DRG system and the recent government
trend ± as the last Financial Law confirms (Legge Finanziaria, 1998) ± is to limit
DRGs usage as case-mix indicators, rather than as reimbursement tariffs.
Second, the new reimbursement system provides an ideal setting for
Activity Based Costing (ABC) (Hilton, 1991; Udpa, 1996). To establish a process
for ABC, it is important to gain staff and physicians' support and to know the
hospital processes in depth. These requirements are still lacking in Italy, where
the accounting culture is not yet developed enough.
Figure 1.
(US dollars: 1$ = Lire
1,610 (average 1996
values))
13:36 ± 12/8/99 ± Total page(s) 12
The lack of an advanced information system obliged us to draw most of our A model for
information from rough manual records. This meant we had to analyse the calculating costs
hospital structure and organisation, particularly to survey health care services of hospital wards
to wards in order to allocate their costs.
Other limitations can be pointed out in the accounting method setting. Due
to the lack of available data, we allocated indirect and overhead costs of some
departments through rough allocation bases, instead of the real consumption, 81
for example, number of personnel instead of real usage for telephone expense.
Conclusions
Setting up a cost analysis method has become crucial since hospital
management has now realised the importance of assessing the costs related to
each service or procedure delivered. Cost control is essential if hospital facilities

are to survive under restricted resources and increased competition.
Despite its limits, the cost analysis method presented here might be useful
for establishing a detailed and complete hospital cost database. It would give a
better picture of the patterns of resource allocation among departments and
could enhance cost savings.
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A model for calculating costs of hospital wards: an Italian experience

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A model for calculating costs A model for

hospitals lack a cost-accounting system, reforms cannot succeed.

. Health care services play an intermediate role between AS and wards;

Housekeeping Wardrobe Radiology Psychiatry Surgery Total

Department costs 100 100 200 250 300 950

latter. When departments provide services to each other, as between

Identification of the cost allocation bases

JMM Wardrobe/laundry costs were charged on the basis of the number of

us to distinguish between general and specific cost per surgical

Average bed day cost

Total wards costs

Average bed day cost

JMM Departments Direct costs Percentage

Maintenance office 351,516

Personnel costs to Wards inpatient A model for

9. Neonatal pathology 2,171,283 828,959 1,342,324

Bed day cost at

1. General medicine 4,113,414,230 17,188 149 153

each service or procedure delivered. Cost control is essential if hospital facilities

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