Accounting for the start of life: Shifting practices, costs, and value in an IVF clinic

Rising healthcare costs are a major societal concern. Yet, little is known about how costs or shortages impact medical practice, or how accounting systems can improve decision-making as care is increasingly personalized to individual patients.
This dissertation investigates the co-creation and implementation of a cost management system in a fertility clinic as part of a value-based healthcare (VBHC) strategy, focusing on how clinicians use and shape accounting. It explores (1) how cost concerns impact daily medical decisions, (2) how cost variation can be traced and managed, and (3) how enabling cost information improves workforce wellbeing across medical domains and contexts. Using a predominantly interventionist research design and a practice-theoretical lens, the research combines ethnographic and quantitative methods across eight studies to develop and evaluate a tailored system—time-driven activity-based costing with process mining (TDABC-PM). Drawing on a decade of fertility care data (4190 pregnancy trajectories, 18 445 treatments), it shows how care pathway re-design (three care delivery changes) significantly reduced costs (€322–€4,089 per patient, about €1.3m nationally) and improved time-to-pregnancy. A national survey across medical domains further reveals how enabling cost information improves psychological wellbeing and motivation in the workforce.
The research introduces the concept of teleological indeterminacy to examine how manager’s and clinician’s engagement with accounting practices impacts their situational judgments of what resource use is appropriate for specific patients. It advances understanding of how cost management systems—when designed with and for users—can improve care value, financial sustainability, and workforce wellbeing. It offers practical and theoretical contributions to tackling cost containment and workforce issues simultaneously.