Because the clinical patterns and symptoms that persist after a COVID-19 infection are diverse, a diagnosis of post-acute COVID-19 syndrome (PACS) is difficult to implement. The current research project therefore aims to evaluate the feasibility and the practicability of a comprehensive, interdisciplinary, and cross-sectoral treatment program consisting of a low-threshold online screening and holistic assessment for PACS. Furthermore, it aims to evaluate digital interventions and the use of so-called personal guides that may help to facilitate the recovery of PACS.This German study consists of a low-threshold online screening for PACS where positively screened participants will be supported throughout by personal pilots. The personal pilots are aimed at empowering patients and helping them to navigate through the study and different treatment options. Patients will then be randomly assigned either to an intervention group (IG) or an active control group (ACG). The IG will receive a comprehensive assessment of physiological and psychological functioning to inform future treatment. The ACG does not receive the assessment but both groups will receive a treatment consisting of an individual digital treatment program . This digital intervention is based on the needs identified during the assessment for participants in the IG. Compared to that, the ACG will receive a more common digital treatment program aiming to reduce PACS symptoms. Importantly, a third comparison group (CompG) will be recruited that does not receive any treatment. A propensity score matching will take place, ensuring comparability between the participants. Primary endpoints of the study are symptom reduction and return to work. Secondary outcomes comprise, for example, social participation and activities in daily life. Furthermore, the feasibility and applicability of the online screening tool, the holistic assessment, digital trainings, and personal pilots will be evaluated.This is one of the first large-scale studies to improve the diagnosis and the care of patients with PACS by means of empowerment. It is to be evaluated whether the methods utilized can be used for the German and international population.Trial registration ClinicalTrials.gov Identifier: NCT05238415; date of registration: February 14, 2022The online version contains supplementary material available at 10.1186/s12879-022-07584-z. By July 15th, 2022, almost 30 million people in Germany have contracted COVID-19 , other oA possible complication or long-term consequence of acute COVID-19 is the occurrence of the post-acute COVID-19 syndrome  . There aIn contrast to the acute infection, there are currently no validated, uniform diagnostic criteria, so that the development and further refinement of scientific evidence for research into this clinical diagnosis is required  and the Symptoms that persist from the acute COVID-19 phase or its treatment,symptoms that have led to a new health limitation, ornew symptoms that have arisen after the end of the acute phase but are understood to be a consequence of COVID-19 disease or worsening of a pre-existing underlying condition.Such symptoms that occur after COVID-19 and that cannot be explained otherwise, indicate the diagnosis of a PACS to be probable , 15. TheAmong a broad variety of other symptoms, emerging symptoms include fatigue, shortness of breath, cognitive dysfunction, abdominal/chest pain, cough, depression, and altered sense of smell/taste . Many, iThe severity of the course of acute COVID-19 is not a reliable predictor of the occurrence of PACS: An analysis of 28 studies found that 5–36% of outpatients, who had a milder course of COVID-19, and 39–72% of inpatients with a serious trajectory reported post-acute COVID-19 symptoms (PACS) in the first quarter. A high number of symptoms and very explicitly the occurrence of diarrhea or anosmia during the acute infection as well as female sex appear to increase the likelihood for the occurrence of post-acute COVID symptoms .In Bavaria/Germany, where the study is being carried out, about 20,000 patients with PACS are expected according to the data of the Association of Statutory Health Insurance Physicians of Bavaria . Thus, aEmployment and workability are important parts of social participation . Work liA possible management strategy to prevent these detrimental trajectories are health-promoting behaviors including the maintenance of activities of daily living (ADL). It has been hypothesized that self-management in terms of physical activity and healthy diet as part of a behavioral health intervention can positively influence PACS and avoid an exacerbation of symptoms . Hence, This will be addressed with a proposed framework of a successful recovery process see Fig.  which buPatient behavior is the kind of actions patients perform to make use of the health care system . These action experiences and resulting health outcomes feed back into behavior management by functioning like outcome expectations. Outcome expectancies are for instance, beliefs and attitudes that our own behavior can improve symptoms instead of only expecting the doctor to fix our health issues. Outcome expectancies are important because they have an impact on higher-level goals. Such higher-level goals drive behavior management centrally as individuals can explicitly or implicitly aim for improving their activity, social participation, and well-being by means of performing actions in that sense Fig. .Due to the wide range of symptoms and limited capacities with specialists, the diagnosis is difficult. Accordingly, a low-threshold screening is of PACS needed to determine PACS, i.e., to support the decision-making processes. Once the diagnosis is made, referrals to different specialists must be made to determine treatment. Since the symptoms of PACS vary greatly among patients , the theIn addition to outpatient treatment and therapy, the German guidelines recommend  inpatient medical rehabilitation if there are impairments regarding social participation which require multimodal medical and therapeutic treatment . The aimOverall, optimal medical care for patients suffering from PACS with the aim of high treatment quality leads to a considerable effort in the coordination of the treatment process. Successful treatment coordination is currently not guaranteed by the existing structures. That is, in the existing structures of the health care system patients usually, first see their primary care practitioner, who will make the appropriate referral if diagnosis and treatment by a specialist are indicated. Due to the diversity of the symptoms, additional specialized post-COVID outpatient clinics have been set up in many hospitals  to whichproject aim is to evaluate a comprehensive, interdisciplinary, and cross-sectoral treatment program consisting of a low-threshold online screening and conducting a holistic assessment for post-acute COVID-19 syndrome (PACS). It also aims to prepare a treatment plan for patients that will be augmented by digital interventions and a so-called personal pilot, who will help patients to navigate through their treatment. In case of the feasibility and effectiveness of the methods applied, our approach will be applied to other regions and countries, too.In particular, young affected persons, who previously had not been treated due to  mild course of the disease, from which it is known to possibly still result in PACS , are rarThe objective of the present study is the early detection of post-acute COVID-19 symptoms (PACS) and subsequently a long-term and sustainable holistic care and support of patients with PACS to avoid long-term illness and chronification, and to enable social participation.The long-term goals of the study are the dissemination of validated instruments  and newly developed treatment approaches  through communication to central stakeholders such as medical associations, health insurance companies, service providers in the outpatient and inpatient sector as well as professional societies and care institutions. In this way, patient care is to be improved beyond the project duration and care services are to be made more efficient.screening can detect the presence of PACS.A short  assessment can validly and reliably determine rehabilitation or remedial needs and the leading rehabilitation indication and be basis of an individual multidisciplinary treatment plan.A comprehensiveindividualization the digital therapy offers, the higher the effectiveness in the treatment of PACS.The more personal pilot  empowering the patient suffering from PACS can -by means of an interdisciplinary and intersectoral treatment planning- ensure the sustainable management of interdisciplinary treatment.As contact point for all involved parties, a interdisciplinary treatment pathway and the personal pilots empower the patients, so that the patients receive the appropriate diagnosis and treatment, and to actively participate in their own recovery, ensuring patients recover quickly and sustainably from their PACS conditions, increase their functional capacity, reduce incapacity to work and regain participation.An Hypotheses, which will be tested with this project, are the following:personal pilot who will help the patients to navigate the study participation as well as through treatment options and help them seek help for further needs. The personal pilot acts as a contact point for patients and service providers and guides patients through the care process. Furthermore, the personal pilots make sure participants will take part in the study questionnaires by continuously reminding the patients in case they did not fill out the questionnaires.This longitudinal randomized control trial study will take place in Bavaria in Germany and has three study arms. Specifically, patients will be randomly assigned to an intervention group (IG) or an active control group . Shortly after the positive screening patients from the IG and ACG receive their first contact with a personal pilot.Patients are invited via primary care physicians, support groups, press releases, and social media. Participants may take part when they show signs of PACS symptoms that last longer than 4 weeks after the acute COVID-19 infection. All participants will first take part in a low-threshold digital interventions . In the IG, this unspecific digital intervention will be made available to bridge the time to an assessment that takes place in a clinic and in which patients will be assessed by a multiprofessional team of health care professionals. After the assessment, patients in the IG receive digital interventions that aim to meet their individual needs in terms of their physical capacity ; patients in the ACG receive digital interventions that are individualized based on the most debilitating symptoms . The digital intervention tools consist of training plans on the one hand and additionally, a chatbot will be developed and made available to complement the interventions on the other hand. This chatbot will answer specific questions of participants, for example, about symptoms or who to contact first, and it will also contain short psychological “learn”, “think”, “do”, exercises to improve participants well-being.Patients from the IG and the ACG will then receive unspecific assessment will be carried out promptly at a clinic to determine the individual need for treatment, the results of which are used as the basis for holistic treatment planning. Possible treatment recommendations are the initiation of rehabilitation, the provision of medical aids, specific therapies, the recommendation of digital health applications, and outpatient treatments.In the IG, a 3-day multidisciplinary The study design does not provide blinding. Participants, their personal pilots, and health care professionals as well as the researchers who evaluate the data will know about which participants were assigned to which group.Data will be collected via unipark.com, an online data collection tool where participants fill out the questionnaires themselves. Within this tool, participants create a unique, pseudonymized study code that they will use at each measurement time point. Furthermore, participants’ full names will be collected within the assessment and during the pilot contacts. The data from the online questionnaires and these surveys will be matched by research associates from the Jacobs University, who will have short-term access to the patient codes and the patients’ true names exclusively for this purpose. The list with the patient codes and the true names will be stored in a protected way and will be destroyed after all matchings have been completed. Furthermore, continuous data backup takes place on protected disks and servers of the institution where the data collection takes place.The current protocol (19. July 2022) is the first version and describes the current status of the procedure.Inclusion and exclusion criteria for the current study are summarized in Table recruitment will be carried out in two ways: Firstly, patients are sought to be reached via multiplicators. These include general practitioners (GPs) and specialized primary care physicians, post-COVID outpatient clinics and administrative institutions. GPs and specialists will be informed in advance about the possibility of the screening based on an existing address database. It is assumed that approximately every tenth physician will identify patients as potential candidates and can refer approximately one patient to the study. If 1000 multiplicators are contacted, about 100 potential participants can be screened.Patients will be asked to participate in the study after they were positively screened in the initial online screening. The Secondly, patients will be recruited via the use of media, including regular press releases (approx. once a month after more frequent press releases in the beginning of the recruitment), radio podcasts as well as social media posts on Facebook and Twitter. If 20% click on the link to the website of WHO and 20% take part in the screening, 2500 people with PACS are needed to be reached, to recruit 100 study participants.In the current project, a comprehensive diagnostic and intervention program is developed including four main categories, outlined in the following figure Fig. .Fig. 4ASTo establish a quick and easy-to-use screening tool for patients who assume that their symptoms are due to PACS, a low-threshold online screening instrument was developed and will be evaluated during the duration of the project   and the need for treatment will be identified depending on the debilitating symptoms.The 3-day inpatient assessment takes place in a specialized clinic . This clinic has the necessary  competence in the fields of neurology and orthopedics including physiotherapy, internal medicine, and psychology. The assessment aims to check in more detail and on basis of objective tests for the presence of PACS. Furthermore, the goal is to determine an individual interdisciplinary and cross-sectoral treatment plan, which can be translated into practice. This plan is then guided by the personal pilot in terms of empowering the patients to know about their symptoms, the recommended treatments, and what they can do themselves also by means of the digital training.Concretely, the assessment is performed by means of physiological and psychological tests .Using such an approach allows us to test Hypothesis 2, that a comprehensive assessment can determine rehabilitation or remedial needs and the leading rehabilitation indication. To assess the applicability of this hypothesis, we will consider a comparison of test–retest reliabilities of the degree of experienced symptoms in the IG compared with the ACG and the CompG. Furthermore, the assessment allows us also to test Hypothesis 5 that an interdisciplinary treatment pathway empowers the patient. To assess the applicability of this hypothesis we will check whether IG, ACG and CompG differ in terms of the development of symptoms, increased activities of daily lives, RTW and increased social participation. To do so, we will consider MANOVA and repeated measurement ANOVA analyses.During the entire care process and after the onboarding performed by the personal pilots, digital intervention in terms of physical training courses and psychological interventions are provided to the patients. Patients can take part individually, regardless of location and time . The diIn addition to the content of the digital tool, an interactive chatbot will be developed and tested during the duration of the ASAP project. The chatbot will focus more on short interventions targeting the management of symptoms in daily life, including self-discrepancies, pacing, and coping.The patients will receive information and training to initiate the treatment of the present symptoms and to strengthen their self-management as well as to contribute to psychological stabilization. Contents include training in relaxation/breathing exercises, autogenic training, mindfulness/relaxation exercises, meditation, muscle relaxation as well as psychoeducation, strength training, physical endurance and coordination training, sensory training (including smell and taste), functional training as well as training on how to deal with the disease in an occupational context (cf. ).Using this method and determining differences in the IG , ACG  and CompG (patients who only received the chatbot on a voluntary basis) in the questions about how effective they found the digital interventions in the treatment of PACS allows us to test Hypothesis 3. Within this hypothesis, it is assumed that the more individualizable digital interventions are, the better they work. To assess this, we will check whether IG, ACG and CompG differ in terms of the development of symptoms, increased activities of daily lives, RTW and increase social participation with individualization as another factor. To do so, we will consider MANOVA and repeated measurement ANOVA analyses considering individualization accordingly.The personal pilots are the first point of contact for all patients who are admitted to the project. Pilots have the qualifications of trained psychologists, social workers/educators, health scientists or health care professionals. They ensure the connection between the project management team providing the outcome from the screening, the specialized clinic conducting the assessment and the patients—both in an anonymized way. A personal pilot is assigned to each patient who was screened positively and who takes part in the study.The personal pilots contact the patient by phone or email within 4 days after the participant has finished the screening tool. They provide information about the study process. The personal pilot arranges the inpatient assessment in the IG by making the referral to the assessment clinic. In addition, the personal pilot recommends and organizes participation in digital services.The personal pilot is available throughout the entire process of care, from screening to implementation of the treatment plan. Thus, the pilot supports the patients throughout the entire medical care as a contact point for both the patients and the medical service providers involved. At regular intervals, they contact the study participants in order to reflect on the progress, make qualitative notes of their observations with the patients  and try to motivate the patients also to increase the study commitment of the patients. Their final aim is to empower patients in their coping with PACS and enable them to find and make use of the best treatment. In the final discussion at the end of the study participation, the personal pilot gives recommendations for further care. The personal pilots are trained in motivational interviewing , 36.The personal pilot supports the referral to any necessary further diagnostics and therapy in the IG and ACG  and helps the patient to identify suitable leisure activities, such as individually appropriate physical exercises, gyms and recreation/fitness centers close to the patient’s home. The pilots help to arrange the appropriate contacts and access to suitable self-help groups. Moreover, the pilot helps to find a general practitioner if none is available yet. The personal pilot serves as an empowering coordinator throughout the entire care process, mediating information to the various service providers in the inpatient and outpatient sectors and the patients not admitted to the study by means of dissemination strategies.With the use of personal pilots, we will assess the applicability of Hypothesis 4 that a personal pilot can ensure the sustainable management of interdisciplinary treatment. To test this hypothesis, we will use a qualitative approach and ask the personal pilots to what extent patients have engaged in sustainable treatment and what factors in the interaction between the pilots and the patients were especially helpful to foster a sustainable treatment. Accordingly, answers will be analyzed by means of qualitative content analysis –39.A longitudinal randomized control trial design is used in this project with a three-group pretest–posttest procedure. Whereas the CompG will be recruited with different links via online invitations , the IG and the ACG are recruited with another separate link. After agreeing to take part in the study, participants will be randomized by throwing a dice. Patients for whom a 1 or 2 was rolled are placed in the IG and patients for whom a 3–6 was rolled are placed in the ACG. If a randomization cannot be realized , patients will be allocated to the ACG but will be marked for statistical analyses. Methodically, a propensity score matching will be used between the IG and the CompG to ensure the comparability of these groups . All groups are repeatedly interviewed with similar instruments in each group  and the participating patients are planned with partially standardized guidelines, which are evaluated with the use of a content analysis. In addition, structured, participatory observations are conducted, and the observations are tracked. The process evaluation is intended to provide information on the implementation fidelity , and implementation dose .summative effectiveness evaluation, the primary endpoint is the symptom reduction regarding PACS, and RTW. Secondary outcomes include social participation, health-promoting behaviors, and activities of daily living (ADL) as well as mental health and life satisfaction/quality of life. Survey and documentation of all endpoints are conducted by means of questionnaires and/or interviews with study participants who have completed interventions over the course of the project as described above. In addition, possible moderators  and mediators  are quantitatively reviewed and added to the analyses. An overview of the measures is provided in Table For the N = 132 (n = 66 in the IG and n = 66 in the ACG) is required to be able to demonstrate an effect of d = 0.15. The evaluation will be conducted statistically using a Multivariate Analysis of Variance . In addition to classical significance tests , the clinical significance will be calculated with effect sizes.With an alpha error of 0.05 and a power of 68%, a sample of To test the aforementioned hypotheses, first, a propensity score matching will be applied between the IG and the CompG. Sensitivity analyses and test–retest reliabilities will be used to test Hypothesis 1 and 2 respectively. To test Hypothesis 3, MANOVA and repeated measurement ANOVAs will be used. To assess Hypothesis 4, no statistical analyses but a qualitative approach will be used. For the last hypothesis (Hypothesis 5), repeated measurement ANOVAs and MANOVAs will be used.The study aims to implement a comprehensive care process for people with post-acute COVID-19 syndrome (PACS) based on theory and evidence. This includes four components: (a) a low-threshold online screening to identify as many individuals as possible with a possible PACS, (b) a physiological and psychological assessment as well as (c) digital interventions as supporting formats within a support system over several weeks and (d) personal pilots supporting the patients to make effective use of the health care system by means of empowerment and guidance. The entire process is aimed at supporting the patient through a personal pilot who acts as the first point of contact for the patient. The personal pilot also coordinates and implements the treatment plan, and after the interventions, supports the patient to find additional and potentially necessary treatment options . In addition, the pilot acts as an executive to also inform all the medical service providers that are included in the screening, assessment, and provision of digital interventions by means of dissemination.After completion of the study project, a large network of outpatient and inpatient providers will have been established who offer the treatment to patients with suspected PACS. If the effects of the personal pilot and the digital training interventions transpire successfully, this provides evidence that such a support system may pay off, especially in times of people in need where no services are available at their convenience.manual that includes a description of the contact session between the personal pilot and the patient will be made freely available after the completion of the project to ensure continuous and standardized care according to a well-established and valid process for individuals diagnosed with PACS. To ensure the future care for individuals with PACS, any doctor can introduce patients into the treatment pathway; we believe that what is needed is contact with the personal pilot. Service providers who meet the professional and structural requirements for interdisciplinary and holistic assessment and treatment planning in the sense of the bio-psycho-social model can guide the treatment with a high level of quality.The aim of the current study is to enable the decision-making processes and the evidence-based treatment of PACS patients in the general population with their diverse and individual complaints in the long term, to discharge them from treatment into their everyday lives, and to reintegrate into society. To do so, a white paper) for diagnostics and care specifically for the target group along with the manual for the personal pilots. Our project, which is intended to close a relevant gap in care, has the potential to not only be transferable regionally, but nationwide and internationally.The comprehensive care process should be able to be transferred to regular care and other illnesses and, after the study is completed, will be presented in a corresponding concept (The results regarding the hypotheses will be disseminated in scientific publications, which will be communicated to experts and the public by means of press work and social media.This study will also provide valuable information on the effectiveness, user acceptability, and feasibility of the different components. It addresses the need to investigate new approaches to improve health care provision and support of vulnerable patients, which can relieve health systems from the growing demands caused by challenges with communication around the world and in all areas of medicine and public health.Additional file 1: Appendix low-threshold online screening for PACS.


Building information modelling (BIM) is considered to be significant for organisational communication in construction projects. However, the role of BIM has not been fully shown in practice. To this end, this study examined the impact of BIM on communication network from inter- and intra- organisational relationships in the construction project. First, the structures of the communication networks before and after the use of BIM in a project in China were determined based on the social capital perspective. Then, the social network analysis was adopted to measure the changes in network metrics . Results shows that the connections among nodes are denser, and all the values of the network centralisation decrease after BIM application compared with the situation before BIM use. Nevertheless, results also shows that some construction project participants, who originally have interaction and communication needs, remain unable to establish effective connections among one another even after BIM use. Accordingly, some suggestions were proposed to solve the issues and deficiencies. This research contributes to (a) the state of knowledge by proposing social capital perspective that can identify inter- and intra-organizational relationships of the construction project from social interaction and common cognition to build communication network, and (b) the state of practice by identifying conditions and proposing strategies for strengthening organisational communication and collaboration in BIM-enabled network relationships. A construction project has the characteristics of temporary and openness, and the project team often involves numerous participants consisting of different departments in various organisations . The comBIM is an advanced and revolutionary technology for generating, visualising, and analysing architectural models, thus changing the way buildings are conceived, designed, built and operated , 8. MoreThe construction project team involves different participating organisations and different departments within each organisation. Both internal and external communication activities exist in a construction project. Internal communication activities within an organisation are often known with fewer tasks compared with external communication, and their importance is often overlooked . EffectiThus, this study introduces the concept of social capital (SC) to reflect the inter- and intra-organisational network relationship of the project, and SC involves social interaction and common cognition dimensions . BridginA more explicit, objective, and direct measure of the organizational communication network changes attributed to BIM implications will facilitate quantifiable and empirically validated BIM impact assessment and further support BIM implementation in the industry. In addition, previous studies have found that social network analysis (SNA) is an effective tool for measuring metrics of the communication network , which iThe main research questions of this study are: (1) Is there a difference between organizational communication networks of the construction project before and after BIM use? (2) If so, how does the difference between before and after BIM use inspire a more effective project management means and organizational communication mode changes? To answer these questions, this study first determined the organisational communication network before and after the BIM use in a project in China based on the social capital perspective. The SNA was then adopted to measure the changes in network metrics. This research contributes to (a) the state of knowledge by proposing social capital perspective that can identify inter- and intra-organizational relationships of the construction project from social interaction and common cognition to build communication network, and (b) the state of practice by identifying conditions and proposing strategies for strengthening organisational communication and collaboration in BIM-enabled network relationships.The remainder of this paper is organised as follows. The next section reviews the related works and elaborates on the existing research gap. Then, good empirical data generated from a BIM construction project in China will be analysed using SNA. Finally, the study’s findings will be presented and discussed.For an organisation, communication is considered the base of its operation . CommuniAs a temporary social system, a construction project involves the interaction of a group of numerous professionals from different disciplines in its prolonged implementation process, resulting in the complexity of the project’s organisational structure and relationships . EffectiOn the one hand, previous studies have provided valuable references for establishing the relationship between BIM implementation and improved organisational communication and collaboration from technological standpoint , 23. HowOn the other hand, research on the combination of inter- and intra-organisational linkages amongst all participants of a construction project under the BIM influence remains limited. Similarly, in practice, internal communication activities are often known to have fewer tasks compared with external communication, and most managers do not realise the importance of internal communication within an organisation .Notably, a significant part of the management literature discussed communication about external and internal organisations at the company level. For example, Campbell and Alexandra  regardedPrevious studies showed that external and internal communications are closely related at the company level. Insight into the nature of this connection will help managers improve their efforts by designing effective external and internal relationships. Similarly, the ad hoc organisational network relationships within a construction project are a combination of external and internal interactions, including consensus connections . Thus, aSocial capital is defined as the sum of embedded, available, and derived resources in a network of social relationships owned by an individual or organisation . The netOrganization level team SC is a special type of SC in which the relations of team members are formed through formal and informal structures , 37. A tThere is no doubt that a construction project team consists of many participants (i.e. organisations and departments within these organisations) and that the characteristics of bonding and bridging SC are reflected in it . AccordiSome research believed that ICT could influence the SC in a team to some extent . The popFor the SC structural dimension, BIM may stimulate more intensive and higher dependent interactions amongst participants by changing the efficiency and means of information exchange, thereby influencing the collaborative process . AccordiFurthermore, as a network variable, SC reflects the degree of control over resources (information) by actors within a social network . Many poInspired by this, the current paper aims to provide additional evidence regarding the impacts of BIM on both inter-and intra-organisational network relationships for all participants of a construction project based on SC theory.This study was carried out in strict accordance with the recommendations and guidelines on Human Subject Research (involving human participants and/or tissue) for scientific purposes, and this study was approved by the Institutional Human Subject Research Committee, China (Protocol Number: CSCUST-DW-2020-075). This research involves Human Subject Research . However, the data in this paper has been collected and analysed anonymously. We ensured the respondents that the survey has been conducted only for academic purposes, and there is no personal identification. The data of expert interview have obtained the written consent of the participants. The interview consent is in the supporting information uploaded by the system.The overall research design is a case study, with SNA at the kernel. Firstly, this study determines the communication network relationships of a project team before and after BIM use from the dimensions of SC. Then, this work measures the changes of network metrics using SNA, and the differences between the two networks were compared. Amongst them, the collection of interview data was mainly based on the ‘self-perceptions’  of interviewees to judge the relational changes of communication network before and after BIM use. The theoretical basis of ‘self-perception’ here is cognitive social structure (CSS) theory proposed by Krackhardt . This isThe case study method is the most appropriate for this research, as the researchers sought to establish rich and empirical descriptions of project team communication in a context where researchers do not interfere .2 and a total construction area of 66,872 m2. This project had three floors underground and 23 floors above ground, with a total investment of RMB 280 million and a total construction period of 29 months. BIM had been used in the whole process management of this project.To make the case representative, the selected case must meet the following criteria: 1) the organisational structure of the construction project selected must be well-defined and the case data obtained must be relatively detailed and complete, and 2) the construction project selected as the case study should have a high level of BIM application, and each participant in the selected case project has a deep understanding of the BIM. The selected BIM project was in a city of China. This project was the first phase of a city commercial complex, covering a gross site area of 6,489.39 mParticipating units in this project included the owner, the designer, the engineering supervision, the BIM consultant, the general contractor, and the subcontractor. The main departments established by the project owner included the engineering, design, operations, and cost department, among others. Meanwhile, the main departments set up by the contractor include the engineering, technology, cost, safety, and material departments. Although several subcontractors participated in the project, only one subcontractor most relevant to BIM use was selected as the representative in this study. The main departments set up by this subcontractor were the engineering and cost department. In addition, the engineering supervision, the designer, and the BIM consultant in the project had no other sub-departments.Apart from the collection of case documents, the structured interview for the main project participants is also another complementary way to obtain data . The strAccording to SC theory, the sense of trust among participants is the subjective condition of information communication, while social interaction and common cognition among them are the objective basis of communication . Trust cFirstly, the category analysis method was used to divide the original interview questions into blocks and form two dimensions . The content analysis method was then used to find the useful information and items from the two dimensions. Then, the semi-structured interviews with experts were conducted to assess the appropriateness of the questions’ scope and avoid ambiguous expressions. All five experts who used the semi-structured interview had more than 20 years of practical or research experience in the AEC domain and are also familiar with BIM application in construction projects. Two of them are project managers of major projects, two are university professors, and another is a senior manager of an architecture firm. Through the semi-structured interviews, redundant items were merged, and missing items were added, and all interview questions were modified to suit the context of the AEC industry. Subsequently, a pilot questionnaire survey involving 166 respondents  as an exploratory factor analysis of all responses was carried out to verify whether all of the questions were classified into their corresponding dimensions . Based on the feedback, the questionnaire was further optimized, and the final questionnaire was formed. Ultimately, the final questionnaire was adjusted appropriately to be the standardise interview outline  Files.As it was necessary to compare the communication networks before and after the application of BIM, two interview outlines were made for the same interviewees from the selected case project. One was about the self-perceived information communication relationships of interviewees before BIM use, in which the BIM consultation party was excluded in the network nodes. The other was about the self-perceived information communication relationships of interviewees after BIM use, in which the BIM consultation party was included in the network nodes.Social network analysis (SNA) is defined as a tool for analysing a set of related actors or parties who either cooperate or compete with one another through social structures . It provThe wide range of network metrics in SNA includes the number of ties, network density, average path length, actor centrality, centralisation, clique, average clustering coefficient and modularity, among others , 63, 65.The premise of establishing the communication network of a construction project team is to collect the relevant node data and relationship data of the network. Firstly, the specific participants were identified according to the documents pertaining to the organisational structure of the selected case project and used as the nodes of communication network. In this case, the network nodes were as follows: owner’s engineering department (OED), owner’s design department (ODD), owner’s operation department (OOD), owner’s cost department (OCD), designer (Des), engineering supervision (Sup), BIM consultation (BC), contractor’s engineering department (CED), contractor’s technology department (CTD), contractor’s cost department (CCD), contractor’s material department (CMD), contractor’s safety department (CSD), subcontractor’s engineering department (SED) and subcontractor’s cost department (SCD).Furthermore, the structured interviews were adopted to collect the relationship data amongst the network nodes before and after BIM use, respectively. This study selected the main managers or backbone employees from each participant  as the representative of the interviewees. All the interviewees had more than 10 years of experience in the AEC industry and over 5 years of learning/practical experience in BIM. An overview of interviewees is in For questions of social interaction dimension, if interviewees A and B mentioned each other in more than half of the total number of questions, then we considered that A and B had an interaction relationship. In this case, their social interaction dimension was given a score of 1. Otherwise, if interviewee A or B mentioned each other less frequently, then we considered that A and B had no interaction relationship. In this case, their social interaction dimension was given a score of 0. For example, the interview for the representative of the OCD revealed that this person mentioned the CCD four times when answering the social interaction questions, and vice versa. The number is greater than half 2.5) of the total (5) number of questions. Therefore, an interaction may exist between these two departments, and their score of the social interaction dimension is 1. However, the two nodes are only verified to have a connection when both the social interaction and common cognition dimensions have a score of 1. In this case, the corresponding value in the final relationship matrix was set to 1. Otherwise, the corresponding value in the final relationship matrix was set to 0. The 0–1 matrixes of communication relationships before and after BIM use are shown in Tables .5 of theWe observed that the scores of social interaction and common cognition between the OCD and the CCD before BIM use are both 1. Therefore, there is an effective information communication between these two parties and a communication line is formed between the corresponding two nodes in the communication network. This point is proven in practical engineering, in which both objective interaction needs (business contact) and subjective common cognition  exists between the OCD and the CCD. In comparison, the score of social interaction between the OCD and the SCD is 0, whilst the score of the common cognition between them is 1. Therefore, there is no effective information communication relationship between the two parties. Specifically, there is no connection between the two nodes in the communication network. This point is also proven in practical engineering: although the OCD shares the same technical language with the SCD, they have no direct business contact with each other during the implementation process of the case study project.Two 0–1 matrixes of information communication relationship were inputted into NetDraw software to form a corresponding graphic of communication networks of the project team before and after BIM intervention, as shown in Obviously, the connections amongst participants in the communication network after BIM use became denser and closer than the situation before BIM use.The overall network density and number of ties represent the degree of connection between network members . Table 4The analysis results of density, number of ties and average path length suggest that the connections amongst participants in the communication network after BIM use became denser and closer than the situation before BIM use. According to Pryke  and LushCentrality is an important metric to measure the degree of network centrality of a node in social network analysis, which reflects the power, status, and importance of a node in the network , 64. TheDegree centrality refers to the number of neighbouring nodes directly connected to a node, whereas closeness centrality reflects the degree of proximity between a node with others in the network , 64. FigThis betweenness centrality denotes actors who are in the network in a privileged position where, because of its location, they bridge between others, that is, this is the actor that one actor must go through to achieve communication with each other . Fig 5 sThe analysis results of centrality indicate that the degree and closeness centrality of most nodes increased after BIM use. Pryke  and Tai Network centralisation metrics, such as degree, closeness and betweenness centralisation, are mainly used to represent the different levels of the corresponding centrality of each member in a network . Fig 6 sCompared with the situation before BIM application, all values of network centralisation of degree, closeness and betweenness decreased after BIM use. According to Borgatti et al. , the smaThe division of players in subsets or cliques is a very important aspect of the social structure and helps to understand the behaviour of the whole network. A clique is a subset of actors who are more strongly connected than they are with other actors who are not part of the group . To knowAs shown in The analysis results of cliques for this project communication network suggest that the number of subgroups involving one or more of the same actors increased after BIM use. Therefore, the application of BIM eliminated a part of the information island, and the diffusion of information resources will become quicker throughout the network.Before the use of BIM, the results show that the connections amongst nodes are relatively sparse. From the perspective of SC, this phenomenon can be further revealed. Firstly, sufficient interaction and common recognition amongst participants of the ad hoc construction project team are lacking. Thus, these participants are unable to form sufficient trust relationships and communication willingness, resulting in the hampered exchange of information amongst numerous nodes. By contrast, the connections amongst nodes became more intensive, and the information distribution within the network becomes more balanced after BIM use. Combined with the SC perspective, the reason is that the degree of social interaction and common cognition amongst more participants become high after BIM use, thereby fostering an atmosphere that is more conducive to the exchange of information.The network centralities and connection relations showed that, in addition to the connections between some network nodes and the new participants  after BIM use, some previously un-contacted participants were also beginning to build communication relationships. All these new connections relate to OED, OCD, ODD, CTD, CCD, SED, and Sup . The new connections mainly included the following: (a) the ODD with the OCD, (b) the OED with the CCD, (c) the Sup with the CTD and the CCD and (d) the CTD with the SED. The reasons for this may be as follows:The accurate statistics of engineering quantities obtained through BIM can be used to analyse the economic indicators of different design schemes within the budget range , 72. ThiIn the process of dealing with engineering changes, the engineering change visa sheets can be associated with the entity model in BIM, thereby facilitating the automatic calculation of the increase or decrease of engineering quantities and costs . This apIn the process of reviewing the construction scheme, BIM can be used to deepen the scheme design, extract the construction model, simulate the construction scheme of key nodes, and evaluate the rationality or practicability of the construction scheme , 8. MeanTherefore, with the application of BIM, the task objectives and work processes become more visualised, indexed, and intuitive. In turn, this approach can help form a unified cognition of all parties to a large extent, thereby eliminating some barriers to information exchange and communication amongst participants.Nevertheless, the subsets analysis results showed that several nodes  are still not sufficiently engaged in generated cliques. Thus, the relevant construction project participants who originally had interaction and communication needs were unable to establish effective connections. These failed connections all relate to OOD, CSD, CMD and SCD. For example, no effective connection existed between the following participants: CMD and CED; CMD and CCD; CSD and BC; CSD and Sup; CMD and Sup; OOD and BC; SCD and BC. The reasons for this may be as follows:Even after introducing BIM, the CMD still cannot clearly present or extract the materials, equipment and components related to the engineering entity information to the CED, CCD or Sup in the process of quality examination . MeanwhiUnlike the progress or cost problems, safety issues in the construction project are too complex to be completely presented by BIM . Safety Traditionally, the project operation plan of the owner does not require many details. OOD tends to rely on experience and uses traditional chart methods to carry out most work rather than BIM. As a result, the acceptance of BIM in the OOD is generally low. Similarly, considering that the subcontractor’s company scale and their work amount are relatively small, CSD is reluctant to increase the upfront investment too much to adapt to the BIM context.In a word, these marginal participants are still unable to utilise BIM to achieve better consensus and collaboration with others. Thus, some issues still need to be solved in the process of promoting the informatisation of construction project management.This research reveals important insights into construction project management and SC theory by focusing on the comprehensive impacts of BIM use on organisational communication of project. At present, research on the simultaneous integration of inter- and intra-organisational network relationships amongst all participants of a construction project is limited, particularly in the case of BIM use. To bridge this gap in the literature, our study introduces the concept of SC, which is closely related to the existing relationships amongst members, to reflect the degrees of communication and collaboration within a relationship network of project. Then, this study explores changes in inter- and intra-organisational network relationships after using BIM in the construction project. To the best of our knowledge, this work is one of the early efforts to investigate communication and collaboration in a construction project team against the background of informatisation of relationships within and amongst organisations. The findings of this work can provide reference for conducting relevant theoretical research in the future.This research also has implications for identifying conditions and proposing strategies for strengthening organisational collaboration in BIM-enabled network relationships of project. Like prior studies, our research has indicated that BIM use plays an important role in fostering communication and collaboration amongst members of a construction project team. However, a deep discussion for the problems existing in communication networks after BIM use remains lacking. Our research suggests that marginal participants still cannot use BIM to improve their communication and collaboration with other members of the team. Then, the conditions and strategies for strengthening BIM-based organisational communication and collaboration were further identified and proposed. The research findings thus expand the understanding of BIM technology in the field of complex engineering applications. This contribution evidently complements the existing body of knowledge regarding BIM.This study presents several implications with a reference value for managerial practice. As a construction ICT, BIM is used throughout the lifecycle of a construction project by bringing together the work of various disciplines, to encourage quick and unified information sharing and improve collaboration amongst participants. Thus, managers should pay increasing attention to the role of BIM in team SC. BIM can overcome time and space barriers of communication among different participants and further promote members’ consensus and trust, which encourage organisation members to share their knowledge effectively.However, managers should understand that there are still some deficiencies in the application of BIM. For example, some tasks are too complex or fragmentary to be presented by a single BIM. As a result, marginal participants are unable to utilise BIM to establish better consensus and collaboration with others.Therefore, managers can combine multiple ICTs to achieve more adequate identification and sharing of security information. For example, geographic information system (GIS), global positioning system (GPS), computer vision and BIM can be combined to better present the specific location of dangerous parts as well as to achieve personnel and equipment position tracking and hazard warning at any time; Unmanned aerial vehicles (UAVs), augmented reality (AR) and BIM can be combined to identify and monitor potential quality hazards at different locations of a project. RFID technology can also be used to track the information of materials and equipment, such as the type, inventory status, use location and consumed quantity, which can be embedded into the BIM model. A cloud-based BIM platform can be built to store and analyse large information of about the construction project, which can help in achieving real-time interaction and unified understanding amongst participants.This study determines the communication network relationships before and after the use of BIM in a project in China from the dimensions of SC and measures the changes of network metrics by SNA. The results show that, compared with the situation before BIM application, the connections between network nodes are closer after BIM application. Thus, participants in the construction project team have more interaction and consensus basis. Furthermore, all the values of the network centralisation decreased, suggesting that the information distribution in the communication network became more balanced after BIM application. Nevertheless, the results also show that some construction project participants with interaction and communication needs remained unable to establish effective connections with others even after BIM use. Therefore, these marginal participants are still unable to utilise BIM to foster better consensus and collaboration with others. Thus, some issues still need to be solved in the process of promoting the informatisation of construction project management.This research contributes to (a) the state of knowledge by proposing social capital perspective that can identify inter- and intra-organizational relationships of the construction project from social interaction and common cognition to build communication network and (b) the state of practice by identifying conditions and proposing strategies for strengthening organisational communication and collaboration in BIM-enabled network relationships.Apart from the findings, some limitations of this study need to be discussed, along with future research directions that need to be explored. One of the limitations of this study is that it focused only on the participants directly involved in the construction project implementation. Other stakeholders who may have had an indirect impact on the project were excluded. The upgraded BIM may further blur the organisational boundaries and flatten the organisational structure. Therefore, future studies can further analyse the network relationships among the general or expanded stakeholders of a construction project under BIM influence.Moreover, this study, as an illustrative example, is probably not the most typical representative of the broader construction industry. The generalisability of this study’s results is restricted by the sample size (one project case) and geographical location (China). Other construction projects may be implemented with various organisational structures and cooperative atmospheres. Therefore, more case studies are needed to make these findings universal.Finally, SC theory contends that social relationships are resources that can lead to the development and accumulation of human capital. Thus, the given method has no discussion on potential downsides, . Therefore, future studies can attempt to further explore the issues.S1 File(DOCX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.S4 File(XLSX)Click here for additional data file.S5 File(SAV)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.


Family policies to reduce conflict in work-life balance and promote gender equality advanced significantly at the legislative level in Spain in the first decades of the twenty-first century. These advances include the 2007 Law for Equality between Men and Women and the extension of paternity leave to 16 weeks in 2020. However, advances in care work and at the professional level have been limited. The COVID-19 pandemic has intensified existing imbalances in family-work responsibilities in general and the ICT gender gap in particular. In crisis situations, women adopt the role of caregivers more easily than men, and women with fewer educational, economic, and job resources are more likely to assume this role, contributing to increasing gender inequalities at work and in the family. COVID-19 has exposed these imbalances, highlighting the need for new narratives and laws that encourage gender equality. Post-COVID-19 scenarios thus present an opportunity for reflection and progress on Spanish family policy. From this perspective, the paradigm of work-family conflict, although interesting, must be examined and resignified. This article proposes to critically resignify the paradigm of work-family conflict based on the new narrative generated by COVID-19. The present analysis suggests a resignification that should involve changing the expectations and practices around work-family balance, based on family diversity, job insecurity, the technological revolution, and new masculinities. It is proposed a prior reflection to clarify definition of the indicators and indexes that enable operationalization of the concept of work-family reconciliation. It is expected that these measures will help to facilitate practical application of reconciliation in areas such as public or/and private organizations, while also enabling international comparative analysis. Parallel to the increase in dual earner families, significant advances have been made in family policies for work-family reconciliation, primarily through the extension of paternity leaves. These advances have encouraged fathers to take more time off work to care for their children during the first years of their lives Balsas, . DespiteThe COVID-19 has meant a reorganization of the public and private spheres, especially affecting care work in families and raising new questions about how the pandemic has affected the organization of the division of labor in the family and thus work-family reconciliation. The research performed seems to indicate that the beginning of the lockdown and subsequently remote work opened new possibilities for renegotiating the distribution of domestic work in couples , it has been seen as easier for women to combine these tasks , the Special Plan on the Equality of Women and Men in the Workplace and Against Wage Discrimination 2015–2017=),–2017=,20As a result of the crisis caused by the pandemic, it has become crucial to detect and determine the difficulties encountered in promoting measures to achieve improved participation of women in the labor market and increase men's involvement in care for dependents. Flexible working arrangements can be an especially powerful tool for retaining women in the workforce. At the same time, the concentration of women in specific employment contracts  has a negative effect on earnings, career progression, and pension entitlements, especially if these contracts are extended in the long term [European Institute for Gender Equality (EIGE), As various studies have demonstrated, the structuralist perspective highlights the influence that changes in social policies such as labor regulations and/or aid for care of dependents can have on the phenomenon of reconciliation in redefining paid—and thus unpaid—work. The different social policies that address reconciliation have a philosophical root that can give rise to policies that prioritize developing ways to make life easier for mothers who work outside the home and to reconcile work and family, protecting and promoting children's wellbeing when their parents are working and policies that especially promote support for women who leave the labor market while their children are young . Campillo Poza  observesReconciliation policies address different dimensions of this situation, depending on how they focus on policies that provide services; childcare and long-term care services for children, the elderly and/or other dependent relatives; leave arrangements and flexibility (flexible arrangements for working hours); or financial aid. It is recognized that failure to promote work-life balance policies in general, and the lack of childcare facilities in particular, is a major obstacle to women's economic independence. “Reconciliation policies” in general, and provision of childcare facilities in particular, enable both women and men to achieve economic independence. As the OECD  affirms,According to data from the European Union's Statistics on Income and Living Conditions (SILC-EU), Spain has managed since 2005 to provide full childcare coverage to children ages 4–5 whose parents requested it, and participation in formal caregiving rose from 40% in 2005 to 44% in 2009. The percentage of children ages 3–6 who attended childcare for up to 29 h/week was around 46.6% in 2015 and over 50% (57.7%) in 2020 EU-SILC, . The figIn the past 11 years (2009–2020), the percentage of children cared for solely by their parents has remained constant EU-SILC, . We mustFor childcare, the two main instruments are leave policiesSpain's leave policy since 1996 has been grounded in the European Council directive that requires member states to introduce legislation on parental leaves so that parents can care for their children full-time for the first 3 months. In theory, this is an individual and untransferable right. The directive ensures a guaranteed minimum in all member states, above and beyond which we find a wide range of national regulations with differences among countries as to payment, length, and rights enjoyed. The length of the leave ranges from the first 3 years of the child's life  to only 3 months (Liechtenstein). In some countries, the leave is not paid. In others, it is, and payments vary from a fixed single amount to payment relative to salary. The level of compensation determines which member of the couple takes the leave. The market sector in which the parents work also influences this decision. In Spain, most men who take paternity leave work in the public sector . This reformulation refocused parental leave policies toward fatherhood and a system of reductions in work time and voluntary, reversible, highly flexible work, while also extending these policies to the contingencies of caring for adults . More specifically, Spain has seen an increasing trend in telework. According to data from the EPA , 11.2% of Spain's working population  worked from their homes over half of the days in the trimester, a figure that has nearly tripled in <2 years (from 4.8% in 2019).Eurostat data (LFS) record even higher percentages, reaching 15.1% in 2020.According to the Eurobarometer , slightlSpain's public spending on family benefits increased from 2003 to 2007 but represented 1.6% of the GDP in 2007, a figure well below the average of the OECD countries (2.2%). In 2020, Spain was bringing up the rear among countries with the lowest rate of public spending on family benefits (1.19% of the GDP), while the average among OECD countries is 2.11 and Denmark and Luxembourg are at the opposite extreme  OECD, . One conAs Armijo  argues, The pandemic has altered the dynamics of our private life and family relationships. These new dynamics are in the process of redefining work life-family reconciliation, as well as the concept of conflict in reconciliation. Public policies must be attentive to these new dynamics and family structures so that they can define mechanisms for family protection sufficient and suitable to the new circumstances and they should consider the idiosyncrasy and features of the Spanish labor market. In 2020, there exists a difference of more than 11-point percentages in relation to male and female employment rate ; part-time employment and temporary contracts are over-represented among women   and work reality .In the case of Spain, successive crises have revealed the family's capability for resilience in facing situations of their members' vulnerability, most recently the 2008 crisis and the current COVID-19 crisis. More specifically, the COVID-19 crisis has revealed families' rapid reaction to the demands imposed by the pandemic on physical and emotional care of people who live together. The studies performed show that lockdown strengthened familialism-traditionalism of caregiving and thus of work-family reconciliation. On the other hand, surveys conducted by CIS confirm that satisfaction with family life and family relationships remained constant during the pandemic and even increased CIS, . Yet allHow can we interpret this paradoxical trend that the pandemic has reaffirmed and that does not correspond to the advance of family policies in Spain, such as the advances that have occurred in paternity leaves? A review of the literature on reconciliation practices in Spain shows clear ambivalence in attitudes and behavior after the birth of the first child, and this ambivalence is stronger in women. Studies confirm that couples with egalitarian ideas find it very difficult to put their ideas into practice due to the structural context of a precarious and fragmented job market  and the weak support for work-family reconciliation in childcare services. Further, studies have confirmed a strict traditional normative mandate for mothers in contrast to a more relaxed normative mandate for fathers in Spain , one clear effect of the pandemic on the division of family work seems to be retraditionalization of reconciliation strategies in Spain. This empirical evidence suggests that, far from substantial advances, there seems to be a disconnect between family reconciliation practices and the advances that have occurred in family policies, as for example with paternity leave. On the one hand, a discourse and narrative of dual earners and egalitarian reconciliation is assumed, but at the same time overload of family caregiving on women has intensified during the pandemic. It is as if the pandemic had reactivated the traditional normative values present in the cultural ethos of familialism in caregiving that had begun to weaken before the pandemic.We could say that we are facing the reproduction of traditional normative subjectivities in the dimension of the family that contradict the opening and implementation of egalitarian attitudes present in the subjectivities and narratives about paid work. This interpretation is consistent with the results obtained in prior studies of job reconciliation in Spain before and during the pandemic. All of the foregoing is reflected in cultural ambivalences that make egalitarian advances more difficult in work-family reconciliation practices  with public ones (family policies), thus also integrating individual and structural perspectives  of idea that caregiving roles deserve a higher position in the hierarchy of values throughout society. If societies before the pandemic revolved around models that extolled economic power, COVID-19 has highlighted the value of “caregiving” and “providing care.” If we add to this the fact that all societies on the planet are moving toward chronic aging, can we expect caregivers' status to improve? If so, we could expect men and women to show more egalitarian distribution of these roles. In this context, it is beneficial to promote any political action that seeks to revalue caregiving work, starting with domestic tasks, we believe that the more these tasks are valued, the more progress will be made toward gender equality. We must therefore create incentives for policies that promote the learning and internalization of values of gender equality in the domestic sphere.As those who have analyzed contemporary shortcomings in this area in Spain suggest, it is crucial to establish measures that respond to the real problems of the present. As Pastor Seller  suggestsThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Considering the gap observed in studies on health costs, this article aims to propose a cost calculation model for surgical hospitalization. A systematic literature review using PRISMA was conducted to map cost drivers adopted in similar studies and provide theoretical background. Based on the review, an integrated model considering real patient flow was developed using CHEERS guidelines. The micro-costing top-down method was adopted to develop the cost model allowing a balance between the accuracy of the information and the feasibility of the cost estimate. The proposed model fills two gaps in the literature: the standardization of a cost model and the ability to assess a vast number of different surgery costs in the same hospital. Flexibility stands out as an important advantage of the proposed model, as its application enables evaluation of elective and urgent surgeries of medium and high complexity performed in public and private hospitals. As a limitation, the hospital should have hospital information and cost systems implemented. The proposed cost model can provide important information that can result in better decision making. This becomes more relevant in public health, especially in low- and middle-income countries, which faces a lack of resources and whose positive effects can improve healthcare. According to the latest data from the World Health Organization (WHO), in 2018, the health systems of its 194 member countries spent USD 8.3 trillion, equivalent to 10% global GDP .Brazil had the ninth-largest expenditure in healthcare in 2018 among WHO member countries, totaling USD 177 billion, equivalent to 9.5% of its GDP . The BraSome studies in Brazil have addressed cost management in healthcare, but economic evaluation is still incipient, including public and teaching hospitals. One explanation is that many institutions do not even have cost systems in place yet ,15,16,17Hospitals are complex and expensive structures  and the Within this context, considering the gap observed in studies on health costs, this paper seeks to answer the question: how to determine resources spent in surgical hospitalizations and how to place monetary values to these resources? To solve this, the main objective of this research was to propose a cost calculation model for surgical hospitalization. To achieve this goal, a systematic literature review was conducted to identify existing models and to map the parameters adopted in similar studies. This review did not identify surgical hospitalization cost models. Thus, this study constitutes a first effort to modeling costs of surgical hospitalization.Application of the model will make it possible to understand the real cost of surgical hospitalizations, analyzed from the hospital perspective, by comparing them with the remuneration values for the hospital foreseen in the health system and also with other hospitals. The correct understanding of this relationship will more precisely direct management actions related to cost reduction, as well as reviews of remunerated amounts.As delimitation of the research, a cost study was not conducted. For this reason, values resulting from the application of the model in this research are not presented.As the first stage of the research, a systematic literature review was carried out to identify possible cost models for surgical hospitalizations, cost drivers, or variables. The PRISMA Statement  recommenThe search parameters and the Boolean operators used to search for titles, abstracts, and keywords were:  AND (“inpatient cost”) AND (surg*). The first set of terms served to delimit articles related to models or recommendations, while the second aimed to identify studies that dealt with inpatients’ cost and, finally, the third one was used to select studies that mentioned surgery.After searching databases, the filter for document type “article/review” was applied. The document filter was intended to include original and literature review articles and to exclude studies that were not peer reviewed. The search resulted in 112 documents in Scopus, 39 documents in WoS, 54 documents in PubMed, and 14 documents in CINAHL being selected.To realize the screening, eligibility, and inclusion stages from the PRISMA protocol, one author read the records and full articles. Subsequently, another author revised independently to validate the selected studies to review.From the state of the art mapped in the systematic literature review, the empirical part of modeling began. In this sense a Brazilian public teaching general hospital, composed of 156 beds and divided into surgical, clinical, pediatric, day hospital, and ICU, was chosen as the scenario to develop the cost calculation model. This hospital provides services exclusively to SUS and services a macro-region composed of 94 municipalities and approximately 1.5 million inhabitants, with reimbursement by SUS according to healthcare production.Empirical data to model development were provided by two computer systems used in the hospital. The first one, a cost management system named APURASUS and provided by Brazilian Ministry of Health, adopts the absorption costing methodology that organizes resource data in cost centers according to the hospital structure. The second one, named AGHU, is a Hospital Information System (HIS) that allows for the identification of main cost drivers related to hospitalizations, such as length of stay (LOS), number of exams, and the distinction between surgical hospitalizations and other types, such as clinical and pediatric. The HIS also provides resource-specific data for supplies and medications spent during each surgery in the operating room, providing direct costs.The three-step modeling process, consisting of conceptualization, modeling, and solution , was folFor the modeling step, this study considered the applicable guidelines for Consolidated Health Economic Evaluation Reporting Standards (CHEERS) . The scoThe micro-costing top-down method was adopted to develop the cost model, using direct costing for medical supplies and medicines spent during surgery and absorption costing for other resources. The micro-costing method was adopted to identify and measure costs as it allowed for a greater level of detail when considering costs of materials, medicines, personnel, and other factors. For the valuation of resources, the top-down method was adopted since the retrospective data were aggregated in cost centers of the different areas of the hospital. The micro-costing top-down combination allowed for the distinction of resources spent for different surgical procedures . This meAt the identification stage, databases were consulted according to the search parameters and additional filters already presented. After reviewing the titles of the 219 identified reports, 89 duplicates were eliminated and 130 reports were kept. There was no inclusion of reports identified from other sources.In the screening stage, the title and summary were read to identify whether the research was related to determining surgical hospitalization costs. In this stage, 50 reports unrelated to the topic were identified and excluded. The reports whose title and summary did not allow for the identification of a relationship were maintained.For the eligibility stage, 80 full articles would be analyzed. However, four papers were not available for download and were excluded; therefore, 77 articles remained for full reading. This stage aimed to identify the existence of articles that presented a model for calculating the costs of surgical hospitalizations and the cost drivers used. During this stage, 65 articles were excluded due to the reasons presented in Most of excluded studies whose stated objective was to infer surgery costs did not actually carry out the costing process. The 36 records excluded for the main reason (Performs an estimate based on the conversion rate available in a database) make their estimates based on charges made by hospitals, and conversion of these values into costs using a conversion rate . The same reasons why these studies were excluded already was also pointed by Finkler  when disTherefore, this research differs from the others because the proposed model considers the costs of a hospital-based on its real expenses instead of the cost estimate based on the conversion of amounts charged through a ratio index.In inclusion stage, 15 articles chosen for eligibility were maintained. Among the countries in which studies on the subject were conducted, there was a high concentration in the United States, with 11 articles, equivalent to 73% of the total ,42,43,44The studies were published in different journals, with no concentration. Most of the articles analyzed were published in medical journals associated with the specialties whose surgical procedures were related.It is also possible to analyze in There were variations in the central objectives of the analyzed studies. However, it is noted that identifying the cost of the procedure was a concern of several researchers. Even so, it is observed that the costing process was carried out differently among the different studies, which can be justified by the absence of a reference model. To fill this gap a surgical hospitalization cost model is proposed in the next topic.The analysis of ® software [From the hospital perspective, the total cost comprises the period from the patient’s admission (preoperative stage) to their discharge (postoperative stage), a process called surgical hospitalization which includes surgery (the main stage) as one of its components. The workflow diagram, created with Bizagi Modelersoftware  and presThe proposed model includes three timeframes in the perioperative process which can be seen in The proposed cost model uses direct costing for medical supplies and medicines spent during surgery and absorption costing for other resources. Absorption costing was used because the studied public hospital adopts the APURASUS system, which organizes data into cost centers, making the extraction and processing of management information more feasible.The department cost (cost centers) used in the model consists of: Surgical centers ; UICC; ICU; Exams (laboratories an imaging exams); and NIR.The following resources are allocated to the aforementioned cost centers: Personnel; Hospital Medical Supplies and Medicines used in the infirmary; Patient Removal; Nutrition and Dietetics Service; Clothing; Common Waste Collection; Cleanliness and conservation; Maintenance and Conservation of Real Estate; Maintenance and Conservation of Machines and Equipment; Reception; Surveillance and/or Security; Water and sewage; Data communication; Electricity; and Telecommunications.To apply the model, the number of surgeries and exams, as well as the average LOS at the UICC and ICU, must be identified in a given period. Additionally, the supplies and medicines consumed for each different procedure during the surgery must be identified with their respective values. These data can be obtained electronically from the HIS.The “Operating room cost” is composed of the sum of the direct unit cost and indirect cost. The direct cost is represented by the median value of Hospital Medical Supplies and Medicines spent during surgery, registered electronically via HIS. The indirect cost for surgery in the operating room is the result of all cost items registered at APURASUS and allocated to the Operating room cost center which is prorated by the respective number of procedures performed in each of the operating rooms from the hospital, except personnel.The “Hospitalization cost” is obtained through the sum of the daily cost for the UICC cost center, daily cost for the ICU cost center, laboratory and imaging exams performed at respective cost centers, and administrative admission costs, which is called Internal Regulation Center (NIR) cost center in the model. Personnel costs are not included in this block. The daily cost for the UICC and ICU is established by apportioning the values assigned to the cost center by the respective cost driver. Daily costs of these centers are then multiplied by the average LOS specific to each surgical procedure. The exams are prorated as a proportion of the exams requested for surgical hospitalizations concerning the total. The admission costs are prorated as a proportion of surgical hospitalizations in relation to total hospitalizations.The “Personnel cost” is estimated using the same cost drivers for apportioning the Hospitalization cost in the UICC, ICU, exams, and NIR cost centers, adding the personnel cost for the operating room. To obtain this last information, the proportion of surgeries by each operating room is considered. Personnel cost is calculated by department but segregated from the Operating room cost and the Hospitalization cost.The next topic will discuss contributions from the literature to the development of the model.As presented in The first important definition related to patient flow. This study considers all stages ranging from the patient’s admission to their discharge, as presented in Regarding the costing method, as seen in Department costs, with the definition of cost centers such as the UICC, ICU, and exams, is coherent with the micro-costing top-down method adopted ,28 and wTo allocate costs to departments or directly to procedures, the distinction in direct and indirect costs adopted in this study was also used by Handy et al. , Kamath The use of central tendency measures was used in this study for the application of cost drivers, such as the average LOS, median costs of supplies and medicines, and also for the presentation of results. The adoption of these measures was observed in other studies ,39,40,43Another pattern observed in other studies is the use of data extracted from computerized systems ,42,43,44Regarding personnel costs, many differences were found among studies. Scales et al.  and KohaAs observed, there is no universally accepted model for determining costs of surgical admissions. There is a wide variation in the methodology applied in studies with a similar purpose and most cost studies covered only one or a few procedures, which demonstrates the difficulty in carrying out such studies. These studies were usually dependent on an investigation full of manual data collection procedures, which also makes them difficult to repeat.The modeling process made it possible to identify the flow of the surgical patient within a hospital. This step is essential int identifying cost sources and to understand that the cost generated occurs from admission to discharge.The micro-costing top-down method was adopted to develop the cost model allowing for a balance between the accuracy of the information and the feasibility of the cost estimate. Thus, the proposed model fills two gaps in the literature which gives originality to this research. The first gap is filled with the standardization of a model for calculating the costs of surgical hospitalizations. The second gap is that the proposed model is applied to assess a wide number of different surgeries in the same hospital, while most research investigates costs for a limited number of surgeries.The studies included in the systematic literature review contributed to the definition of essential characteristics of the proposed model, i.e., defining the scope of patient flow; the use of cost centers and treating direct and indirect costs; the adoption of central tendency measures in calculations and the presentation of results; the support of computerized systems for the extraction and processing of data; and determining how to define a specific approach to personnel costs. These features make up the designed model which consists of three distinct cost blocks: the “Operating room cost”, the “Hospitalization cost”, and the “Personnel cost”. These blocks allow hospital managers to observe their costs in greater detail, which also allows for comparisons between different hospitals and studies.Flexibility stands out as an essential advantage of the proposed model, as its application is possible for calculating costs in different areas and contexts of hospitalization which encompasses elective and urgent surgeries of medium and high complexity performed in public hospitals and in private hospitals. The proposed model can also be adapted to other hospitalization types, such as clinical hospitalization, pediatric hospitalization, and obstetric hospitalization. This allows for application in other health establishments that are general or specialized in some of these types of hospitalization, which expands its potential.The limitations of this research are the number of databases consulted, the search parameters for the literature review (that may have restricted the results), and the scope of the study which limited it to modeling the problem and not presenting values of its application.For future studies, this cost model will be applied in the public teaching hospital analyzed and has been suggested to be applied in other hospitals. Studies aimed at analyzing KPIs to evaluate the model are also suggested, as well as indicators derived from its application, such as “Average cost of a portfolio of surgical procedures performed by the Hospital” and “Index of financial sustainability of the surgical procedure”. The proposed cost model could provide information with a high degree of accuracy and celerity, which can induce better decision making. This becomes more relevant in public health, especially in low- and middle-income countries, which faces a lack of resources and whose positive effects can improve healthcare and provide better functioning of the health system.