The Big Picture of Making a Business Case for Infection Prevention and Control

Connie Steed, MSN, RN, CIC Director, Infection Prevention Greenville Health System Greenville, S.C.

Objectives
Identify the burden, including the cost of healthcareassociated infections (HAIs).
List key components to establishing a business plan/case. Discuss how infection preventionists can demonstrate value to the organization.

Current Landscape
Enhanced scrutiny of HAI Public/consumer groups Legislators; National HAI Plan Payors and regulatory agencies Legal liability Patient safety initiatives Expectation of best practices Prospects of decreased payment Increased pressure on administrators to reduce infection rates>>>Focus on infection prevention

Messages on HAIs From the Federal Action Plan

1. Many HAIs are preventable. 2. A systemic approach to reduce disease transmission can be more effective than disease-specific approaches. 3. Developing and supporting research to address gaps in the science in HAI prevention will generate additional preventive strategies. 4. Strong partnership between federal and local/state governments and communities is vital. HHS is committed.

Messages on HAIs From the Federal

Action Plan continued

5. Preventive steps to control and prevent HAIs are costeffective, save lives, and reduce disability for Americans. 6. The time to act on HAIs is now, and HHS and its partners are working closely with providers, health systems, community leaders and government to help prevent HAIs.

Attributable Costs
HAI Cost Analysis January 2001 June 2004

Type HAI Surgical Site Bloodstream Vent. Associated Pneumonia Urinary Tract (UTI)

Attributable Costs Range Mean (SD) $25,546 (39,875) $1783 134,602 $36,441 (37,078) $9669 (2920) $1006 (503) $1822 107,156 $7904 12,034 $650 - 1361

70 studies: 39 US, 17 Europe, 4 Australia/New Zealand, 10 others. Analysis includes only those studies that calculated individual (vs. aggregate) cost of patient outcomes.
SOURCE: Stone et al. AJIC Nov 2005; 33:501-509

Attributable Costs and Excess Length of Stay Associated with HAI

SOURCE: Eli N. Perencevich EP, Stone P, Wright, SB , t al. Infect Control Hosp Epidemiol 2007;28:1121-1133

Volumes and patient flow = $$$

Patients without HAI are discharged sooner New patients move into those beds Assuming fixed costs stay the same (building, utilities, etc.), available bed-days increase volumes and revenue, reimbursement. Example: Table 1. shows CABG SSI mean excess LOS = 26 days. *Preventing 10 CABG SSI would open up 260 bed-days. If average LOS without complication is 4 days, then 65 new patients could be admitted.
*Modified from: Perencevich, Stone, Wright

Attributable Costs
The services provided and billed to a patient that were caused by an HAI. Best to use local data ( financial partner). Published data can be used as surrogate. e.g., patient with hip joint SSI is compared to a matched patient with same surgery and other characteristics, but not the SSI

Source: Murphy, D, Whiting, CS. Dispelling the myths: The true cost of Healthcare Associated Infections. APIC briefing; February 2007.

Comparison of Economics
Patients With and Without Central Line-Associated Bloodstream Infection
N = 20
Admit diagnosis Age Payer Revenue $ Expense $ Gross margin $ Costs attributable to BSI LOS (days) 10 Respiratory failure 71 Medicare + commercial 20,792 19,501 +1,291

Patient
Respiratory failure 75 Medicare + commercial 20,417 37,075 -16,658 13,696 15

SOURCE: Shannon et al. Amer J Med Quality Nov/Dec 2006; pgs 7S-16S

Source: http://www.safetyleaders.org/greenlight/HAIcostCalculator.jsp/

The Burden of HAI

> 99,000 death per year in United States Increased ICU stay 8 days Increased average hospital stay: 7.4 -9.4 days Total dollar cost: $4.5-$5.7 billion Average cost per infection: $13,973 Increase total cost / patient who survived ~$40,000.

Business Case
From the perspective of all stakeholders: Administrative leadership, consumer, infection preventionist Impact: 1. Clinical quality/outcomes: Morbidity and mortality 2. Cost
Communicate value to decision-makers to justify existing program or to obtain additional resources -- Must show return on investment (ROI)

Components of Total Costs

Direct Costs Direct payment for healthcare goods and services Indirect Costs Lost work productivity Intangible Costs Cannot easily assign a monetary value Opportunity Costs What you give up when you use a resource

Applying. to IPC Practice

Direct cost savings: No routine ventilator circuit changes $1M savings across BJC (equipment/supplies)
Indirect cost savings Increase in respiratory therapist productivity due to fewer vent circuit changes (focus on reducing VAP) 25% increase in flu vaccine (lower RN absenteeism/ agency costs)
Source: Denise Murphy, The Business case for infection control: Knowledge, Tools, Timing, Chicago APIC, 2009.

Intangible Costs
Physical pain and discomfort Prolonged or permanent disability Disruption to patient and family Emotional/social burden Decreased trust in the healthcare system Increased use of antibiotics (emerging MDROs)

Other Dimensions of Costs

Fixed costs Costs incurred for fixed inputs Cannot easily be eliminated in the short run Buildings Variable costs Costs incurred for variable inputs Can easily be eliminated in the short run Labor

SOURCE: C.S. Hollenbeak, 2006

Estimation Methods
Compare costs for patients with infections to patients without infections (matched comparison; like case-control study) Problem: are the patients who get infection just like those who do not? Age Gender Diabetes Smoking Weight
SOURCE: C.S. Hollenbeak, 2006

Who Should Be Involved In Business Case Development for Infection Prevention?

This doesnt need to be a one-person project Multi-disciplinary: Finance partner, infection preventionist, quality experts, leaders in the area of interest Key is to obtain true engagement by stakeholders Identify an opportunity that will motivate interest

What is the Need?

Assess Program ( gap analysis) Outcomes: CLABSI, VAP, SSI, CAUTI, MRSA ? Processes: Impact of interventions on outcome, Evidencebased practice being used? Hard-wired? Does decision-making leadership have concerns? Choose an area of opportunity High Infection rate; high mortality/ morbidity; high cost Conduct literature review to identify best practice

Business Case continued

Addresses the business need that the project seeks to resolve. 1. Purpose 2. Expected benefits: Business: cost savings/ avoidance, reduced Length of stay Quality: infection elimination >> improved outcomes Intangible benefits (while soft, good to mention) 3. Options (e.g., doing nothing, implementing bundle) 4. Expected costs/include risk of doing nothing 5. Gap analysis 6. Plan to communicate impact of plan/ interventions

Keys to a Successful Plan

Clear and Concise Communication, Communication, Communication!!!

1. Who should present? The infection preventionist may not be best person to do so? What if finance presented it?! 2. Discussions with key decision makers: Are the cost estimates, etc. going to be acceptable?

Barnes Jewish Hospital: Impact of Interventions to Decrease HAIs

2000 CABG Surgical Site #SSI 43 %SSI 6.8% Excess Cost $825,000 Spinal Surgical Site Infections (SSI) #SSI 20 %SSI 2.07% Excess Cost $716,345 Bloodstream Infections (BSI) #BSI 309 BSI/1,000 patient days 8.4/1,000 Excess Cost $2,639,520 Ventilator Associated Pneumonia (VAP) #VAP VAP/1,000 ventilator days Excess Cost Total Cost of All HAI tracked 166 10.1/1000 $1,382,780 $3,955,225 2004 14 5.6% $ 322,610 5 0.8% $659,394 87 1.5/1,000 $2,639,540 73 4.8/1,000 $632,180 $1,459,303 Impact of Interventions -25 -18% -$502,390 -15 -61% -$90,000 -222 -82% -$107,140 -93 -52% -$750,600 -$2,495,924

Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of Healthcare-Associated Infections, An APIC Briefing: February 2007.

Call To Action
Identify financial partner Quantify the economic impact of HAIs Based on economic analysis, target high-risk, high-volume procedure or pt population and lead efforts to eliminate HAIs Ensure Specialists are educating HCWs about infection prevention and driving evidence base practice Identify process defects and intervene Measure the results and repeat the process
Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of Healthcare-Associated Infections, An APIC Briefing: February 2007.

Results First
Demonstrate Value (return on investment) A great case for enhancing resources

Succeed, then ask

Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of HealthcareAssociated Infections, An APIC Briefing: February 2007

Know the Cost-Benefit

Impact of Prevention

Excess cost of HAIs

$1 million* % preventable with effective IC 32% Costs prevented $320,000 Cost of program $200,000 Net Benefit $120,000
Must always subtract program costs from potential cost savings!

Source: Haley, JAMA 1987; 257:1611-1614. *1985

Know the Cost of an Effective Infection Prevention and Control Program

Component Personnel 0.5 Physician 1 Nurse 1 Secretary 0.5 Computer Programmer Supplies, fax. Etc. Fringe benefits and overhead Total
Source: Wentzel. J Hosp Inf 1995; 31: 79-87; *1992

Annual Cost(s)

70,000 30,000 15,000 15,000 20,000 50,000 $200,000*

Plan for the Resources Needed: Sample IPC Program Budget

Acct. Desc. Salaries (Professional) Salary (Clerical) Misc. Benefits Minor Equip. PCs Softw are Office Supp. Publications Telephone Education Postage Travel Special Events Printing Purchased Purchase MD Services Lab Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

Demonstrate VALUE
Eliminate waste/improving productivity through: Wise product selection Appropriate application of expensive technology Sensible policies and procedures Protection of employees from injury Maintain regulatory/Joint Commission compliance Facilitate effective collaboration between clinicians/administration Create a safer environment for patients and staff, increasing satisfaction Help to maintain organizational reputation for service excellence

Secure Resources to Support Effective Programs

What is NOT BEING DONE due to inadequate resources THAT SHOULD BE DONE to improve outcomes/quality IC resources should be allocated based on: Demographics of population Most common diagnosis High risk populations Services offered Type and volume of procedures performed
Source: OBoyle C, Jackson MM, Henly SJ. Staffing requirements for infection control programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.

The Business Case?

Negotiate Every Year: Routinely communicate value. Market yourself >> Does the CEO, CFO know you and what you do? Look outside FTEs for additional help if organization doesnt want to increase FTEs, but is open to other venues: - Database/ software >> increase productivity - Students who need projects - Hospital Foundation may fund project

Continue to reduce healthcareassociated infections

Infection-Related Claims
Claim frequency is increasing: Increased availability of public data; and Increased transparency, resulting in: In the past = known risk of treatment Currently = believe a preventable injury

Examples of Claims
Infection developing during hospitalization (even in severely immuno-compromised patients) Contaminated medications prepared by New England Compounding Center (NECC) Notification of > 4000 patients. Shared multi-dose vials Insulin syringe on one patient used on another patient. 25% of practitioners re-enter vials with previously used needles

Additional Costs

Healthcare Associated Infection Cases

Average loss $210,000 Average indemnity payment $414,000 Patient outcome: 25% cases involved high severity injury 16% cases resulted in deaths (CRICO/RMF) Recent high verdict/settlement cases $13.5 M bacterial infection in MA $16 M infection following delivery in UT $5.5 M & $3 M delays in treating infection in PA $2.58 million infection after pacemaker in MO

Evaluating Impact
Frequency
10
Extremely rare Sentinel Event adverse outcome

Warning
10
No warning, impact is immediate Products Liability; Human factors

Scope
10
> 80 % patients served (or procedures/year) Medications

Outcome
10
Immediate and Direct Patient and Organizational Outcome(s) Patient outcome with Regulatory Impact (i.e. sanctions and/or fine(s)) Mandatory Reporting

Rare

Sentinuel Event no harm to patient

Warning occurs over shortest period of time (days) Staffing issue providing little opportunity to adjust or react Warning occurs over shorter period of time (weeks) providing some opportunity to adjust or react

60 - 80% patients served

Radiology

Direct Regulatory Impact

Periodic

Serious Event adverse outcome

Systems issue

40 - 60% patients served

Surgery

Patient outcome or potential for organizational outcome Minor patient outcome to few individuals

Serious Event adverse outcome Serious Event near miss; Reques Service Recovery Efforts of multiple staff; Minor unanticipated event or dissatisfaction

Recurrent

Serious Event - no harm to patient

Warning occurs over months providing opportunity to Processes or policies adjust or react Warning occurs over years with documented trend providing opportunity to adjust or react

20 - 40% patients served

Procedure

Occurs frequently

Unanticipated event

Infrastructure/building /fixtures

Infections; < 20% patients served Falls

Client dissatisfaction handled locally

Score = (Probability + Time to Impact + Scope) x Severity Score= Frequency+Warning+Scope+Outcome+Severity

Evaluating Impact Continued

Risk Management assesses events to identify the amount of: Resources including people and liability activity to assist with Prioritization

Developed by Sharon Dunning, MBA, RN, manager, risk management, Greenville Health System

Evaluating Impact Example

CJD case Diagnosed post mortem, 10 patients impacted Disclosures made to families>> Legal Sanctions likely>>cost high Frequency + Warning+ Scope+ Outcome+ Severity = Score 10 10 2 10 10 42

Impact Example
Catheter Associated UTIs Hospital just beginning initiative to reduce Assessment shows that 30% of pts have Foleys and are at risk CAUTI rates are high/processes are not being following Frequency + Warning+ Scope+ Outcome+ Severity = Score 2 2 4 8 2 18

Cost/Benefit Analysis

Developed by Sharon Dunning, MBA, RN, manager, risk management, Greenville Health System

Questions?
Connie Steed, MSN, RN, CIC Phone: 864-455-6267 Email: csteed@ghs.org