Transcript Document 7120972

The Business Case for Infection
Prevention and Control:
c
Educating Yourself and Your Exe utives
Denise Murphy, RN, BSN, MPH, CIC
Vice President, Quality and Patient Safety
Main Line Health System
Philadelphia, PA
About the Business Case
(Objectives)
• What is the business case…from everyone’s perspective and
how to share it with decision-making leaders
– Clinical impact: morbidity and mortality
– Cost of infections… the total cost
• How to get the investment if it isn’t already there
– Use of hard data, influence and persuasion
– In negotiations…timing is almost everything!
• How to use the investment and demonstrate returns
so you can keep it
Cost
Benefit
VS.
The U.S. Burden of HAI
TOTAL = 1.7 million HAI
• 1.3 million adults & children outside of ICU
•
•
•
•
•
418,000 adults and children in ICU
33K newborns in high-risk nurseries
19K newborns in well-baby nurseries
9.3 HAI/1,000 pt. days
4.5HAI/100 admissions
Excess LOS: 7.5 million days
Excess charges: >$6.5 billion
*Nicolas Graves. Economics of Preventing HAIs; **Klevens, Edwards, Richards et al. Pub Health Report. 2007
Death from HAI (U.S. 2002)
Number Deaths in Thousands
40
35
The Most Important Bottom Line!
36K
31K
N = 98,987
30
Pneumonia
25
20
BSI
UTI
13K
15
10
5
0
Source: Public Health Report/March-April 2007/Volume 122
8K
11K
SSI
Other HAI
Attributable Costs
HAI Cost Analysis January 2001 – June 2004
Type HAI
Surgical Site
Attributable Costs
Mean (SD)
$25,546 (39,875)
Range
$1783 – 134,602
Bloodstream
$36,441 (37,078)
$1822 – 107,156
Vent. Associated
Pneumonia
Urinary Tract (UTI)
$9669 (2920)
$7904 – 12,034
$1006 (503)
$650 - 1361
70 studies: 39 US, 17 Europe, 4 Australia/New Zealand, 10 other. Analysis includes only
those studies that calculated individual (vs. aggregate) cost of patient outcomes.
SOURCE: Stone et al. AJIC Nov 2005; 33:501-509
SOURCE: Eli N. Perencevich, MD, MS; Patricia W. Stone, PhD, MPH, RN;
Sharon B. Wright, MD, MPH et al. Infect Control Hosp Epidemiol 2007;28:1121-1133
Author: R. Douglas Scott II, Economist, CDC, DHQP March 2009
Economic Comparison
Without CLABSI
N = 20
With CLABSI
Patient
Admit diagnosis
Respiratory failure
Respiratory failure
Age
71
75
Payer
Medicare + commercial
Medicare + commercial
Revenue $
20,792
20,417
Expense $
19,501
37,075
Gross margin $
+1,291
-16,658
Costs attributable to BSI
LOS (days)
13,696
10
Source: Shannon et al. Amer J Med Quality Nov/Dec 2006; pgs 7S-16S
15
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
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
C.S. Hollenbeak, 2006
Where Can You Start?
– Select type of infection to estimate; SSI easiest
– Use accounting dept to obtain individual costs and LOS
for patients undergoing specific surgical procedure
– List patients who developed SSI.
– Use accounting to calculate additional costs: readmission,
return to OR, ICU stay, antibiotics, etc.
– Compare cost of patients without SSI to patients with SSI
who had procedure during same time period
– Compare length of hospital stay, including readmission
for SSI, for those with infection
Societal Costs of HAI
Applying Economics….
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)
Cost (or revenue loss) avoidance
Outbreak of SSI: difference in observed vs. expected
SSI rates/excess cost & LOS ($37K & 18 d.)*
– Reduced excess cost and LOS (reimbursement lower after
3-5 days of re-admission for SSI)
– Reduce adverse outcomes on CMS list of “healthcare
acquired conditions” that will no longer receive associated
excess reimbursement (e.g., CR-BSI; Mediastinitis, Total
Joint Replacement; Bariatric SSI; UTI)
Comparison of Endemic vs. Epidemic SSI Rates
BJC Operating unit:
Period of increased SSI
Surgical procedure
Number of procedures performed in 1998
Reported “benchmark” SSI rate/100 procedures
Operating unit endemic rate/100 procedures
Operating unit epidemic rate/100 procedures
Average LOS for uninfected vs. infected
Mean excess LOS per SSI
Average cost for uninfected vs. infected
Mean excess cost per SSI
Rate reduced to baseline/ benchmark (date)
Projected # procedures 2000
Expected # SSI based on endemic (3.0) rate
Expected # SSI based on epidemic (22.6%) rate
# SSI avoided (based on *reduced rate)
*Estimated cost avoidance 1999 - 2000
Hospital A
6/98 - 12/98
Gastric Bypass
70
2.7-5.1
2.86% (2 SSI / 70 procedures)
22.6% (7 SSI / 31 procedures)
4 days vs. 22 days
18 days
$7,816 vs. $44,963
$37,147
3.0% (4/99 through 4/2000)
70 cases
2 SSI
16 SSI
14 SSI annually
$520,058 ($37,147 x 14)
*Estimated cost avoidance is based on the #SSI avoided annually when rates remain
at baseline (endemic) compared to epidemic rates.
Lost opportunity costs
– Fewer CABG SSI resulted in fewer I&D cases in OR;
– Opportunity for more 1st time CABG surgery cases
brought higher reimbursement
Intangible costs
–
–
–
–
Lessen risk for negative PR (impact on referrals)
Impact on societal trust
Changes in insurance premiums due to high HAI costs
Impact on status with accreditation and regulatory
agencies
Attributable Cost
– Much better estimate of cost attributable to infection
– Use economic modeling to tease out in-pt. cost of other
co-morbidities*
 diabetes costs include glucose monitoring, insulin
 CHF costs include Rx with ACE/ARB/beta blocker
– Much easier to do with surgical patients: readmission/
re-operation purely due acquisition of SSI
– Found attributable cost of CABG SSI ~$20K in our
study; ($35K deep chest; 15K non-deep SSIs)*
*Source: Hollenbeak CS, Murphy DM, Dunagan WC, Fraser VJ. Chest 2000; 118:397-402.
Personal/Individual Costs
•
•
•
•
•
•
Physical pain and discomfort
Mental and financial stress
Increased length of stay in hospital
Prolonged or permanent disability
Disruption to patient and family
Time lost from work for patient and
caregivers
• Death
Communicating Financial Impact
– Display cost and LOS data graphically
– Approach Clinical Leadership and Senior Executives
to demonstrate financial impact of HAI (avoidable
cost, opportunity cost, revenue enhancement)
– Use *literature to show cost-benefit of Infection
Prevention – impact of interventions to reduce HAI
– Demonstrate your value!
– You then argue for a larger investment in IPC…
*Raising Standards While Watching the Bottom Line: Making a Business Case For Infection Control.
Eli N. Perencevich, MD, MS; Patricia W. Stone, PhD, MPH, RN; Sharon B. Wright, MD, MPH;
Yehuda Carmeli, MD, MPH; David Fishman, MD, MPH; Sarah Cosgrove, MD, MS.
Infect Control Hosp Epidemiol 2007; 28:1121-1133
Getting local information is powerful
but complicated.
Pick something, be able to explain it,
then stick to it!
Consider Using the Literature
and Adjusting Dollars
 Healthcare inflation rate has been about 4 -4.5% annually, so
1985$ ~ adjusting up to 2009$ means multiplying EACH
YEAR between 1985-2009 by annual inflation rate.
 This is a very crude adjustment.
 Medical care services increased 5.2% in 2007, 2.6% in 2008
and 3.4% in 2009
 A BSI that cost $38,336 in 2007 (36,441 x 1.052 or 5.2%)
will cost $39,337. in 2008 (38,336 x 1.026 or 2.6%) and
$40,674 in 2009 (39,337 x 1.034 or 3.4%)
 Or use the CPI “cost calculator!
http://www.bls.gov/data/inflation_calculator.htm
Source: D. Murphy, 2006 revised 2011
How about a 5% inflation rate for the sake
of adjusting costs in literature?
After You’ve Made the Business Case…




Learned organizational priorities – aligned with them
Created the IPC mission, vision, goals and objectives
Obtained resources to support effective program
Tracking on goals, reducing HAI rates...what next?
“The more you know about executive leadership,
the more executive leadership knows about you.”
Wharton School of Business; University of PA
Demonstrate Functional Value
• Eliminating waste/improving productivity through
Wise product selection
Appropriate application of expensive technology
Sensible policies & procedures
Protection of employees from injury
• Maintaining regulatory compliance
• Creating effective collaboration between clinicians and
administration
• Creating a safer environment for patients and staff,
increasing satisfaction; maintain reputation for service
Demonstrate Strategic Value
Supporting organization’s strategic plan
To grow volumes:
Empty out ICU beds more quickly by reducing
To grow services:
Show how interventions to reduce HAI rates on specific services
can be utilized to plan and design new programs and services
Gastric bypass surgery new for your organization? Use literature
and experience of others to build in risk reduction strategies.
To hit target on 100% of quality scorecards!
Same skills used for outbreak investigation can help PI teams get to
root causes of poor performance.
Planning - Strategies
 Lay out three year plan with someone who knows how
 Tactics to meet goals – refine them each year
Focus on the critical few first
 Needs assessment –
do one every year; even a *SWOT Analysis
use to create long and short term goals
setting direction based on assessment
new goals and priorities
*Strengths, Weaknesses, Opportunities, Threats
Planning - Strategies
Evidence-based medicine: as it changes, your interventions
must follow: Need system for keeping up, environmental
scans, literature search, journal clubs.
Performance Measurement and Improvement basics
 Tools, methods, SMART goals and meaningful metrics -
with accurate data analysis and reporting
Trained facilitators and leaders
Executive and physician champions
Outbriefs to educate, engage and gain leadership commitment
Budget / Financial Management
 Budgeting – take and keep some control
 Resources vs. what program can/cannot do…just say NO!
 Role of technology: cost / benefit analysis, use literature,
experience of others
 Executive incentives / Scorecard and dashboards:
exert influence on senior leadership to include HAIs
 Board education about HAIs and impact of interventions
will help sustain financial support from management
The Business Plan
Not One and Done, continue demonstrating value and:
 Use data to show current state;
 Highlight successes and ROI
 Outline short and long term needs
 Propose IPC expansion aligned with resources
 Request professional development opportunities
 Propose technology solutions that have been proven
 Access to clinical/administrative decision-makers
Action Plans and Tactics
to Drive the Action








Specific actions to fix broken processes and systems
Specific actions to address staff behavior/compliance
Responsible parties to drive each tactic or step
Timelines
Required resources to complete actions
Briefings to senior leaders
Make performance transparent: briefings/scorecards
Watch for barriers in each step of implementation
If Everyone is Responsible…
Action Item
Who is
Responsible
By When
Post screen saver
C. Hampton
4/24/08
Communication plan
(Publications, Meetings)
J. Gagliardi
Place line removal training
module on Pathlore (intranet)
V. Ferris
A. Dixon
Upon
completion
of final RIE
05/16/08
Central line removal pictures
M. Schultz
V. Ferris
4/24/08
Sustaining the Gains
Accountability through monitoring
Responsible parties reporting to key leaders
Clear expectations and follow up
What’s in it for those who must change/sustain
Performance management – discuss how to
keep people compliant: part of their performance
expectations…they are evaluated on patient safety
and IPC!
HUMAN FACTORS and impact on compliance!
Demonstrating The Value of Infection
Prevention and Control
Know the Cost of Effective
Infection Prevention and Control
Annual Cost(s)
Total
70,000
30,000 Remember,
15,000 this is 1992 $$
15,000
20,000
50,000
$200,000*
:(
Personnel
0.5 Physician
1 Nurse
1 Secretary
0.5 Computer Programmer
Supplies, fax. Etc.
Fringe benefits and overhead
*Add computer & adjust for inflation, this cost would be >$315,000 in 2011
Wentzel. J Hosp Inf 1995; 31: 79-87; *1992$
Plan for the Resources You Need!
Sample IPC Program Budget
Acct. Desc.
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Salaries (Professional)
7,084
7,084
7,084
7,084
7,084
7,084
7,084
7,084
7,084
7,084
7,084
7,084
125,008
Salary (Clerical)
2,083
2,083
2,083
2,083
2,083
2,083
2,083
2,083
2,083
2,083
2,083
2,083
24,996
Misc. Benefits
2,291
2,291
2,291
2,291
2,291
2,291
2,291
2,291
2,291
2,291
2,291
2,291
37,492
Minor Equip.
Sep
Oct
Nov
Dec
1,000
Total
1,000
PCs
5,000
5,000
Software
1,000
1,000
Office Supp.
100
100
100
100
Publications
100
100
100
200
Telephone
72
Education
2,400
Postage
100
72
72
72
72
100
100
100
100
200
72
72
72
72
1,200
400
72
72
72
2,400
864
4,800
10
10
10
10
10
10
10
10
10
10
10
10
120
Travel
100
100
100
100
100
100
100
100
100
100
100
100
1,200
Special Events
584
2920
3504
Printing Purchased
Purchase MD Services
Lab
7,008
25
25
25
25
25
25
25
25
25
25
25
25
300
5,417
5,417
5,417
5,417
5,417
5,417
5,417
5,417
5,417
5,417
5,417
5,417
85,004
416
416
416
416
416
416
416
416
416
416
416
416
5000
2010 BUDGET TOTAL
300,392
Staff = 2 IPs; 1 Secretary; 1 Medical Director
Secure Resources to
Support Effective Programs
IPC resources should be allocated based on:
–
–
–
–
–
–
Demographics of population
Most common diagnosis
High risk populations
Services offered
Type and volume of procedures performed
What is NOT BEING DONE due to
inadequate resources THAT SHOULD BE
DONE to improve patient care
*O’Boyle C, Jackson MM, Henly SJ. Staffing requirements for infection control
programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.
Staffing Requirements?
2001 Delphi Study
• *0.8 to 1.0 ICP per 100 occupied beds
acute and long-term care
• Physician time not measured
O’Boyle C, Jackson MM, Henly SJ. Staffing requirements for infection control
programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.
How did we get more resources at my hospital?
Constant assessment and relentless annual negotiations.
Looking outside of hospital: contracts for IPC services,
grants support temporary resources (students, data
collection), Internship program support (MPH, MHA).
Proving our value year after year; increasing visibility of
program; focusing on interventions =
REDUCING HAIs!
FOCUS ON INTERVENTIONS!
What Percent of HAIs
are Preventable?
• In 1985 SENIC study estimated 32% of HAIs
preventable if effective IC program in place*
• 1995: British Hospital Infection Working Group stated
that about 30% of HAIs could be avoided by better
application of existing knowledge**
• 10-70% HAIs preventable with appropriate infection
control depending on setting, study design, baseline
infection rates and type of infection***
• Concluded at least 20% of all healthcare-associated
infections probably preventable***
Sources: Haley, et al. Study on the Efficacy of Nosocomial Infection Control
Am J Epidemiol 1985; 121:159-67, 182-205*
Management and Control of HAI in Acute NHS Trusts in England. Feb 2000**
Harbarth S, et al. J Hosp Infect 2003;54:258-266***
Getting to Zero HAI
What’s Standard?
• Targeting zero =culture change
• Strong Sr. Leader
support/CHAMPIONS/
multidisciplinary teams
• Bundle approach/EBM
• Transparency/data feedback
• Analysis – real time
• Personalize HAI
• Communication!
• Celebrate
• Market value of IP
What’s Different?
• Critical event analysis
• Daily assessment of device
use/reminders to remove
• Board involvement
• IPC Liaisons
• Weekly Executive Report
• Web-based education
• Empowered staff
STOP THE LINE
• Human Factors training
Cost Benefit Analysis
Example: Intervention Modules to Prevent CLABSI – 2 ICUs @ BJC
Development costs:
6 IPs @ $23/2 hrs./12 mos. =$3,312
Graphics & printing
=$1,300
$4,612
Implementation costs:
20 ICPs @ $23/16hrs.
= $12,000
600 RNs @ $23/1hr.
= $13,800
100 PCTs @ $12/1hr.
= $ 1,200
52 MDs @ $100/1hr.
= $ 5,200
$32,200
IPC
BSI
Development & Implementation costs = $36,812
Cost Benefit Analysis (continued)
CLABSIs prevented (in 2 ICUS) in 2000
Expected BSI = 90 (based on previous two years rates)
Observed BSI = 45
BSI prevented post intervention = 45
Estimated cost savings = $4,500 x 45 = $202,500
Cost Savings - Intervention Costs = Net Savings
$202,500
- $36,812
= $165,688
So what’s my
real return on
investment?
NOTE: Once our value was established, we didn’t have to keep proving it
to executives (in dollars saved!) We changed the way they think about IPC!
We just have to keep reducing infections!
BJC HealthCare –
Impact of Interventions to Decrease HAIs
CABG Surgical Site Infections (SSI)
2000
#SSI
116
%SSI
5.21%
Excess Cost
$2,440,000
Spinal Surgical Site Infections (SSI)
#SSI
64
%SSI
1.7%
Excess Cost
$716,345
Bloodstream Infections (BSI)
#BSI
564
BSI/1,000 patient days
3.5/1,000
Excess Cost
$2,639,520
Ventilator Associated Pneumonia (VAP)
#VAP
VAP/1,000 ventilator days
294
7.5/1,000
2001
86
4.26%
$1,737,945
Impact of Interventions
-30
-26%
-$801,340
58
1.5%
$659,394
-6
-10%
-$90,000
542
3.4/1,000
$2,639,540
-22
-4%
-$107,140
160
3.9/1,000
-134
-46%
Excess Cost
$2,449,020
$1,385,600
-$1,160,440
Total Cost of All HAI tracked
$8,244,885
$6,422,479
-$2,158,920
Barnes-Jewish Hospital
Excess Cost of HAI
2000 to 2007
$9,000,000
$8,000,000
Excess Cost
$7,000,000
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
2000
2001
2002
2003
2004
2005
2006
YTD 2007
Barnes-Jewish Hospital
Excess LOS Associated with HAI
2000 to 2007
4000
Excess Length of Stay (Days)
3500
3000
2500
2000
1500
1000
500
0
2000
2001
2002
2003
2004
2005
2006
YTD 2007
Main Line Health System Cost of Infections
July 2008 - December 2010
2,500,000
Cost of Infections
2,000,000
CA UTI
1,500,000
SSI
VAP
1,000,000
CLABSI
500,000
0
July-Sept Oct-Dec
08
08
Jan-Mar Apr-June July-Sept Jan-Mar
10
09
09
09
Apr-Jun
10
Jul-Sep
10
Oct-Dec
10
What impresses leaders the most?
Let’s look at the
Chief Financial Officers
Presentation of achievements at the
MLH Annual Leadership Meeting
Main Line Health (Critical Care Units)
CLABSI (#) April 2008 - March 2011
12
83% decrease from second quarter
of 2008 to first quarter 2011
10
Trend line: p< .005, R2 = 0.59
9
7
6
5
6
4
4
3
2
1
Apr-Jun Jul-Sep
2008
OctDec
JanMar
2009
Apr-Jun Jul-Sep
Data Source: NHSN via DMA Infection Control Database
OctDec
JanMar
2010
Apr-Jun Jul-Sep
OctDec
JanMar
2011
Main Line Health (*All Patients)
CLABSI (#) April 2008 - March 2011
28
26
75% decrease from second quarter
of 2008 to first quarter 2011
23
22
Trend line: p< .001, R2 = 0.71
18
17
12
10
10
7
Apr-Jun Jul-Sep
2008
OctDec
JanMar
2009
Apr-Jun Jul-Sep
OctDec
*All Patients = all patients in house with central line
Data Source: NHSN via DMA Infection Control Database
JanMar
2010
9
Apr-Jun Jul-Sep
7
OctDec
JanMar
2011
Main Line Health (Med/Surg/Tele Units)
CAUTI (#) April 2008 - March 2011
68% decrease from second quarter
of 2008 to first quarter 2011
26
Trend line: not significant, R2 = 0.29
22
16
13
13
10
11
11
8
10
7
7
Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar
'08
'09
'10
'11
Data Source: NHSN via DMA Infection Control Database
Main Line Health (Critical Care Units)
Ventilator Associated Pneumonia (#)
April 2008 through March 2011
67% decrease from second
quarter of 2008 to first quarter
2011
30
Trend line: p< .05, R2 = 0.45
18
15
6
5
2
Apr-Jun Jul-Sep
2008
OctDec
JanMar
2009
4
5
Apr-Jun Jul-Sep
Data Source: NHSN via DMA Infection Control Database
3
3
6
3
OctDec
JanMar
2010
Apr-Jun Jul-Sep
OctDec
JanMar
2011
A few other pearls…
Your IPC Culture
Culture is the set of beliefs and values, learned
organizational behaviors, the way we do things around here
Can you describe the culture of the IPC program?
 Service culture?
 Safety culture?
 What do customers want from you and your program?
 How do you get others to embrace IPC culture
Partnerships
 Champions, partners, facilitators –
actively seek them out, work to keep them: WIIF them?
 Patient Safety/Risk Management;
Performance/Quality Improvement
 Data management and analysis
 Information Technology
 Occupational Health
 Accounting and finance
Financial impact
IPC program and intervention investment ROI
 Marketing – celebrate successes widely
Managing Your Boss
Source: Harvard Business Review (checklist) May-Jun 1993
Make sure you understand your boss and his or her context, including:
Goals and objectives
Pressures
Strengths, weaknesses, blind spots
Preferred work style
Assess yourself and your needs, including:
Strengths and weaknesses
Personal style
Predisposition toward dependence on authority figures
Develop and maintain a relationship that:
Fits both your needs and styles
Is characterized by mutual expectations
Keeps your boss informed
Is based on dependability and honesty
Selectively uses your boss’s time and resources
Thanks for your time and attention!
[email protected]
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