By Kelly M. Pyrek
Long seen as a cost center by healthcare administrators, infection prevention programs have taken a beating when hospital budgets are cut. Infection preventionists are fighting back by making the business case for their programs to fend off additional cost-cutting as well as to demonstrate return on investment (ROI). While infection prevention has always been about patient and healthcare worker safety, it increasingly must show economic dividends -- it's a departure from the purely clinical path that infection preventionists have always taken, but essential for the future viability.
"Making the business case for infection prevention is a very important skill to master," says Patricia Stone, PhD, RN, FAAN, director of the Center for Health Policy as well as co-director of the PhD Program at Columbia University School of Nursing in New York. "I think it is a constant endeavor because things are always changing in the field and within healthcare institutions. It should also be part of the curriculum for the professional development of new infection prevention personnel, especially since people come and go in the infection control department. Even for the individuals who already understand the concepts, doing it once is not enough, as making the business case is an ongoing process -- you are always going to have to make the case for new programs or new interventions or additional personnel to your institution's leadership. The good news is that infection preventionists and their programs have more visibility than ever before because of mandatory reporting, healthcare reform and pay for performance-related issues that have the attention of hospital board trustees."
Key to a successful business case is understanding the current forces that are driving healthcare economics. There are numerous treatises on healthcare economics in the literature that can help provide the basic concepts. One of the more notable developments, of course, is the Oct. 1, 2008 action by the Centers for Medicare & Medicaid Services (CMS) to halt reimbursement to hospitals for the cost of treating certain healthcare-acquired infections such as catheter-associated urinary tract infections, vascular catheter-associated bloodstream infections, and certain surgical site infections. This regulation was triggered by the 2006 Deficit Reduction Act that called for a reduction in the increases in Medicare and Medicaid spending by stopping payments for conditions that result in the assignment of a higher-cost diagnosis related group and, according to regulators, are “reasonably preventable” by the application of evidence-based guidelines. (Graves and McGowan, 2008) Also figuring strongly in the healthcare picture in addition to pay-for-performance is mandatory public reporting of infections.
Infection preventionists must make their individual business cases within this greater context of healthcare economics. Graves (2004) sums up the economic rationale for preventing hospital-acquired infections: "Hospital-acquired infections take up scarce health sector resources by prolonging patients’ hospital stay; effective infection control strategies release these resources for alternative uses. If these resources have a value in an alternative use, then the infection control programs can be credited with generating cost savings; these infection control programs are costly themselves, so the expense of infection control should be compared to the savings." Additionally, Leatherman, et al. (2003) note that a business case “exists if the entity that invests in the intervention realizes a financial return on its investment in a reasonable time frame.” This ROI can be achieved through profit, loss reduction, or cost avoidance.
To put it simply, infection prevention programs must be positioned as saving the healthcare institution more money than it costs to fund the program. As Perencevich, et al. (2007) explain, "The purpose is to look purely at the dollar costs and benefits of an infection control intervention or an entire infection control program to justify its existence to hospital administrators."
But this process is not without its challenges. As Perencevich, et al. (2007) observe, "Unfortunately, one current perception is that investments to improve quality might actually financially penalize the hospitals that make these improvements. Because infection control programs are often seen as cost centers and not as revenue generators, they are often identified as potential areas for budget cuts. In fact, many infection control programs have faced downsizing in recent years. Demonstrating value to administrators is increasingly important as healthcare executives are faced with the need to support many initiatives with limited resources."
Infection preventionists don't have to go it alone, however, as Perencevich, et al. (2007) note: "The difficulty in making a business case cannot be overlooked, because many infection control programs often lack the economic expertise necessary to complete such an analysis on their own. Anyone considering a business-case analysis should contact their local institution’s finance administrators for assistance in using the available local cost data."
Stone concurs. "Infection preventionists should definitely work with their hospital's finance experts," she says. "It's one thing to go to the literature and say that an infection costs X amount of dollars, but be prepared for your facility's chief financial officer to question you and you will have to defend that number. I would definitely get your institution's finance people on your side ahead of time. Show him or her the literature and ask what he or she thinks this costs at your facility, to be certain that you are incorporating all of the costs involved. You want them to understand the data you have before you make a presentation to institution leadership."
Stone also recommends that infection preventionists do their homework and be prepared in order to ward off presentation-related jitters. "I think it comes down to practice, and knowing your stuff. I remember the first presentation I had to do -- I practiced to no end. You do get better with time but there's nothing like good preparation to make you feel confident. I recommend practicing in front of other people, whether it's family members or colleagues from your local APIC chapter. Preparation and practice will ensure that you will be able to successfully articulate your message."