Making a Business Case for Infection Control
By Kelly M. Pyrek
One of the most important ways an infection control practitioner (ICP) can validate his or her program is to master an understanding of the principles of healthcare economics (HE) and how they can use it as a tool with which to demonstrate the fiscal and clinical value of infection prevention and control efforts to facility administrators. That was the message of the Science to Practice lecture at the 2005 meeting of the Association for Professionals in Infection Control and Epidemiology, sponsored by 3M Health Care. A panel of experts addressed the need for ICPs to constantly demonstrate their value to hospital executives to protect their programs and services to patients and healthcare colleagues.
Patricia Stone, PhD, RN, of Columbia University, reminded ICPs that they are soldiers in the battle against the 2 million cases of healthcare-acquired infections (HAIs) that result in as many as 90,000 deaths annually. Not only are lives lost, but these HAIs can cost up to $6.5 billion, a figure adjusted upward for inflation from the 1992 CDC estimate of $4.5 billion. Healthcare costs alone were 15.3 percent of the U.S. Gross Domestic Product (GDP) in 2003; that figure is expected to climb to 18.4 percent by 2013 when adjusted for inflation. Stone says this is creating immense pressure for todays healthcare facilities to be cost-effective in their operations, so ICPs must take these financial concerns into consideration when asking for an increased IC program budget .
In 2002, Stone and colleagues published their review of the current literature addressing the economic ramifications of adverse events such as HAIs. They examined more than 150 studies that were conducted from 2001 to 2004 which looked at the simple cost of infections or which performed a cost analysis of interventions. The studies examined the frequency and average cost (in parentheses) of the following commons HAIs: surgical site infections, 24 percent ($25,546); bloodstream infections 18 percent ($36,441); ventilator-associated pneumonia, 8 percent ($9,969); and urinary tract infections, 3 percent ($1,006).
Stone recommended that in making a business case for their programs, ICPs should follow accepted guidelines for conducting an economic analysis and look for the most sophisticated mathematical models available in the medical literature, as well as seek out additional training in HE related to evidence-based practice. Money does talk, she said, adding that ICPs can make a strong case for their surveillance models.
However, many ICPs need a refresher in the HE vernacular. Edwin Hedblom, PharmD, global manager of health economics for 3M Medical, reviewed the essentials of HE-speak by defining a few basic concepts that administrators use when reviewing their profit-and-loss statements and balance sheets. Hedblom defined HE as the most efficient use of available resources defined in terms of patient outcome and cost; wants and needs exceed limited resources. He explained that there are economic, clinical, and humanistic outcomes involved in HE. Economic outcomes include direct costs (such as those related to products and labor) and indirect costs (such as lost employment or lower productivity).
Clinical outcomes include faster wound healing and lower infection rates, while humanistic outcomes encompass quality-of-life issues. Cost-minimization analysis compares two or more alternatives with identical outcomes; cost-effective analysis compares the cost of alternative approaches to obtaining a common therapeutic objective; and cost-utility analysis is the cost of therapeutic alternatives for which outcomes are adjusted for patient preferences.
Intimidating financial formulations arent the only barriers to ICPs using HE principles. According to Hedblom, the top impediments to using HE data include institutional problems, insufficient training on HE-data analysis, inability to transfer evidence into practice, and the short-term nature of decision making coupled with the long-term nature of HE benefits. Above all, Hedblom said, ICPs must not only speak an administrators language, they must understand that the economic outlook for the healthcare facility colors an administrators viewpoint. Hedblom explained that healthcare executives are worrying constantly about issues such as financial viability, controlling costs, making appropriate capital investments, engaging in proper labor relations, ensuring regulatory compliance, maintaining a competitive position in the marketplace, upholding quality, avoiding adverse outcomes and liability issues, preventing medical errors, and ensuring disaster preparedness, among other issues. ICPs should always consider what their administrators are thinking about when they ask for resources for their department, Hedblom advised.
Denise Murphy, MPH, RN, CIC, of Barnes-Jewish Hospital in St. Louis, emphasized, Know the business case for infection control. The impact of HAIs makes the best case, including data on the clinical impact of morbidity and mortality, as well as the cost of infections and exposures. Its imperative to show data to management on how cost savings can fund an IC program and prevent about half of a facilitys HAIs. The bottom line is that people are dying from preventable HAIs.
Murphy said that ICPs should know where opportunities in intervention lie in your facility, and where are the pockets of high risk (for HAIs). Documents costs to your own facility if possible, and extrapolate this data for meaning. Use cost estimates from the literature, adjusted for inflation, if you cannot obtain your own organizational costs. Murphy added, The impact of occupational exposures can help make the case for IC resources. She pointed out that, for example, according to data from the CDC, there are 1,000 sharps injuries per day, and that 84 percent of documented HIV transmission is from needlesticks. The cost of such injuries can run in the thousands of dollars, and opens up the facility to lost productivity or litigation. Facilities should consider the total impact on the community, including staff, third-party payors, etc.
ICPs were encouraged to consider hidden-opportunity costs in which resources consumed for one purpose that are therefore unavailable for another potentially higher-value purpose. Additionally, there are societal costs to healthcare consumers, including decreased trust in the community healthcare system, or increased use of antibiotics which contributes to antibiotic resistance.
ICPs bring to the job a special brand of expertise, Murphy said, including skills such as infection prevention and control, epidemiology and surveillance skills, quality improvement processes, patient safety expertise, and education and consultation abilities. She added that HE knowledge complements this skills set, and allows the ICP to place these skills into an economic context. The value of ICPs, according to Murphy, lies in their abilities to eliminate waste and boost productivity; engage in cost-effective product selection; protect the occupational health of employees; ensure the appropriate application of expensive technology; maintain regulatory compliance; create collaboration between clinicians and administrators; and maintain an organizations reputation for service excellence. Murphy added that ICPs can also support an organizations strategic plan to grow volume and grow services, as well as hit the target 100 percent on quality-scorecard indicators such as improving surgical prophylaxis timing and making surgical-site infection prevention projects part of the ICPs overall program goals.
Murphy touched upon one of the most significant challenges to ICPs performance, including the tug of war between traditional and non-traditional ICP tasks such as bioterrorism, workers compensation, latex allergies, safety fairs, and environmental safety. Murphy alluded to the Delphi Project, which looked at staffing issues related to infection control one of the biggest issues facing ICPs today. In the white paper, Staffing requirements for infection control programs in U.S. healthcare facilities: Delphi project, three researchers from the University of Minnesota School of Nursing examined the 1985 guideline for staffing infection control programs of one ICP for every 250 occupied acute-care beds. The researchers used the Delphi method; data were obtained from a group of ICPs through a series of 10 surveys. Through this iterative process, participant responses were progressively synthesized and areas of agreement and disagreement identified. These surveys were conducted by electronic and paper mail to identify the personal ICP characteristics and structural variables associated with performance of activities required for contemporary infection prevention and control programs in a variety of healthcare settings. Thirty-two Delphi panel members from 20 states (representing acute-care, long-term care, and community-care settings) reported tasks in addition to those identified in earlier task analyses as well as expanded responsibilities. Competing responsibilities and lack of adequate resources were the most frequently cited reasons for nonperformance of essential infection control tasks. A ratio of 0.8 to 1.0 ICPs for every 100 occupied acute-care beds was suggested as adequate staffing by the Delphi panel.
Murphy added that the Delphi project cited a significant lack of resources to ICPs, including inadequate staffing, lab support, medical records access, and data collection. Murphy underscored the recommendations of the Delphi project, including one trained ICP per 100 occupied beds, the presence of a well-qualified physician leader, adequate information systems, and sufficient clinical, analytical and statistical support. When Murphy asked APIC attendees for a show of hands, not even half of the audience of many hundreds of ICPs had a dedicated IC program budget. Know the cost of an effective IC budget, Murphy admonished. Be relentless in your pursuit, backing up your requests with concrete data.
Concurring with Murphy on the need for this data, Steven Miller, MD, chief medical officer at Barnes-Jewish Hospital, commented, Understand the administrators view of the world. I care about the quality of care passionately but I also care about healthcare economics. I tell my people, no margin, no mission, but the margin isnt the mission. You have to balance both. He continued, The need for ICPs is at an all-time high. You are more powerful than ever before. But you are passive people. You can be your own worst enemies. Until you develop a passion for funding your program, I wont develop a passion.
Miller pointed to a typical hospital administrators concerns, adding, Infection control is a cost center, and you cant bill for it. However, Miller added that ICPs represent best practices for the facility, improved patient outcomes, regulatory compliance, malpractice avoidance, and return on investment (ROI). The latter, Miller said is critical because, If you dont develop ROI, I will ignore you. Miller continued, Hospitals continue to be challenged by profitability issues, the need for operating efficiencies, and trying to satisfy many stakeholders. There are numerous external pressures, and profit margins are wobbly; 27 percent of hospitals are losing money, and only one-third of hospitals see capital expansion as viable in the future. Executives have less money to spend and every department in the hospital is vying for the same dollars; you wont get the money if you dont ask for it. My advice to you as ICPs is to strike next week, not during the next budget cycle. Go to administrators during the off budget cycle when there is less competition among hospital departments. Be more strategic before heading into tougher economic times.
Miller outlined several steps ICPs can take to make a bullet-proof business case for increased resources and to sell administrators on their IC program:
- Use data as leverage
- Provide ROI
- Solve problems for management
- Be prepared, concise, and accurate
- Have a physician advocate
- Have an economic imperative
- Develop negotiation skills
- Provide options
Miller explained, I look for whats wrong in your argument, not whats right, so ICPs need to make their arguments as solid as possible. Ill never give you more than you ask for, so think big. Be prepared to go three rounds in negotiations to be successful, and remember to achieve that perfect balance between costs and benefits.