Making the business case for infection prevention

February 7, 2011

By Kelly M. Pyrek
One of the most critical skills an infection preventionist can have is the ability to construct a solid business case for infection prevention and control at his or her healthcare institution, especially in the age of dwindling resources and funding. Although the task may appear to be intimidating, at the core of this endeavor are several simple steps: use a healthcare-associated infection (HAI ) cost calculator tool to estimate the cost of infections in your facility; interpret the results of statistical models; build a customized business case and effectively present it to healthcare administrative leadership; create a compelling proposal to increase resources for infection prevention and control; and finally market these accomplishments and demonstrate value to all stakeholders.
Several years ago, the Association for Professionals in Infection Control and Epidemiology (APIC) issued a white paper, "Dispelling the Myths: The True Cost of Healthcare-Associated Infections," written by Denise Murphy, RN, BSN, MPH, CIC, and Joseph Whiting, MBA, FACHE, that paved the way to a better understanding of the business case process. In the paper they emphasize that "pursuing perfection, setting HAI reduction strategies at the theoretical ideal (zero preventable infections), represents a substantial opportunity for hospital leaders to improve safety, quality and significantly reduce cost." The APIC white paper provides solid instruction on how to calculate the costs of HAIs in your facility and suggests that once you have this data, to use this information to target an area that has significant opportunity for improvement.
A key aspect of making the business case requires data mining and gathering so that a return on investment (ROI) can be demonstrated. Nationally, HAIs) represent 4.5 infections for every 100 hospital admissions and account for an estimated 99,000 deaths in the United States annually. Murphy and Whiting point to a recent study of 1.69 million admissions from 77 hospitals that found patients with an HAI infection reduced overall net inpatient margins by $286 million or $5,018 per infected patient. The study found that the average additional incremental direct cost for patients with an HAI was $8,832. Locally, infection preventionists should know how to seek this kind of data for their state. For example, in 2007, the Pennsylvania Health Care Cost Containment Council reported hospital charges ranging from $35,168 in cases without an HAI, to $191,872 in cases with an HAI, with a difference of 15.3 days in the average length of stay. The PHCCCC notes, "Effective infection prevention and control programs demonstrate a valuable return on investment by releasing hospital resources for alternative uses and beds for new admissions. The Centers for Disease Control and Prevention estimates that the $45 billion annual direct cost of HAIs could be significantly reduced by as much as $31.5 billion with well resourced, quality infection prevention and control programs. Organizations may have inadequate methods to investigate the true cost of HAIs or the cost-effectiveness of infection prevention and control program."
The PHCCCC explains that in order to develop a compelling business case for infection prevention and control programs, infection preventionists and hospital epidemiologists must engage healthcare executives in evaluating the cost of HAIs in their organization and to dispel common misperceptions about the significance of HAIs, reimbursement, and cost savings associated with effective HAI reduction programs.
The council adds further, "An important function of the hospital epidemiologist and the infection preventionist is to demonstrate the value of infection prevention and control programs to healthcare executives. The most important aspect of a business case for prevention is reduction of harm and loss of life. But from a financial health perspective, boards, executives, and healthcare managers are interested in cutting costs and getting maximum value for expenditures. They may not see the benefit of new infection prevention and control programs if the return on investment is not realized within a certain time frame. An infection control business case analysis of the excess cost of HAIs and of the excessive length of stay can help gain needed resources and physician support. Practical methods are needed to engage healthcare executives in evaluating the true cost of HAIs in their organizations. Hospital leaders’ awareness that HAIs impact their patients may not always lead to understanding the extent of the financial burden of HAIs or the cost-effectiveness of infection prevention and control programs. Organizations may have inadequate methods to investigate the true cost of HAI in their institutions. Executives and clinicians in hospitals with HAI rates at or below nationally published rates may become complacent, accepting that a certain degree of patient harm from infections is an unavoidable price of caring for older, sicker patients. Common misconceptions about HAIs need to be dispelled. These misperceptions include the fallacy that the incidence of HAI in most institutions is insignificant; the erroneous belief that additional cost of HAIs is largely offset by reimbursement, making cost savings associated with reduction of HAIs not worth the investment; and the misperception that HAIs are an expected outcome of treating an older, sicker patient population with escalating use of invasive procedures."
This may sound like a tall order, and it is, but one expert encourages infection preventionists not to be intimidated. "Sometimes people make it harder than it is," says Connie Steed, RN, MSN, CIC, director of infection prevention and control at Greenville Hospital System University Medical Center in Greenville, S.C. "I do think it’s challenging for infections preventionists to make the business case because many of them don't have the basic knowledge they need to get started, including looking at the impact of HAIs on their healthcare organization. There is a clinical impact that relates to improving outcomes by reducing morbidity and mortality, and there's also an impact related to the cost of infections, and we have been able to prove that implementation of processes can reduce the infection rate and therefore reduce the length of stay. Infection preventionists should be able to show that the cost of an infection prevention program or intervention such as a central line bundle is justified. After all, wouldn't it be nice to be able to show hospital leadership that because they did a good job of implementing a CLABSI bundle, their central line rates were reduced and they saved X number of lives and they saved X amount of dollars? Doing that underscores to facility administrators the value of the infection prevention and control program. If infection preventionists can produce those kinds of results, hospital leadership is more apt to give resources to a team or a department when they are needed."
Steed adds, "There is increased pressure on leadership to reduce infection rates, so now is a really good time to try to increase your resources. But you will need to put some numbers around that to do so. One way to do that is to focus on one specific infection and cost-out what you did or what you want to do to cost-justify it, as well as determine what is the risk of not doing anything at all. It's critical to conduct a gap analysis of your program. Before you can even establish a business case you must assess your program to see what you are doing well and what you are not doing well. Infection preventionists must do an honest and thorough assessment to know where their risks are and build from there."
Steed points to business case guru Denise Murphy's work when she was at Barnes Jewish Hospital in St. Louis: "In conducting a gap analysis on their infection control program, she looked at their infection rates, the knowledge of their infection preventionists, the levels of their expertise, the experience they had with data, etc. She identified the opportunities for their program, which included training and process improvement, and that there needed to be more resources given to infection prevention. That is a much more challenging business case to make but it can be done. The challenge for new infection preventionists when evaluating their program is that it's hard for them to do that when they are still learning what their program should include. They may not know what an infection prevention and control program should contain, and how do they know if their program is good or bad? Again, it requires analysis and assessment to see where you stand."
To calculate the economic value of reducing and eliminating HAIs in the hospital, Murphy and Whiting outline the following methodology:
1. Select one of the following options for the population to be analyzed:
a. Option 1 – select a number such as 10 patients who acquired a CLABSI
b. Option 2 – select a class of HAIs for the last year (include any case where a payor was billed for any service related to an HAI; do not include a case if the primary cause of admission was for an infection; do include readmissions for HAI)
2. Identify the actual or estimated reimbursement for each case
3. Identify the total costs associated with the case, based upon activity-based cost accounting, if available
4. Identify the costs attributable to the HAI
5. Calculate the gross margin for the case by subtracting the expenses from the reimbursement
6. Compare the gross margin for the case to the gross margin of similar cases without an HAI, matched for age, principal diagnosis and admission severity
Variations on this methodology do exist. In a guideline issued by the Society for Healthcare Epidemiology of America (SHEA), Eli Perencevich, MD, MS, and colleagues outline a methodology that assists hospital epidemiologists in justifying and expanding their programs. They describe the basic steps needed to complete a business-case analysis for an individual institution, detail important basic economic concepts, including types of economic analyses and their strengths, and describe approaches used to assess the financial impact of infection prevention, surveillance, and control interventions, and approaches used to measure the attributable costs of specific HAIs.
Perencevich, et al. (2007) outline the following steps in creating a business-case analysis:
1. Frame the problem and develop a hypothesis about potential solutions
2. Meet with key administrators
3. Determine the annual cost
4. Determine what costs can be avoided through reduced infection rates
5. Determine the costs associated with the infection of interest at your hospital
6. Calculate the financial impact
7. Include the additional financial or health benefits
8. Make the case for your business case
9. Prospectively collect cost and outcome data once the program is in effect

http://www.infectioncontroltoday.com/articles/2011/02/making-the-business-case-for-infection-prevention.aspx

Innovation in Indian healthcare

Health care in India
Lessons from a frugal innovator
The rich world’s bloated health-care systems can learn from India’s entrepreneurs

Apr 16th 2009 Bangalore- from the print edition of The Economist
Tom Pietrasik

ENTER the main cardiac operating-room at Bangalore’s Wockhardt hospital on a typical morning, and you will find a patient on the operating table with a screen hanging between his head and chest. On a recent visit the table was occupied by a middle-aged Indian man whose serene look suggested that he was ready for the operation to come. Asked how he was, he smiled and answered in Kannada that he felt fine. Only when you stand on a stool to look over the screen do you realise that his chest cavity has already been cut open.
As the patient was chatting away, Vivek Jawali and his team had nearly completed his complex heart bypass. Because such “beating heart” surgery causes little pain and does not require general anaesthesia or blood thinners, patients are back on their feet much faster than usual. This approach, pioneered by Wockhardt, an Indian hospital chain, has proved so safe and successful that medical tourists come to Bangalore from all over the world.
This is just one of many innovations in health care that have been devised in India. Its entrepreneurs are channelling the country’s rich technological and medical talent towards frugal approaches that have much to teach the rich world’s bloated health-care systems. Dr Jawali is feted today as a pioneer, but he remembers how Western colleagues ridiculed him for years for advocating his inventive “awake surgery”. He thinks that snub reflects an innate cultural advantage enjoyed by India.
Unlike the hidebound health systems of the rich world, he says, “in our country’s patient-centric health system you must innovate.” This does not mean adopting every fancy new piece of equipment. Over the years he has rejected surgical robots and “keyhole surgery” kit because the costs did not justify the benefits. Instead, he has looked for tools and techniques that spare resources and improve outcomes.
Shivinder Singh, head of Fortis, a rival hospital chain based in New Delhi, says that most of the new, expensive imaging machines are only a little better than older models. Meanwhile, vast markets for poorer patients go unserved. “We got out of this arms race a few years ago,” he says. Fortis now promises only that its scanners are “world class”, not the newest.
Mr Singh is not alone in thinking that many firms in the rich world are looking at innovation the wrong way. Paul Yock, head of the bio-design laboratory at Stanford University, which develops medical devices, argues that medical-technology giants have “looked at need, but been blind to cost.” Amid growing concern about runaway health spending, he thinks the industry can find inspiration in India.
Poverty, geography and poor infrastructure mean that India faces perhaps the world’s heaviest disease burden, ranging from infectious diseases, the traditional scourge of the poor, to diseases of affluence such as diabetes and hypertension. The public sector has been overwhelmed, which is not surprising considering how little India’s government spends on health as a share of national income (see chart). Accordingly, nearly four-fifths of all health services are supplied by private firms and charities—a higher share than in any other big country.

In the past that was more a reflection of the state’s failure than the dynamism of entrepreneurs, but this is changing fast. Technopak Healthcare, a consulting firm, expects spending on health care in India to grow from $40 billion in 2008 to $323 billion in 2023. In part, that is the result of the growing affluence of India’s emerging middle classes. Another cause is the nascent boom in health insurance, now offered both by private firms and, in some cases, by the state. In addition, the government has recently liberalised the industry, easing restrictions on lending and foreign investment in health care, encouraging public-private partnerships and offering tax breaks for health investments in smaller cities and rural areas.
Cheaper and smarter
This has attracted a wave of investment from some of India’s biggest corporate groups, including Ranbaxy (the generic-drugs pioneer behind Fortis) and Reliance (one of India’s biggest conglomerates). The happy collision of need and greed has produced a cauldron of innovation, as Indian entrepreneurs have devised new business models. Some just set out to do things cheaply, but others are more radical, and have helped India leapfrog the rich world.
For years India’s private-health providers, such as Apollo Hospitals, focused on the affluent upper classes, but they are now racing down the pyramid. Vishal Bali, Wockhardt’s boss, plans to take advantage of tax breaks to build hospitals in small and medium-sized cities (which, in India, means those with up to 3m inhabitants). Prathap Reddy, Apollo’s founder, plans to do the same. He thinks he can cut costs in half for patients: a quarter saved through lower overheads, and another quarter by eliminating travel to bigger cities.
Columbia Asia, a privately held American firm with over a dozen hospitals across Asia, is also making a big push into India. Rick Evans, its boss, says his investors left America to escape over-regulation and the political power of the medical lobby. His model involves building no-frills hospitals using standardised designs, connected like spokes to a hub that can handle more complex ailments. His firm offers modestly priced services to those earning $10,000-20,000 a year within wealthy cities, thereby going after customers overlooked by fancier chains. Its small hospital on the fringes of Bangalore lacks a marble foyer and expensive imaging machines—but it does have fully integrated health information-technology (HIT) systems, including electronic health records (EHRs).
New competitors are also emerging. A recent report from Monitor, a consultancy, points to LifeSpring Hospitals, a chain of small maternity hospitals around Hyderabad. This for-profit outfit offers normal deliveries attended by private doctors for just $40 in its general ward, and Caesarean sections for about $140—as little as one-fifth of the price at the big private hospitals. It has cut costs with a basic approach: it has no canteens and outsources laboratory tests and pharmacy services.
It also achieves economies of scale by attracting large numbers of patients using marketing. Monitor estimates that its operating theatres accommodate 22-27 procedures a week, compared with four to six in other private clinics. LifeSpring’s doctors perform four times as many operations a month as their counterparts do elsewhere—and, crucially, get better results as a result of high volumes and specialisation. Cheap and cheerful really can mean better.
But there is more to India’s approach than cutting costs. Its health-care providers also make better use of HIT. According to a recent study in the Journal of the American Medical Association, fewer than 20% of doctors’ surgeries in America use HIT. In contrast, according to Technopak, nearly 60% of Indian hospitals do so. And instead of grafting technology onto existing, inefficient processes, as often happens in America, Indian providers build their model around it. Apollo’s integrated approach to HIT has enabled the chain to increase efficiency while cutting medical errors and labour. EHRs and drug records zip between hospitals, clinics and pharmacies, and its systems also handle patient registration and billing. Apollo is already selling its expertise to American hospitals.
Eye on the prize
A casual visitor to Madurai, a vibrant medieval-temple town in southern India, would not think it was a hotbed of innovation. And yet that is exactly what you will find at Aravind, the world’s biggest eye-hospital chain, based in the town. There are perhaps 12m blind people in India, with most cases arising from treatable or preventable causes such as cataracts. Rather than rely on government handouts or charity, Aravind’s founders use a tiered pricing structure that charges wealthier patients more (for example, for fancy meals or air-conditioned rooms), letting the firm cross-subsidise free care for the poorest.
Aravind also benefits from its scale. Its staff screen over 2.7m patients a year via clinics in remote areas, referring 285,000 of them for surgery at its hospitals. International experts vouch that the care is good, not least because Aravind’s doctors perform so many more operations than they would in the West that they become expert. Furthermore, the staff are rotated to deal with both paying and non-paying patients so there is no difference in quality. Monitor’s new report argues that Aravind’s model does not just depend on pricing, scale, technology or process, but on a clever combination of all of them.
C.K. Prahalad and other management gurus trumpet examples like Aravind, but do the rich countries accept that they could learn from India? Unsurprisingly, some reject the notion that America’s model is broken. William Tauzin, head of America’s pharmaceutical lobby, warns that regulatory efforts to cut costs could stifle life-saving innovation. Sandra Peterson of Bayer, a German drugs and devices giant, stoutly defends the industry’s record. She argues that overall cost increases mask how medical devices, “like cars or personal computers, give better value for the money over time.” Diabetes monitors and pacemakers have improved dramatically in the past 20 years and have fallen in price—but costs have gone up because they are now being used by more patients.
But those examples are exceptions. Many studies show that America’s spending on health care is soaring, yet its medical outcomes remain mediocre. Mark McClellen of the Brookings Institution, an American think-tank, says that a big problem is the overuse of technology. Whether or not a scan is needed, the system usually pays if a doctor orders it—and the scan might help defend the doctor against a malpractice claim. “The root cause is not greed, but tremendous technological progress imposed upon a fractured health system,” says Thomas Lee of Partners Community HealthCare, a health provider in Boston.
Dr McClellen, a former head of America’s Food and Drug Administration, points out that other innovative industries often sell new products at a loss, and recoup their investments later. In genuinely competitive industries, innovators are rarely rewarded with the “cost plus” reimbursements demanded by medical-device makers for their gold-plated gizmos.
That is why Stanford’s Dr Yock wants to turn innovation upside down. He has extended his bio-design programme to India, in part to instil an understanding of the benefits of frugality in his students. He believes that India’s combination of poverty and outstanding medical and engineering talents will produce a world-class medical-devices industry. Tim Brown, the head of Ideo, a design consultancy, agrees. In the past, he notes, health bosses thought all devices had to be Rolls-Royces or Ferraris. But cost matters, too. Pointing to another recent example of India’s frugal engineering, he says: “In health care, as in life, there is need for both Ferraris and Tata Nanos.”
from the print edition Business

Cleveland Clinic’s Low Cost Health Care Model

Today is the age of innovation in healthcare. One of the pressing innovation needs, as healthcare costs zoom, is provision of low-cost healthcare.

Cleveland Clinic is showing the way for this paradigm in the US. The factors behind this?

1. The Clinic’s doctors are all on salary

2. There is no concept of fee for service -whether a cardiac surgeon performs one surgery or ten they get paid the same.

3. EMR (Electronic medical records) have been available since May 2008

4. An emphasis on preventive care that goes beyond health and wellness bulletins – A heart healthy cafeteria and a fully functional gym.

Complete details at:

Patient as a Healthcare Consumer :"A Mindset Shift"

By

Dr. Shalini Ratan, MD
Founder and Chief Knowledge Facilitator
Nirvan Life Sciences Pvt. Ltd.
ratanshalini10@gmail.com


Health care today is unlike health care yesterday. Any actual or potential recipient of healthcare, such as a patient in a hospital, is a healthcare consumer rather just being a diseased person. Patient has become a healthcare consumer with demands similar to any other service industry consumer.
The role of a medical practitioner today is not only of a clinician and an academician but also a manager and executer for providing excellent medical services. Their work requires the mastery of a complex body of knowledge, patient service skills and the art and humanism of medicine.
Knowledge and understanding of the needs of patients and their families now is more crucial than ever in providing exceptional patient service. Today medical practice is driven by the combination of patient experience and perception of services provided to them. This would ultimately help in winning patient loyalty.
What is patient loyalty ?
Patient loyalty is defined as his commitment to consult a particular medical service provider. It is characterized by both affective as well as behavioral components. The affective aspect of patient loyalty is a psychological commitment to the service provider while the behavioral component is the act of repeat consultation.
The overall attributes that influence loyalty depends on the service provider’s performance in specific areas of service which fulfills patients’ expectations.
Basic attributes: These expectations must be met in order for a provider to retain patients. Eg: medical expertise of the doctor, modern equipments and procedures etc.
Value adding attributes: These attributes are perceived as highly valuable in the relationship between the service provider and the patient. High performance in these areas leads to patient loyalty as well as differentiation in the healthcare marketplace. Likewise, low performance in these areas will have a significant negative impact on patient acquisition and retention. Eg: personal care about patient’s physical and emotional needs, comfortable stay, communication with the patient etc.
When a patient visits for the first time in a hospital, a great VALUE is attributed to the doctors and on the hospital’s technical capabilities, such as modern equipments and procedures. On the other hand, for patients with previous hospital stay and experience the technical capabilities become the BASIC attributes. The issues that now drives the patient is the VALUE perceived for personal care of the patient, comfortable and quiet room, amenities for the patient and visitors and how the doctor and the staff respond to their needs The past experience with a hospital stay
causes patients to put a higher priority on comfort-related issues than medical issues.
The actual experience of a hospital stay, therefore, makes the selection of a service provider more experience-based than outcome-based. The ability of the hospital to treat the ailment becomes a BASIC, while physical and psychological comfort becomes VALUE Issues.
Berry et al (2006) describe three elements of a consumer’s experience with a service provider: functional, mechanical and humanic.
In case where consumer is the patient then:
Functional issue is technical expertise of the physician. This forms the basis of fundamental service delivery.
Mechanical issues are generally sensory in nature and are helpful for creating first impression. This could be clean environment of the hospital, uniform of the staff and even the color of the patient’s room.
Lasting attitudes and opportunities for differentiation are found in the humanic area. These are issues related to the patient’s emotional preferences and needs.
Humanic issues are the key to the loyalty of the patient and differentiation from others.