Build a Business Case for Quality Improvement: Slide Presentation

Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients

Build a Business Case for Quality Improvement

Slide 2: Learning Objectives

After this session, you will be able to—

• Describe how this safety program can affect the hospital’s financial bottom line.
• List the elements of a strong business case.
• Give statistics local meaning to support your initiative.
• Present your initiative in a way meaningful to financial leaders.

Slide 3: Impact of Mechanical Ventilation

• Affects 800,000 hospitalized patients in the U.S. each year.¹
• Five to 10 percent of mechanically ventilated patients develop a ventilator-associated event (VAE).^2,3

^1. Carson SS, Cox CE, Homes GM, et al. The changing epidemiology of mechanical ventilation: a population-based study. J Intensive Care Med 2006; 21(3):173-82. PMID: 16672639.

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation. PLoS ONE 2011 Mar 22;6(3):e18062. PMID: 21445364.

^3. Klein Klouwenberg PM, van Mourik MS, Ong DS, et al. Electronic implementation of a novel surveillance paradigm for ventilator-associated events: feasibility and validation. Am J Respir Crit Care Med 2014 Apr 15;189(8):947-55. PMID: 24498886.

Slide 4: Impact of Mechanical Ventilation

• Historically, ventilator-associated pneumonia (VAP) was considered one of the most lethal healthcare-associated infections.⁴
• 35% mortality rate for ventilated patients:⁵
  • 24% for patients 15–19 years.
  • 60% for patients 85 years and older.

^4. Safdar N, Dezfullian C, Collard HR, et al. Clinical and economic consequences of ventilator–associated pneumonia: a systematic review. Crit Care Med 2005; 33(10):2184-93. PMID: 16215368.

^5. Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation use in the United States. Crit Care Med 2010; 38(10):1947-53. PMID: 20639743.

Slide 5: Impact on Mechanical Ventilated Patients

Poses a significant burden to patients and caregivers.

Short-term:

• Increase in complications:
  • VAP.
  • Sepsis.
  • Acute respiratory distress syndrome.
  • Pulmonary embolism.
  • Barotrauma.
  • Pulmonary edema.
• Increase in health care costs.
• Increase in length of stay.

Long-term:

• Slower overall recovery time.
• Debilitating physical disabilities.
• Lingering cognitive dysfunction.
• Psychiatric issues, including anxiety, depression, and post-traumatic stress disorder.

Slide 6: Financial Impact of Mechanical Ventilation

• Average acute care cost for ventilated patient: $2,300 per day.⁶
• After 4^th day, cost rises to over $3,900 per day.⁷
• Example:^8,9
  • 400-bed hospital with 40 critical care ventilators.
  • $18 million per year for daily costs.
  • 20% reduction could save $2 million per year.

^6. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator associated pneumonia in the ICU. Infect Control Hosp Epidemiol 2011; 32(4):305-314. PMID: 21460481.

^7. Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011;342:d219. PMID: 21282262.

^8. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Medicine 2011;39(5):934-9. PMID: 21297460.

^9. Waters HR, Korn R Jr, Colantuoni E, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual 2011;26(5):333–339. PMID: 21856956.

Slide 7: Ventilator-Associated Events (VAEs) Attributable Hospital Mortality^10-13

• Recent retrospective cohort studies examined attributable mortality, among other metrics, surrounding all VAE tiers:
  • Estimate 10% attributable mortality for VAP.
  • Varies for different categories of cases.

^10. Nguile-Makao M, Zahar JR, Francais A, et al. Attributable mortality of ventilator-associated pneumonia: retrospective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state variables. Intensive Care Med 2010 May;36(5):781-9. PMID: 20232046.

^11. Bekaert M, Timsit JF, Vansteelandt S, et al. Attributable mortality of ventilator-associated pneumonia: a reappraisal using causal analysis. Am J Respire Crit Care Med 2011 Nov 15;184(10):1133-9. PMID: 21852541.

^12. Melsen WG,  Rovers MM, Koeman M, et al. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med 2011 Dec;39(12):2736-42. PMID: 21765351.

^13. Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomized prevention studies. Lancet Infect Dis 2013 Aug;13(8):665-71. PMID: 23622939.

Slide 8: VAPs Among Most Expensive HACs¹⁴

Image: Bar graph demonstrating the significant additional costs of VAPs among other HACs. CAUTI = catheter-associated urinary tract infection; CLABSI = central line associated bloodstream infection; DVT = deep vein thrombosis; VAP = ventilator-associated pneumonia; SSI = surgical site infection.

^14. Saving Lives and Saving Money: Hospital-Acquired Conditions Update. December 2015. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html. Accessed June 2, 2016.

Slide 9: What Do We Need To Do?

• Improve patient and family experience.
• Reduce complications.
• Get patients off the ventilator.
• Get patients ready to leave the intensive care unit (ICU) and hospital faster.
• Improve efficiency while reducing costs.

Slide 10: AHRQ Safety Program Goals

• To reduce risk of patient harms associated with mechanical ventilation:
  • Reduce VAEs, including VAP.
  • Reduce the duration of mechanical ventilation, length of stay (LOS), and mortality.
• To achieve significant improvements in teamwork and safety culture in ICUs.

Slide 11: Ventilator-Associated Events Successes

CDC Epicenters Wake Up and Breathe Collaborative¹⁵

Ventilator Days and LOS Reductions:

• -2.4 vent days.
• -3.0 ICU days.
• -6.3 LOS days.

VAE Reductions:

• -37% in VACs.
• -65% in IVACs.*

SAT and SBT Increases:

• +63% in SATs.
• +16% in SBTs.
• +81% in SBTs done with sedatives off.

Images: Arrow pointing down covering ventilator days and LOS reductions and VAE reductions. Arrow pointing up covering SAT and SBT increases.

* Infection-related Ventilator-Associated Condition (IVAC).

^15. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014; 35(5):502-510. PMID: 24709718.

Slide 12: Why Build a Business Case?

Before agreeing to move forward with quality improvement efforts, your stakeholders may question your proposal by asking the following:

• Where will we get the money to pay for this?
• Why should we devote our scarce resources to this program?
• Can we afford these expense increases now?

Build a business case to prepare for these questions.

Slide 13: The Basic Business Model

Image: Components of organizational performance displayed as a circular path: capacity, volume, revenue, staffing and salaries, supplies and equipment, profit.

Slide 14: Focus for Business Case

What do financial stakeholders focus on?

• Cost efficiency.
• Real cost reduction.
• Revenue enhancement.
• Balance sheet improvements.
• Intangible improvements.

Slide 15: Cost Efficiency

Improved quality results in…

• Increased capacity.
• Increased work output.
• No change in total cost.

Image: Same cost plus increased work output yields reduced cost per unit of work.

Slide 16: Real Cost Reduction

Improved quality results in…

• Increased capacity.
• No change in work output.
• Reduction in staffing levels.

Slide 17: Revenue Enhancement¹⁵

How does this quality improvement impact revenue?

• Reduces time on ventilator by 2.4 days.
• Reduces ICU length of stay by 3.0 days.
• Reduces hospital length of stay by 6.3 days.
• Increases capacity to care for new patients.
• Reduces VACs by 37%.
• Reduces IVACs by 65%.
• Reduces financial toll of complications.

^15. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014; 35(5):502-510. PMID: 24709718.

Slide 18: Balance Sheet Improvements

How does quality improvement impact balance sheets?

• Maximizes brick and mortar investment.
• Increases funds available for capital purchases and other investments.
• Reduces the need for borrowing to increase capacity or invest in new programs.

Slide 19: Intangible Improvements

What are the intangible effects of quality improvement?

• Improved patient outcomes including reduction of long-term complications.
• Higher satisfaction scores from patients and families.
• Higher engagement and fulfilment among staff.
• Improved reputation of your institution.
• Reduced malpractice claims.
• Better market position in your community.

Slide 20: Return on Investment

Value (return) derived from making an investment:

• Interest on a savings account.
• Rental property income.
• Profits from new technology or a new program.

Image: Average return plus average investment yields return on investment.

Slide 21: Understanding Your Target Audience

The hospital CFO is—

• A consultant to hospital leadership.
• The gatekeeper of hospital assets.
• Focused on the bottom line.
• Most likely a "concrete thinker."
• Impressed with frontline clinicians.

Slide 22: Giving Statistics Local Meaning

• Use statistics from literature to support investment:
  • Incidence of VAE.
  • Duration of mechanical ventilation.
  • Reductions in length of stay in intensive care unit and/or hospital through specific interventions.
• Collect local data:
  • Volume of patients on mechanical ventilation.
  • Current length of stay information.
• Extrapolate general statistics to local context.

Slide 23: Giving Statistics Local Meaning

Example: If we reduce VAP by 50%, how many patients avoid VAP and how much can we save?

• Literature:
  • Evidence suggest at least 50% of VAP can be prevented.¹⁴
  • Estimate $21,000 additional costs per VAP case.¹⁴
  • Interventions from this safety program can reduce VAE and VAP.
• Local data:
  • Current VAP rate is 6%.
  • Approximately 500 patients receive mechanical ventilation (MV) in your ICU per year.
• By implementing these interventions, you can—
  • Prevent at least 15 VAP cases each year.
  • Save approximately $315,000 each year (at $21,000 per case.

^14. Saving Lives and Saving Money: Hospital-Acquired Conditions Update. December 2015. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html. Accessed June 2, 2016.

Slide 24: Giving Statistics Local Meaning

Example: If you reduce ICU LOS by 3 days, how many patient days per year could be reduced?

• Literature:
  • Evidence shows 3-day reduction in ICU LOS after significantly increased compliance with spontaneous awakening and breathing trials (SATs and SBTs).¹³
• Local data:
  • Current ICU LOS for MV patients, if available.
  • Current SAT and SBT compliance rates, if available.
  • Approximately 500 patients receive MV per year.
• By implementing these interventions, you can—
  • Reduce your ICU LOS by 1,500 patient days per year (3 days x 500 patients).
  • Improve tracking of process measures for evidence-based care.

Slide 25: Questions To Ask Your Leaders

Ask your leaders the following:

• Where will we get the money to pay for the associated costs for patients with preventable healthcare-acquired infections?
• How can we realize these savings and patient improvements?
• Can we afford to ignore these patient and financial costs?
• Would you want your loved one treated in a unit not practicing evidence-based care?

Slide 26: Making the Pitch

How should you present this to your CFO?

• Start with the anticipated return on investment.
• Focus on revenue first, then share operating or investment costs.
• Come prepared with revenue and expense estimations.
• Provide solid application example of how quality improvement is good for both patients and business.

Slide 27: Questions?

Image: Picture of multicolored hanging tags with question marks on them.

Slide 28: References

^1. Carson SS, Cox CE, Homes GM, et al. The changing epidemiology of mechanical ventilation: a population-based study. J Intensive Care Med 2006; 21(3):173-82. PMID: 16672639.

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation. PLoS ONE 2011 Mar 22;6(3):e18062. PMID: 21445364.

^3. Klein Klouwenberg PM, van Mourik MS, Ong DS, et al. Electronic implementation of a novel surveillance paradigm for ventilator-associated events: feasibility and validation. Am J Respir Crit Care Med 2014 Apr 15;189(8):947-55. PMID: 24498886.

^4. Safdar N, Dezfullian C, Collard HR, et al. Clinical and economic consequences of ventilator–associated pneumonia: a systematic review. Crit Care Med 2005; 33(10):2184-93. PMID: 16215368.

^5. Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation use in the United States. Crit Care Med 2010; 38(10):1947-53. PMID: 20639743.

Slide 29: References

^6. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator associated pneumonia in the ICU. Infect Control Hosp Epidemiol 2011; 32(4):305-314. PMID: 21460481.

^7. Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011;342:d219. PMID: 21282262.

^8. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Medicine 2011;39(5):934-9. PMID: 21297460.

^9. Waters HR, Korn R Jr, Colantuoni E, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual 2011;26(5):333–339. PMID: 21856956.

Slide 30: References

^10. Nguile-Makao M, Zahar JR, Francais A, et al. Attributable mortality of ventilator-associated pneumonia: retrospective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state variables. Intensive Care Med 2010 May;36(5):781-9. PMID: 20232046.

^11. Bekaert M, Timsit JF, Vansteelandt S, et al. Attributable mortality of ventilator-associated pneumonia: a reappraisal using causal analysis. Am J Respire Crit Care Med 2011 Nov 15;184(10):1133-9. PMID: 21852541.

^12. Melsen WG,  Rovers MM, Koeman M, et al. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med 2011 Dec;39(12):2736-42. PMID: 21765351.

^13. Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomized prevention studies. Lancet Infect Dis 2013 Aug;13(8):665-71. PMID: 23622939.

Slide 31: References

^14. Saving Lives and Saving Money: Hospital-Acquired Conditions Update. December 2015. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html. Accessed June 2, 2016.

^15. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014; 35(5):502-510. PMID: 24709718.