Developing a Business Case for Quality

Dr. Elizabeth Bryce Linda Dempster Sydney Scharf Rizwan Damji

Vancouver Coastal Health Authority February 28, 2014

Traditional Business Case 1. Background –current state, problem/opportunity

2. Project Description – Objectives, scope, deliverables, operational impacts, strategic alignment

3. Cost and Benefit analysis – resource requirements, costs and benefits and assumptions

4. Risk Assessment – project risks and risk of not proceeding with project

5. Evaluation – how will we know the impacts

6. Alternative Analysis – what other options are there

7. High Level Implementation plan –what will be done by when

Our areas of focus 1. Apply framework to assess situation 2. Clearly define the problem 3. Develop a plan; identifying options 4. Engage the team – think partnerships 5. Identify measurable deliverables 6. Share results early and often 7. Remember the PDSA cycle

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• Evaluation of costs and

consequences in monetary units

• Opportunity Costs • Cost Avoidance Is an intervention

worthwhile?

Cost-Benefit Analysis

• Competition between resource scarcity and providing the best possible care • Economic outcome measurement, efficient use of resources • Patient focused • Long-term evaluation

Health Economic Evaluation

• Translate results into improved access to the system, e.g.

• Bed days / Patient days

• Wait times • Patient Volume

• Assess the potential of a quality improvement initiative before implementation

Projection Analysis

1. The framework

System Access

Our emphasis was on

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3. Health Economics • Cost-Benefit Analysis • Return-on-Investment

• Cost Avoidance • Access (e.g. additional patient days, beds freed)

1. Quality Outcomes • Patient/Employee Satisfaction and

Experiences • Adverse Events / Occurrences • Healthcare Acquired Infections

• Mortality & Morbidity

4. Program Costs / Investments • Operational Costs

• Implementation Costs • Training and Education • Consultancy Support

2. Productivity & Efficiency • Length of Stay

• Admissions / Readmissions • Work Flow / Direct Care Time

• Employee Turnover and Staff Absence • Reducing Waste /Clutter-Free

Environment Making Cents

Assess the situation

The health economic framework is useful in building a business case as it takes into consideration multiple factors and it can be applied to evaluate a number of different programs

Economic Burden of Adverse Events*

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The rate of AE

7.5 %

The total number of discharges per year

84,043 (VCHA)

Additional attributable acute care days per AE

6 days**

Median cost per acute care day

$ 1,100

Economic burden of AE

$ 41,601,285

Economic burden of preventable AE $ 15,329,475

Of which 37 % are

preventable

Resources: * Baker, N. et al.: The Canadian Adverse Events Study. CMAJ. 2004. Vol. 170(11): 1678-86. **Etchells, E. et al.: The Economics of Patient Safety in Acute Care. Canadian Patient Safety Institute. 2012.

Money, Money, Money…

…is not the only deliverable

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Healthcare-associated infections (particularly C.difficile) need to be improved

Roles/Responsibilities for cleaning of portable equipment have never been assigned (ward clutter, hoarding, mixing clean and dirty)

Minimal antimicrobial stewardship program, limited accountability for antimicrobial resistance rates, prescribing practices and drug utilization contributes to the problem

Cleaning of surfaces impeded by clutter, out-dated tools (e.g. cleaning carts, rags), inadequate instructional aids and logistical issues

2. Clearly define the problem

3. Develop the plan • What are you trying to improve? • How will you get there? • What resources do you need? • What is the ROI? • How long do you need?

What did we want to improve

Standardize equipment cleaning and reducing C. difficile rates Need to identify: • All the elements • Clear direction • Who is accountable

Elements of our plan • Environmental de-cluttering to improve overall

surface cleanliness on the wards • An environmental management program to improve

clinical equipment surface cleanliness • Antimicrobial stewardship program to ensure

appropriate, cost effective use of antibiotics on the clinical units within our hospitals

• Implementation of a risk-managed approach to the isolation of VRE clients in an effort to support patient flow and reduce unit supply costs

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Environmental Program • De-cluttering • Introduction of color coded microfiber cleaning

cloths and color coded buckets • Equipment management includes cleaning,

preventative maintenance, establishing par levels, and ensuring that the right piece of equipment is available and is clean at all times.

• Labeling/tagging • Introduction of PPE carts

Antimicrobial Stewardship Program

• Right drug • Right time • Right route • Most focused therapy • Least invasive therapy • Optimal duration of therapy

4. Engaging the Team

• Thinking win – win • According to Steven Covey it is one of the

seven habits of highly effective people • It is the habit of EFFECTIVE

INTERPERSONAL LEADERSHIP • Take the time to consider the other

persons perspective and engage them with that in mind

Leadership support is the key

• When we think of leadership we need to think of in context of the layers within the organization – Senior Leadership – Project Leadership – Front Line Leadership

Project Leadership • Regular updates • Working groups • Continuous engagement • Culture shift • Project influences were reported routinely • Updates for senior leaders and what was

the goal.

About working together

• Goals have to resonate with the team • Acknowledge and recognize team effort • Thank team members • Report on successes • Share successes

Our partners • Aramark • Biomedical Engineering • BISS • CDI Working Group at VGH, Goldie Luong • Clinical Services • FMO • HSSBC • IMIS • Infection Control • Leslie Forrester & Epidemiology Team • Medical Microbiology • Pharmacy • Professional Practice

Speaking the same language

Be Flexible • You may have to change

your plan along the way • You may have to play

many different roles: bookkeeper, labour lawyer, coach and expert

stay calm and REMAIN FOCUSED!

5. Measureable deliverables

• Identify indicators for each projected benefit

• This comes from being able define and link each benefit “cause” to an “effect” – Environmental cleaning will show a change in

UV audit results – Switching to less costly generic drugs that

have the same efficacy will overall drug costs

Our deliverables

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Implement an environmental program to improve equipment and surface cleanliness

Establish a VCH antimicrobial stewardship program to ensure appropriate, cost effective antibiotic use

Decrease healthcare-associated infections following implementation of the two programs

Implement a risk-managed approach to the isolation of VRE

1

2

3

4

Hand Hygiene

Antimicrobial Stewardship

Standardized Protocols

Environmental Program

Metric ↓ Equipment management

↓Isolation Management Costs

Isolation Cost Avoidance

Product Replacement

Improve use of antibiotics

Decrease costs of antimicrobials

Antibiotic resistance

Decreased rates of: UTIs, MRSA, VRE, VAP, BSI, SSI

Staff Satisfaction

↓ Lab costs

6. Share the results early and often

1. Regular reporting and updates to leadership team(s)

2. Show them the results early 3. Look for low hanging fruit early 4. Remain focused 5. No surprises – if something goes sideways,

must report 6. Spend the money early!

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De-cluttering Before After

Yellow gowns Before

Yellow gowns After

Savings -- Environmental Achieved

Soap-Swap Out $65,490.00

Lab Savings $64,830.00

Yellow Gowns $154,170.00

Decreased FTE Equipment Program $480,000.00

$764,490.00 Total for 1 year

Patients isolated for VRE at VGH Before After

32 beds/day

7 beds/day

Four Cornerstones VGH: Pre and Post Implementation

375

263

0

50

100

150

200

250

300

350

400

Pre Post

Tota

l Num

ber o

f Cas

es

Total CDI Acquired at VGH (Pre & Post Implementation)

Sep 2012 - Dec 2013Jun 2011 - Aug 2012

↓ 30%

Dollars saved Bed Days saved Patients protected from CDI

ASPIRES Antimicrobial Stewardship Program –

Innovation, Research and Education for Safety

Clinical Care Education

Research Collaboration

Excellence

IV to PO Step-Down Interventions: •Stepping down from IV to PO anti-infectives when patients can tolerate PO Outcomes: •Reduced utilization of IV anti-infectives with PO bio-equivalence at VGH and RH

13.8

10.7

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10121416

Pre Post

DD

Ds

per 1

00 P

atie

nt D

ays

IV Anti-Infective Utilization (DDDs per 100 Patient Days)

RH

7.3

5.6

012345678

Pre Post

DD

Ds

per 1

00 P

atie

nt D

ays

IV Anti-Infective Utilization (DDDs per 100 Patient Days)

VGH

Financials -- ASPIRES Run Rate for Imipenem to Generic Meropenem Substitution VGH:

$144,524*

Audit and Feedback - Reduction in Antibiotic Utilization VGH, CTU:

$34,812 IV to PO Step-down : VGH: $22,901 RH: $4,448

Total Cost Savings (FY 2013/14 Periods 1- 8): $199, 538

* In collaboration with pharmacy

7. Remember the PDSA cycle

Plan (operationalize)

Do (Trial)

Study (assess/review)

Act (adjust)

Questions

IHI Calculator

• http://www.ihi.org/knowledge/Pages/Tools/AdverseEventsPreventedCalculator.aspx

Adverse Events Prevented Calculator