Strategic Optimization: A Vehicle for Driving a Measurable Impact on Hospital-Acquired Infections
The rise of consumerism and the advent of payment reforms linked to value-based care are driving a heightened level of transparency in hospital-reported quality data. The Centers for Medicare and Medicaid Services (CMS) Five-Star Quality Rating System and The Leapfrog Group dashboards are just two of programs that measure the quality of provider organizations based on this reported data. CMS reports that by 2018, 90 percent of Medicare payments will be tied to quality. Couple these requirements with the toll that existing mandatory risk programs are taking on providers and the potential impact becomes significant. The Advisory Board Company reports that the estimated impact of pay-for-performance programs in 2015 resulted in 50 percent of hospitals receiving some kind of penalty, while only 28 percent received a payment or break-even. New payment reforms, such as the Medicare Access and CHIP Reauthorization Act (MACRA) and bundled payments, will also require that safety, quality, and efficiency be top priorities in order to improve outcomes and reduce penalties.
Providers Struggle as Rates of Hospital-Acquired Infections Rise
Hospital-acquired infections (HAIs) have risen to a crisis level. The Centers for Disease Control and Prevention (CDC) reports that on any given day, one in every 25 hospital patients will have at least one HAI. In 2014, the results of a project known as the HAI Prevalence Survey were published. The survey described the burden of these infections and reported that in 2011 there were an estimated 722,000 HAIs in acute care hospitals. Further, about 75,000 patients with HAIs died during their hospitalizations. More than half of these deaths took place outside of the ICU.
There are many examples of programs that have resulted in reduced infections, such as the Institute for Healthcare Improvement’s (IHI) bundle program, which reported a 50 percent decrease in central line-associated bloodstream infections. However, despite these improvements, there are areas of no change, such as overall catheter-associated urinary tract infections, and more alarming, areas that continue to see an increase such as the rate of hospital-acquired Clostridium difficile (C. diff), which saw a four percent increase between 2013 and 2014.
Case Example: How One Community Hospital Leveraged Technology to Reduce HAI Rates and Recognize Related Cost Savings
While the IHI bundles rely on process change, CTG has found through client experience that the addition of technology as an enabler can have a significant impact on infection reduction. One community hospital experienced immediate results using this approach. The hospital was making an impact on decreasing infections such as ventilator-acquired pneumonia (VAP) and Methicillin-resistant Staphylococcus aureus (MRSA), but continued to see increases in C. diff infections. This hospital was facing all too familiar challenges. Frequently, patients coming from long-term care facilities might already be carrying the bacteria, making early detection critical. Common challenges in combating this infection include incomplete documentation, an overuse of antibiotics, a lack of prevention knowledge and training, delays in detection of community-acquired cases, poor hand washing, and late implementation of prevention protocols.
A Phased Approach to Optimization, Powered by Technology
The approach used at this hospital involved six key steps:
- Identify and select the optimization opportunity (in this case, a reduction in C. diff)
- Define benefit areas and establish success metrics and goals
- Perform rapid assessment (less than five days) with findings and recommendations
- Plan and perform baseline measurement; set metrics and targets
- Implement remediation activities
- Provide for continuous improvement with post-go-live metrics and outcomes measures
In the first phase, the owners for this project were identified as the Quality department (CQO), Infection Prevention physicians and nurses, nursing, and finance, which provided data for calculation of the ROI. The benefit areas for optimization were defined as:
- A reduction in hospital-acquired C. diff infections
- A reduction in direct costs associated with infected patients
Success metrics and goals were defined as:
- Direct costs associated with the prevention and treatment of C. diff patients (these did not factor in any value-based payments)
- The number of hospital-acquired C. diff infections per 1,000 patient days
To begin the assessment phase of the project, a team undertook a rapid discovery process that included the review of organizational quality dashboards, meetings with key stakeholders, and the review of current related electronic health record (EHR) nursing documentation workflows and statistics. The team then summarized the findings and presented those to the organization’s leadership. Best practice for this assessment team calls for the inclusion of both a client stakeholder, or stakeholders, and an Advisory and Implementation consultant. This “at-the-hip” model ensured rapid knowledge transfer to the consulting partners and resulted in client ownership throughout the process. This client ownership is critical to the organization hardwiring changes into the Quality department as a model for improvement. Recommendations from the assessment addressed process, policy, and technology changes.
During the fourth phase, the organization begins the planning work along with baseline measurements. Finance becomes an important partner in this phase of selecting metrics and targets. Key data points included:
- The total and direct cost per case, including length of stay (LOS) impact
- Itemized direct cost to remove outlier procedures and treatments (such as dialysis)
- The average LOS for both community and hospital-acquired C. diff patients
- Total numbers of patient days as denominators
- Benchmark data from regional, state, and national averages
Once the metrics are set and baseline data is measured, the remediation activities take place. The involvement of the hospital team, which included Quality, nursing, lab, physicians, and IT, was critical to the ongoing internal ownership for this improvement initiative. As such, knowledge transfer was a constant throughout the process. In this phase, process change and EHR configuration was addressed. Build and future workflows were approved and signed off on and unit and integrated testing occurred. In parallel to the EHR build, a reporting mechanism was selected. Quite often, reporting becomes an afterthought and is delegated to some type of manual or Microsoft Excel or Access-based process. The use of dashboards available through a business intelligence (BI) program allows for drill down to the root cause level, while providing data in near real time. A review of current reporting tools was conducted, with collaboration between IT and the analytics team occurring early in the process. Throughout this process, the team worked with the end users to ensure proper training prior to roll out with a strong focus on linking the new process to improved quality in order to achieve buy-in
Post go-live, two weeks were allowed for post-live stabilization and adoption of the new build. Post-go-live metrics were taken, compared against the pre-set targets and goals, and then necessary modifications were made.
The development of a communication plan for these types of improvement efforts is a key element to success. Preparing the team for the work with targeted messaging that links the project to quality improvement and patient outcomes sets a foundation for acceptance. Providing regular milestones and results of success allow for celebration and support further improvement activities.
Building the Foundation for Quality Improvement and Cost Savings
Over the course of just three months, these targeted interventions combining quality, evidenced-based care, and technology yielded rapid results, including:
- 970 percent (10x) improved documentation within a week after go-live
- Significant direct cost reduction of between 13 and 20 percent in all C. diff patients over the first three-month period
- An approximate cost savings of $260,000 annually and $1.3 million over five years from C. diff prevention and the resulting reduction in LOS due to early detection and intervention of hospital and community-acquired C. diff cases
These powerful results resulted from relatively simple technology-powered changes. When you link these real results to pay-for-performance, risk-based contracting, and bundled payments, the value proposition becomes even stronger.
Other “soft” results included improvements in patient satisfaction, staff satisfaction, and the organization’s external quality scores.
The goals of the Triple Aim, which guides today’s healthcare policy, call for an improvement in the experience of care, improvement in outcomes, and reduction in costs. The interventions described in this white paper show that technology provides a solid foundation and an enabler for the realization of these goals, while also saving lives—a result that cannot be measured in dollars. The link between informatics and quality has never presented a stronger case of the ability to bring healthier outcomes to our hospitals.
CTG is a recognized leader in the planning, design, implementation, and optimization of today’s leading healthcare information technology solutions and business processes.
CTG’s Advisory and Implementation Services combine experienced clinical and technical consultants, deep knowledge of the healthcare industry, and a wide breadth of technical knowledge, including hands-on experience with more than 200 healthcare systems. By tightly integrating strategy, technology, vendor knowledge, and industry best practice, CTG’s offerings help our client’s achieve the foundational governance necessary to support technical and clinical transformation.