NUR 8420 Module 6 Business Case Paper: Infection Prevention, Preventable Fractions and Who Keeps the Savings Example

Who Gets the Savings? A Business Case for Preventing Line and Catheter Infections at a Voorhees Hospital

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8420: Organizational and Systems Leadership II

Mentor Name

Month Day, Year

Who Gets the Savings? A Business Case for Preventing Line and Catheter Infections at a Voorhees Hospital

The Proposal

The hospital in this paper is invented: 340 beds in Voorhees, three adult intensive care units and a payer mix of about 45 percent Medicare, 15 percent Medicaid and 40 percent commercial insurance, most of it paid per admission. Last year the hospital recorded 14 central line-associated bloodstream infections and 31 catheter-associated urinary tract infections. Both rates were above the national benchmark, and the hospital has been in the worst-performing quarter of the Hospital-Acquired Condition Reduction Program, which cut its Medicare payments by 1 percent.

The nursing chief, who completed a DNP in systems leadership, proposes a two-year program: a dedicated vascular access team, daily nurse-led review of every line and catheter with authority to remove those no longer needed, a catheter insertion kit redesign, real-time feedback of infection data to units and two infection prevention nurses. The finance committee has asked whether the program pays for itself.

What Counts as a Business Case

Leatherman et al. (2003) distinguished a business case from a social or economic case. A business case exists when the organization that invests in an improvement receives a financial return within a reasonable time, after discounting. An improvement can be good for patients and for society and still lack a business case for the hospital, if the savings go to payers or if payment rises with complications. The authors found that, under many payment systems of the time, hospitals could lose money by preventing complications because complications generated additional billable care.

That distinction shapes this analysis. The committee needs to know which savings the hospital keeps, not only what the program saves the health system.

The Cost of Infections

Zimlichman et al. (2013) pooled published estimates of the cost of five major hospital-acquired infections in the United States. They estimated a total of about $9.8 billion a year. Counted case by case, a central line bloodstream infection cost the most, about $45,814, followed by ventilator-associated pneumonia, surgical site infections and Clostridioides difficile infection, while catheter-associated urinary tract infections cost about $896 per case. Surgical site infections contributed the largest share of the total because they are common.

How Many Are Preventable

Umscheid et al. (2011) reviewed studies of infection prevention programs and estimated that as many as 65 to 70 percent of central line and catheter-associated infections, and about 55 percent of ventilator-associated pneumonias and surgical site infections, may be preventable with evidence-based practices. They also estimated the deaths and costs that prevention could avoid nationally. The authors noted that their estimates were drawn from studies with varying designs and that results in practice may be lower.

The Calculation

The assumptions are deliberately conservative. Half of current infections are assumed avoidable, below the published estimate, because the hospital's starting practices are already partly in place. The hospital's share of cost avoided is lower than the gross figure because, under payment per admission, avoided complications mostly reduce the hospital's costs, while under fee-for-service commercial contracts part of the savings goes to insurers. The Medicare penalty is the largest single item, and it depends on the hospital's ranking against others, which it does not fully control.

Beyond the Hospital's Ledger

Using the national estimates, avoiding 14 line infections over two years would prevent several deaths and many ICU days. Those benefits appear in the social case, not the business case. A complete proposal presents both. Shorter stays also free beds in an occupied hospital, letting it admit patients who now wait in the emergency department, a capacity gain that the committee values at about $250,000 over two years, enough to change the result to a modest positive return.

Sensitivity

The result depends most on two assumptions. If the program prevents only a third of expected infections, the hospital's share of avoided cost falls to about $267,000 and the net loss before capacity grows to about $250,000. If the hospital does not leave the worst-performing quarter, the penalty line disappears and the program loses well over a million dollars on the hospital's ledger, even though patients still benefit. In the other direction, if commercial contracts move further toward payment per admission, the hospital keeps more of what it saves. Presenting these cases lets the committee see that the decision turns largely on the penalty ranking.

Recommendation

The chief nursing officer recommends approving the program with three conditions: report line and catheter infections, device days and catheter removal rates monthly; review the penalty status each year; and stop or redesign the access team if infection counts have not fallen by a third after 12 months. Finally, she recommends that the hospital open talks on shared savings with its two largest commercial insurers, who gain from avoided infections.

Limits of the Estimate

The catheter infection cost is small for each case, so most of the gross saving comes from line infections, which are fewer and vary more from year to year. Per-case cost estimates are national averages and may not match the hospital's costs. Penalty rules can change, and the hospital's ranking depends on how quickly other hospitals improve. Prevention fractions come from studies of programs that may have been better resourced.

Conclusion

The program is clearly worth doing for patients, and it is close to breaking even for the hospital once the penalty and freed capacity are counted. Leatherman's distinction kept the analysis honest about who saves. A stopping rule and a request for shared savings make the recommendation one the finance committee can approve with open eyes.

References

Leatherman, S., Berwick, D., Iles, D., Lewin, L. S., Davidoff, F., Nolan, T., & Bisognano, M. (2003). The business case for quality: Case studies and an analysis. Health Affairs, 22(2), 17-30. https://doi.org/10.1377/hlthaff.22.2.17

Umscheid, C. A., Mitchell, M. D., Doshi, J. A., Agarwal, R., Williams, K., & Brennan, P. J. (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology, 32(2), 101-114. https://doi.org/10.1086/657912

Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K., Keohane, C., Denham, C. R., & Bates, D. W. (2013). Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine, 173(22), 2039-2046. https://doi.org/10.1001/jamainternmed.2013.9763