No longer business as usual: ICPs must prove cost-effective to survive
Ask yourself: Does the institution value the ICP role or merely tolerate it?’
Wresting order out of chaos, infection control professionals must create cost-effective prevention programs across the continuum if they are to remain key players in the market-driven health care delivery system of the 21st century, keynote speaker Julie Gerberding, MD, MPH, told some 3,000 ICPs in Baltimore recently at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
"We are really operating in the era of market power, where our entire health care delivery system is being driven and framed by the economic forces that face business communities in the rest of corporate America," said Gerberding, director of the hospital infections program at the Centers for Disease Control and Prevention. ". . . It is no longer sufficient to do what we do because we know it’s the right thing. We must do what we do because it is cost-effective. The bottom line is what is driving decisions."
ICPs may find their current programs undermined by conflicting business and medical imperatives that result in a dizzying rate of change that closely resembles chaos — "a dynamic state on the boundary between anarchy and order," Gerberding noted. The converging trends include health care systems merging and consolidating, personnel shifts and cutbacks, declining hospital stays, infection control resources stretched thinner across an expanding continuum, and patients with rising acuity exposed to pathogens increasingly resistant to antibiotics, she noted.
"Our highly competitive, market-driven system really is plagued with a diminishing infection control prevention capacity," Gerberding said. "We are not seeing an expansion of the number of infection control professionals in the delivery system; we are seeing a redistribution of those professionals. More people are being asked to do more with less resources across a larger number of venues. We are being dispersed and our resources are being spread thinner and thinner. At the same time that our staffs are being dispersed, our sick patients are being dispersed so that the acuity of individuals with health problems is being distributed over a much wider variety of health care settings. . . . In other words, the entire health care delivery system in which we operate is a system of chaos."
Gerberding accented themes of change and challenge that were echoed by other APIC speakers throughout the conference, as the future role of ICPs in a rapidly changing health care system was subjected to a series of frank but cautiously optimistic assessments. For example, chaos theory ascribes a kind of underlying order and even a certain beauty to states of flux, Gerberding reminded APIC attendees. She also noted that despite the swirl of change, ICPs’ jobs distill down to a few constants.
"Our first priority is really to enhance our capacity to prevent infections among patients and health care workers across the entire spectrum of the health care delivery system," she said. "When we’re talking about infection prevention in health care settings, when you get right down to it, there really are only four things that we can do. We can try to prevent the primary infection in the first place. We can try to treat infections when they do occur and eradicate the pathogen as quickly as possible. We can do everything possible to minimize antimicrobial selection pressure so that the pathogens that we do encounter will at least be susceptible to the drugs that we are using. And, last but not least, we must prevent cross-transmission from person to person once an infection has occurred."
All the while, these goals must now be accomplished in a cost-effective manner that can be described to health care business leaders in their own language, she noted. In that regard, the CDC hospital infections program is undertaking a research initiative on the cost-effectiveness of infection control and prevention that may include contracts and grants to stimulate investigations.
"We need your help," Gerberding appealed to APIC attendees. "We need your ideas and experience in doing cost-effective analysis so that we can pull this together into a package and say, Look, here it is: Infection control is cost-effective.’"
Some job justification successes
Indeed, many ICPs are already emphasizing cost-effectiveness, as several APIC studies and presentations underscored the importance of compiling and reporting financial data to bolster program profiles and enhance job security. (See related story, p. 102.) Denise Murphy, RN, MPH, CIC, director of infection control at BJC Health System in St. Louis, described a program particularly in tune with many of the themes raised by Gerberding. BJC is a system of 13 acute care and six long-term care facilities in Missouri and Illinois. As BJC merged at the corporate level during the last few years, Murphy and the ICPs at the other BJC facilities formed an infection control consortium to emphasize cost savings in infection prevention.
"I don’t mean to belittle the impact that it has on our patients physically and psychologically when they develop nosocomial infections, but unfortunately, for our programs to survive, we really need to know what the bottom line is and be able to express that to our health care administrators," Murphy told APIC attendees. "If your hospital is in bad financial shape, one way that infection control can survive is to point out many of the cost-saving projects that you are involved in. If you are not involved in any of them, it might be important to get involved in some of them."
As the ICPs at BJC began sharing data and working together, it became clear that they could collectively underscore the economic importance of infection control and prevention across their health care system. "We sat down with each hospital president and talked about what infections were costing across the system," she said, noting that for 1997, some $4.6 million in excess costs were caused by infections that included bloodstream infections, surgical site infections related to coronary artery bypass grafts, and surgical site infections following knee and hip replacements.
"They were very interested in that figure, and I really do believe that providing them with financial impact data — especially when the infection control programs cost so little — was very important," Murphy said.
The consortium has since developed sharply focused surveillance and cost-saving interventions that have resulted in more than $1 million saved and a considerable increase in infection control staff and resources at the participating facilities, she said.
Such cost-saving efforts do not necessarily require state-of-the-art computer support, she emphasized. "Whether it is drawing an epi-curve for an outbreak investigation, plotting your improvement in vaccination rates, or improvements in bloodstream infection rates, you can do this with a piece of graph paper and a pencil," she said. "What is important is that you are doing it and getting that information out to the right people. [Use] your data to impact change."
ICPs in hospitals that are part of mergers should consider such consortium efforts, but even independent practitioners can band together as part of their local APIC chapters, she added. "This is just about team-building and teamwork," Murphy said. "I can’t stress enough the importance of expanding your infection control team to include other members of the health care team — like people from surgery, ICU, pharmacy and the lab — that are really experts in their area."
Indeed, ICPs have traditionally operated with a sense of autonomy that needs to be cast aside to some degree to get "out of the box" and find new opportunities in a changing system, added another APIC speaker, Marguerite Jackson, RN, PhD, CIC, FAAN, administrative director of the clinical epidemiology unit at the University of California in San Diego.
"Staying in the box permitted us to be experts in a narrow area, and it was comfortable," she told APIC attendees. "[Today] there is much more scrutiny, much more accountability, because the circumstances have changed so dramatically that there is very little extra time to do things that are not directly related to the mission, the vision, and the bottom line."
Noting that the only constant appears to be change, Jackson emphasized that ICPs must assess their own role and management perceptions within their facility. "Does the organization value the ICP role or merely tolerate it? Ask yourself that question," she said. "Is the ICP’s expert knowledge used widely, or held tightly and let out of the box only when a question is asked? When the money gets tight, who gets laid off?"
Make yourself indispensable
ICPs who make themselves indispensable to the facility’s mission will survive, while those who pursue personal autonomy at the expense of institutional goals may not enjoy "long-term survival," Jackson noted. And ICPs need not think merely in terms of survival, as their diverse epidemiologic backgrounds also lend them to leadership and executive roles, added Trisha Barrett, BSN, CIC, MBA, director of infection control and sterile processing at Alta Bates Medical Center in Berkeley.
Having received her master’s degree in business administration in 1998, Barrett offered some recent insights from the business world. ICPs today are in a good position to have a valuable operational overview of their work sites, she noted. The very nature of the profession demands observational, analytical, and communication skills. Those factors, combined with oversight and responsibility for regulatory issues, give ICPs a strong background for health care leadership, she noted. In that regard, ICPs should look for opportunities to expand their authority, capitalizing on management needs in related areas like central supply and sterilization, intravenous services, and inpatient testing. Concerning the current turmoil in health care, Barrett reminded that ICPs typically have always had a high "tolerance for ambiguity" in order to work in a field seemingly beset by change since its inception.
"I don’t think there is anything new about the change issues, and those of us who like this job and succeed in the job are good at managing change," Barrett says. "That is a good springboard skill."
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