Cost of hospital-wide activities to improve patient safety and infection control: A multi-centre study in Japan

Abstract

Objective

The aim of this study was to assess the financial costs to hospitals for the implementation of hospital-wide patient safety and infection control programs.

Methods

We conducted questionnaire surveys and structured interviews in seven acute-care teaching hospitals with an established reputation for their efforts towards improving patient safety. We defined the scope of patient safety activities by use of an incremental activity measure between 1999 and 2004. Hospital-wide incremental manpower, material, and financial resources to implement patient safety programs were measured.

Results

The total incremental activities were 19,414–78,540 person-hours per year. The estimated incremental costs of activities for patient safety and infection control were calculated as US$ 1.100–2.335 million per year, equivalent to the employment of 17–40 full-time healthcare staff. The ratio of estimated costs to total medical revenue ranged from 0.55% to 2.57%. Smaller hospitals tend to shoulder a higher burden compared to larger hospitals.

Conclusions

Our study provides a framework for measuring hospital-wide activities for patient safety. Study findings suggest that the total amount of resources is so great that cost-effective and evidence-based health policy is needed to assure the sustainability of hospital safety programs.

Introduction

Adverse events including hospital-acquired infections enact heavy disease tolls on patients and place large financial burdens on healthcare institutions. According to the Institute of Medicine [1], preventable adverse events in the United States (US) cause 44,000–98,000 deaths annually and represent a cost of US$ 17–29 billion. In the United Kingdom (UK), between 0.3 and 1.4 million patients in the National Health Service hospital sectors are affected by adverse events each year, resulting in £2 billion in inpatient costs. The costs attributable to hospital-acquired infections were estimated at nearly £1 billion a year, which was regarded as preventable in about 15% of cases [2].

Over the past 10 years, the Japanese government has taken measures against adverse events in healthcare institutions. The first measures were conducted in 1996 for the prevention and control of hospital-acquired infection [3]. These measures included new medical regulations requiring hospitals to implement several infection control policies, including establishing infection control committees, reporting comprehensive infection data, and developing hand hygiene activities. By implementing these programs, hospitals received additional payments of US$ 0.43 (JPN¥ 50) per patient-day as an incentive. Later, in 2000, following growing concerns for patient safety, the reimbursement system was changed to a punitive approach whereby hospitals failing to implement these programs were charged a decreased hospital reimbursement US$ 0.43 (JPN¥ 50) per patient-day [4].

After a devastating medical error at a university hospital in 1999, concerns over patient safety in Japan further increased. The government responded by issuing a new series of patient safety regulations for healthcare institutions. These measures were enacted in 2000, requiring all university hospitals and two large medical centres to (1) establish institutional guidelines for patient safety, (2) develop reporting systems of adverse events, (3) organize patient safety committees, and (4) provide continuous staff education and training about patient safety [5]. In 2002 these measures were extended to all hospitals in Japan [6]. Additionally, the government took a punitive approach in providing a decreased hospital reimbursement of US$ 0.85 (JPN¥ 100) per patient-day for those hospitals that did not implement these programs [7].

In 2006, regulations for infection control and for patient safety did not reflect national fee schedules. Instead, as long as hospitals employed full-time staff who had professional training for patient safety, hospitals could receive additional payment of about US$ 4.26 (JPN¥ 500) per patient [8]. In contrast, in the US, the Centres for Medicare and Medicaid Services will stop reimbursing hospitals for clearly preventable adverse events from 2008 [9].

Contrary to the policies encouraging hospitals to implement these programs for patient safety, there are few financial incentives in Japan's payment system to invest in such programs. Under the existing fee-for-service reimbursement system or new per-diem payment system, even the costs incurred by treatment of complications resulting in additional length of stay are compensated by the payment systems. In such systems, there is a conflict of interest between society and hospitals; decreases in healthcare resources benefit society and patients, but increases in resources are financially beneficial for hospitals. Moreover, increasing pressure to contain the growth of healthcare expenditures has made safety program implementation extremely difficult, since there are limited resources, and the challenge of balancing the hospital budget is great. If studies demonstrate that safety programs can improve patient outcomes, the information could be used to support the financial worth of patient safety activities. However, patient safety is difficult to measure and there is a limited number of validated measures to use [10], [11], [12]. Therefore, the formulation or use of such outcomes remains highly unlikely.

Despite these formidable barriers, the healthcare system should be well poised to increase the pace of improving patient safety. The first step is to assess the costs of activities related to patient safety. Detailed cost information is valuable for the following reasons. First, cost information can help hospital administrators make decisions that contribute to the front-line practitioners who work to promote patient safety. Cost analysis is an essential tool for visualizing actual activity conditions in a quantitative context. Second, cost information can help in the budgeting of safety improvement activities [13]. The sustainability of hospital safety programs is a potential threat to the medical delivery system due to constrained finances and limited staff time to implement safety-related activities. A potential way to deal with this problem is clear budgeting, for which cost information is imperative. Finally, from a societal perspective, cost information can provide a guide for how to supply health services at a patient safety level that the community agrees to. The main driving force for patient safety regulations has been an increased demand from the community. Although the community has good reasons to ensure their own safety in hospitals, the underlying and inevitable increase in associated costs has received little attention in the claim. However, in order for patient safety levels to increase, the community must also be prepared to bear an equitable share of these costs. Successive improvements in safety are generally associated with progressively higher costs for each increment of improvements gained [14]. Without knowing the actual costs of safety programs, it can be impossible to decide what measure is feasible within a constrained financial environment. At present, however, past estimates of the costs associated with programs for patient safety have had serious limitations; they have either mainly focused only on single programs for infection control such as education [15] and surveillance [16], or targeted material interventions [17]. Therefore there is scant data regarding the resources necessary to implement hospital-wide activities involving patient safety and infection control. To address this lack of data, this study aimed to perform a multi-centre cost analysis to assess the amount of financial resources that Japanese hospitals invest for patient safety activities. The main outcome measures were the volume and the monetary value of activities for patient safety and hospital infection control.