Leading the Way

Does evidence-based nursing increase ROI?

Catholic Health Initiatives (CHI) is committed to improving the patient and family experience through evidence-based practices (EBP) and other effective improvement strategies. Based in Englewood, Colorado, CHI is the third largest not-for-profit healthcare system in the United States, with more than 70 hospitals and 30,000 nurses.

Our EBP program aims to bring evidence-based care to the patient using systemwide standards of care, toolkits, education, organizational-level engagement, and metrics for determining clinical and fiscal impact. The program includes four clinical metrics and one financial metric for cost-of-care avoidance related to reducing preventable adverse events for which the Centers for Medicare & Medicaid Services no longer reimburses healthcare costs.

This article describes CHI’s cost-of-care metric for five healthcare-acquired conditions (HACs)—catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus infections, Clostridium difficile infections, surgical “never” events, and patient falls. Our metric calculates cost savings when an HAC is avoided. Developed and successfully implemented within 18 months, this initiative serves as an organizational- and system-level vehicle for evaluating costs avoided by implementing specific care bun­dles for HAC prevention.

To help prevent surgical “never” events, CHI implemented the World Health Organization’s surgical checklist and recommended practices of the Association of periOperative Registered Nurses to reduce complications and death rates in patients undergoing surgery across a diverse group of hospitals. CHI also implemented a care bundle to prevent healthcare-associated infections, based on established guidelines from national sources, such as the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Cost avoidance plus cost savings

The Institute for Healthcare Improvement uses the term “dark green dollars” when quality-improvement initiatives yield cost savings that can be tracked to the bottom line through both cost avoidance and cost savings. At CHI, the average cost of each incident type was established during the planning phase of our initiative through an extensive review of empirical literature on cost averages associated with each HAC. This allowed us to establish a benchmark cost to gauge the return on investment (ROI) realized through cost avoidance. (See Costs for each healthcare-acquired condition by clicking the PDF icon above.)

Advancing understanding of data

Our cost-of-care calculator tool allows local and system-level users to understand the contributions of nurses and other caregivers to EBP, specific to care bundles and estimated cost avoidance when these bundles are used. Data transparency advances clinicians’ understanding of nurse-sensitive measures linked to ROI methodology and accountability.


Created with Excel Workbook, our cost-of-care metric was designed to measure organizational- and system-level estimated cost-avoidance costs by volume-of-event occurrences during baseline and measurement periods. In the metric, the volume of baseline-period event occurrences is multiplied by the estimated cost associated with one event occurrence, followed by subtraction of data for the measurement period.

HAC occurrences are reported quarterly using agreed-on formulas. The general formula for calculating cost-avoidance costs incorporates the numerator divided by the denominator, along with rate definitions and calculations for specific outcome metrics. (For detailed formulas used with each care bundle, see Formulas for calculating event occurrences.) At CHI, total system findings between the baseline and measurement periods for each of five care bundles implemented showed a 30% decrease in HACs, yielding an overall estimated cost avoidance of more than $8 million aggregated for fiscal year 2010.

CHI’s cost-of-care metric supports a culture of safety and nursing’s contribution to creating healthcare value. It focuses on the role of event prevention in improving patient outcomes during hospitalization, and links prevention with fiscal metrics in determining estimated cost avoidance. A synopsis of clinical outcome improvement and estimated cost avoidance provides compelling evidence that connects EBP to financial metrics.

Selected references

Aleccia J. Who foots the bill for medical mistakes? MSNBC; February 28, 2008. http://www.nbcnews.com/id/23341360/ns/health-health_care/t/patients-still-stuck-bill-medical-errors/. Accessed November 14, 2011.

Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care. 1999 Jan-Feb;12(1):22-30.

Anderson DJ, Kirkland KB, Kaye KS, et al. Underresourced hospital infection control and prevention programs: penny wise, pound foolish? Infect Control Hosp Epidemiol. 2007 Jul;28:767-73.

Association of PeriOperative Registered Nurses. Perioperative Standards, Recommended Practices and Guidelines 2010. Denver, CO: Author; 2010.

Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med. 1995 Aug; 99(2):137-43.

Centers for Disease Control and Prevention. Central line insertion practices (CLIP) adherence monitoring. June 2011. http://www.cdc.gov/nhsn/PDFs/pscManual/5psc_CLIPcurrent.pdf. Accessed November 22, 2011.

Dubberke ER, Reske KA, Olsen MA, et al. Short- and long-term attributable costs of Clostridium difficile–associated disease in nonsurgical patients. Clin Infect Dis. 2008 Feb 15;46:497-504.

Elixhauser A, Steiner C. Infections with methicillin-resistant Staphylococcus aureus (MRSA) in U.S. hospitals, 1993-2005. HCUP Statistical Brief #35. July 2007. Agency for Healthcare Research and Quality.

5 Million Lives Campaign. Getting started kit: Prevent central line infections; How-to guide. Institute for Healthcare Improvement. Last updated October 1, 2008. www.ihi.org/knowledge/Pages/Tools/howtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx. Accessed November 22, 2011.

5 Million Lives Campaign. Getting started kit: Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection; How-to guide. Institute for Healthcare Improvement. Last updated December 17, 2008. www.ihi.org/knowledge/Pages/Tools/HowtoGuideReduceMRSAInfection.aspx. Accessed November 22, 2011.

Haynes AB, Weiser TG, Lipsitz S, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Eng J Med. 2009;Jan 20:491-9. doi:10.1056/NEJMsa0810119.

National Quality Forum (NQF). Safe Practices for Better Healthcare–2009 Update: A Consensus Report. Washington, DC: NQF; 2009:279-83.

Schifalacqua MM, Mamula J, Mason AR. Return on investment imperative: the cost of care calculator for an evidence-based practice program. Nurs Adm Q. 2011 Jan-Mar;35(1):15-20. doi:10.1097/NAQ.0b013e318203227a.

Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Publication No. CS200891-A; March 2009. Centers for Disease Control and Prevention.

Marita MacKinnon Schifalacqua is a principal with M. Schifalacqua Consulting in Henderson, Nevada and a former vice president of evidence-based practice and clinical technology at Catholic Health Initiatives (CHI) in Englewood, Colorado. Sr. Maurita Soukup is a Health Trustee for Mercy Hospital in Sioux City, Iowa and Mercy Medical Center in Cedar Rapids, Iowa; she is also a nurse consultant/researcher in the areas of critical care and evidence-based practice. Wanda Kelley and Alison Rich Mason are clinical process specialists in evidence-based practice at CHI.

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