DISCUSSION: PATIENT PREFERENCES AND DECISION MAKING

Abstract 

What is the return on investment for the time and resources spent for professional development activities? This is an update of the two articles published in 2016, which reviewed literature and demonstrated how financial analysis of educational activities can drive decision-making. Professional development activities are routinely planned based on needs assessments, implemented with evidence-based learning modalities, and evaluated for effectiveness through linkage to outcomes. The next level of evaluation is consideration of the economic impact of professional development activities. This article includes a review of the most recent studies that provide cost of educational interventions along with a description of economic outcomes and an update to the "Known Costs of Outcomes Table."

As nursing professional development (NPD) practitioners, we are challenged by the question "What is the return on investment (ROI) for professional development activities?" As described in Part I of this series, NPD practitioners are often the first to be called when a problem exists and among the first to have funding restricted when budgets are tight. Program evaluation models, a summary of the literature reporting on ROI for professional development activities, and the "Known Costs of Outcomes Table" were included in this first article ( Opperman, Liebig, Bowling, Johnson, & Harper, 2016a). The second article added "how to" calculate financial impact with scenario examples, including simple cost analysis, benefit-cost ratios, cost-effectiveness analysis, and ROI ( Opperman, Liebig, Bowling, Johnson, & Harper, 2016b). Through examples of various-sized educational programs, it was demonstrated how an NPD practitioner can use these calculations for decision-making.

INTRODUCTION

This article builds on the themes of the prior two articles on ROI. Following these publications, presentations at the Annual ANPD Conventions, and numerous webinars, requests were received for updating the literature search and the tables on the Known Costs of Outcomes Table. These requests led to this article. This article will describe the recent literature including four articles having educational interventions with reported outcomes and financial impact published between 2014 and 2018. Following the literature review, the updated Known Costs of Outcomes Table lists the economic impact of a variety of conditions.

UPDATE OF LITERATURE REVIEW

The original project used the seven steps of evidence base practice described by  Melnyk and Fineout-Overholt (2015). Using the same keywords, the literature was examined for interventional studies that included an educational intervention and calculation of financial impact. Four additional articles were found demonstrating increasing awareness of the need to calculate and publish financial impact of professional development activities (see  Table 1).

Frampton et al. (2014) completed a literature search of studies reporting educational interventions for preventing vascular catheter bloodstream infections, resulting in 74 studies between 2000 and 2012. This 398-page report used a decision-analytic economic model to analyze the cost-effectiveness of educational interventions for preventing catheter bloodstream infections. The model showed diverse types of educational interventions reduce the incidence, increasing survival by 3.55 years and 2.72 QALYs (quality-adjusted life-years).

Kram, DiBartolo, Hinderer, and Jones (2015) implemented the ABCDE bundle for patients in the intensive care unit (ICU) by educational interventions resulting in a decreased average length of stay and decreased mechanical ventilation days. The education included (a) a live presentation on the evidence regarding the ABCDE bundle for all nursing, respiratory therapy, and rehabilitation staff; (b) a nursing-specific class on proper administration of the Intensive Care Delirium Screening Checklist tool; and (c) an online module for all disciplines on the new administrative policy. The authors reported an average savings of $2,156 per patient after a combination of educational interventions. However, information on the cost of the educational intervention was not provided, so further economic impact calculations could not be made.

Young, Borris-Hale, Falconio-West, and Chakravarthy (2015) provided caregiver education by an interactive web-based program on pressure ulcer prevention strategies including how to use new skin care products and an algorithm for treatment of wounds. The RNs received 7.5 hours of education, and the patient care technicians had 5.5 hours. This education, the development of an algorithm and change in skin care products, resulted in a significant reduction in nosocomial pressure ulcers from a mean of 5.9/month to a mean of 0.2/month after the program. By educating the RNs and patient care technicians, significant cost avoidance was achieved in this long-term care setting. Though ROI was not calculated by the authors, enough information was reported to calculate a 381% ROI for their interventions.

Garrison and Beverage (2018) used the process described in  Opperman et al. (2016b) to calculate the ROI for two different programs: Peritoneal Dialysis Quarterly Review (reduce length of stay) and a Colon Clean Closure program (reduced surgical site infection). In 2017, their NPD practitioners challenged themselves to each completed an ROI calculation for at least one project, resulting in a total of 13 calculations. From this effort, they reported an increased awareness of program effectiveness and economic impact of the NPD department activities and a collection of objective data to help with "future project decision-making." Garrison and Beverage listed lessons learned as the need to (a) identify an economic impact leader within NPD; (b) repeatedly revisit the topic with articles, examples, and reminders to keep NPD practitioners engaged; (c) lead by example through completing calculations and sharing them with the team; (d) offer assistance with calculating financial impact with projects; and (e) add measuring economic impact of programs to the planning stage of programs. This NPD department's process to incorporate economic impact into their practice is a challenge to all NPD practitioners. With publication of more financial measures, the value of NPD contributions will become more apparent to decision makers.

Each of these articles contributes to the body of literature demonstrating the value of professional development activities through economic impact evaluations. Through increasing awareness of the financial side of education, the authors pointed out the role education plays, which is beneficial to both patients and healthcare organizations by

* reducing central line-associated bloodstream infections-both infection rates and saving lives;

* decreasing length of stay;

* preventing pressure injuries;

* improving staff confidence in high-risk, low-volume procedures, that is, peritoneal dialysis; and

* decreasing surgical site infections.

As nurses, our focus is on improving the well-being and comfort of our patients, including decreasing patient length of stay, decreasing risk of infections, and preventing pressure ulcers. As NPD practitioners, calculating the financial impact of educational interventions by measuring the outcomes can change the perspective of organizational leaders toward education from one of activities to meaningful accomplishments with great benefit to the organization.

HIGHLIGHTS FROM ARTICLES NOT INCLUDED IN SYNTHESIS

Through review of the literature, five additional articles revealed benefits to the effort to demonstrate the economic value of NPD activities but did not have all the information needed for inclusion in the synthesis.  Spetz, Brown, Aydin, and Donaldson (2013) studied implementing nursing approaches to prevent hospital-acquired pressure ulcers. The authors' conclusion was that surveillance and prevention of hospital-acquired pressure ulcers can be cost-saving and should be considered a strategy by nurse executives as demonstrated by a net savings of $127.51 per patient. This study did not provide information on costs for personnel training, except in the fixed costs, so it was excluded from synthesis.

Curado and Teixeira (2014) used the Kirkpatrick levels model to evaluate training programs in a small logistics company. The authors estimated the fifth level of the model-ROI by reviewing (a) performance reports, (b) attained objectives, (c) service and productivity levels, (d) quality audits, and (e) accounting data. The training programs addressing work quality and conditions had above average returns, and the program on corporate social responsibility produced below average results. Barriers to successful ROI estimation were reported as lack of qualification to calculate personnel time and financial resources consumed. Curado and Teixeira discussed the long-term challenge of human resource managers to pragmatically obtain accurate data to calculate learning benefits as stymied until  Phillips and Phillips (2009) and  Noe (2010)added ROI to the fifth level of Kirkpatrick's model.

Herzer, Niessen, Constenla, Ward, and Pronovost (2014) listed the cost of education as $3,579 of total program ($192,292) on central line-associated bloodstream infections prevention. The total initiative was a multifaceted quality improvement program in ICUs reporting employee education as only a small part of efforts. The basis of the initiative was to examine the cost-effectiveness of the Keystone ICU project ( Waters et al., 2011) using hospital data and nationally representative data sources. We excluded this study because the NPD economic impact was difficult to sort out from the impact of the other interventions. The estimate of costs for education of clinicians was very low, creating questions about how it was calculated.

Quinn et al. (2014) reported a cost avoidance of $1.6 million from nonventilator hospital-acquired pneumonia as a result of implementing oral nursing care. However, the cost and methods of educating the nurses was not described in the article; therefore, it was not included in the synthesis.

Finally,  Simmons et al. (2017) studied training nonnursing staff to provide caloric supplementation for nutritionally at-risk nursing home residents. These authors concluded that it is cost-effective to train nonnurses to provide caloric supplementation, and the practice had a positive effect on the residents' intake. This was excluded from our synthesis because the method of calculating the costs of training was unclear and the participants were largely nonprofessionals, adding questions regarding correlation to NPD.

KNOWN COSTS OF OUTCOMES TABLE

The original Known Costs of Outcomes Table published in 2016 ( Opperman et al., 2016b) made it easier for NPD practitioners to identify the financial value of improved outcomes and calculate economic impact. In particular, benefit-cost ratios and ROI percentages require a monetary balancing measure to the expenses of the interventions. A search was conducted for published costs associated with a wide variety of conditions. This update of the Known Costs of Outcomes Table (see  Table 2) includes (a) most recent costs reported since 2010, (b) a revised format organizing the conditions with similar topics, (c) an increased number of conditions, and (d) an alphabetized order for ease of locating the correct table.

IMPLICATIONS FOR NPD

A consistent method was not found in the literature to describe the financial and clinical impact of professional development activities. The original articles demonstrate how to calculate cost analysis, benefit-cost ratio, cost-effectiveness analysis, and ROI with educational interventions. Within this article, updated literature shows greater reporting in publications, but disseminating more economic impact of educational interventions will contribute to the body of evidence regarding the value of professional development activities. NPD practitioners routinely measure the impact of education interventions but seldom addressed the financial impact. More consistent measuring and reporting of the financial and clinical impact of NPD activities is warranted.

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