the business case for infection prevention and control: educating yourself and your exe c utives

The Business Case for The Business Case for Infection Prevention and Infection Prevention and

Control: Control: Educating Yourself and Your Educating Yourself and Your

ExeExeccutivesutivesDenise Murphy, RN, BSN, MPH, CICVice President, Quality and Patient

Safety Main Line Health System

Philadelphia, PA

• What is the business case…from everyone’s perspective and how to share it with decision-making leaders – Clinical impact: morbidity and mortality– Cost of infections… the total cost

• How to get the investment if it isn’t already there– Use of hard data, influence and persuasion– In negotiations…timing is almost everything!

• How to use the investment and demonstrate returns so you can keep it

VS.Cost Benefit

About the Business About the Business Case (Objectives)Case (Objectives)

TOTAL = 1.7 million HAI• 1.3 million adults & children

outside of ICU• 418,000 adults and children in ICU• 33K newborns in high-risk nurseries• 19K newborns in well-baby nurseries• 9.3 HAI/1,000 pt. days• 4.5HAI/100 admissions Excess LOS: 7.5 million daysExcess charges: >$6.5 billion

*Nicolas Graves. Economics of Preventing HAIs; **Klevens, Edwards, Richards et al.*Nicolas Graves. Economics of Preventing HAIs; **Klevens, Edwards, Richards et al. Pub Health Report. Pub Health Report. 2007 2007

The U.S. Burden of The U.S. Burden of HAIHAI

Death from HAI (U.S. Death from HAI (U.S. 2002)2002)

0

N = 98,987

36K

31K

13K

8K11K

Num

ber

Dea

ths

in

Tho

usan

ds

5

10

15

20

25

30

35

40

Pneumonia

BSI

UTI

SSI

Other HAI

Source: Public Health Report/March-April 2007/Volume 122

The Most Important Bottom Line!

Attributable CostsAttributable Costs

Type HAI Attributable Costs

Mean (SD)

Range

Surgical Site $25,546 (39,875) $1783 – 134,602

Bloodstream $36,441 (37,078) $1822 – 107,156

Vent. Associated Pneumonia

$9669 (2920) $7904 – 12,034

Urinary Tract (UTI) $1006 (503) $650 - 1361

70 studies: 39 US, 17 Europe, 4 Australia/New Zealand, 10 other. Analysis includes only those studies that calculated individual (vs. aggregate) cost of patient outcomes.

SOURCE: Stone et al. AJIC Nov 2005; 33:501-509

HAI Cost Analysis January 2001 – June 2004

SOURCE: Eli N. Perencevich, MD, MS; Patricia W. Stone, PhD, MPH, RN; SOURCE: Eli N. Perencevich, MD, MS; Patricia W. Stone, PhD, MPH, RN; Sharon B. Wright, MD, MPH et al. Sharon B. Wright, MD, MPH et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2007;28:1121-1133 2007;28:1121-1133

Author: R. Douglas Scott II, Economist, CDC, DHQP March 2009Author: R. Douglas Scott II, Economist, CDC, DHQP March 2009

Economic ComparisonEconomic Comparison

N = 20 Patient

Admit diagnosis Respiratory failure Respiratory failure

Age 71 75

Payer Medicare + commercial Medicare + commercial

Revenue $ 20,792 20,417

Expense $ 19,501 37,075

Gross margin $ +1,291 -16,658

Costs attributable to BSI 13,696

LOS (days) 10 15

Source: Shannon et al. Source: Shannon et al. Amer J Med QualityAmer J Med Quality Nov/Dec 2006; pgs 7S-16S Nov/Dec 2006; pgs 7S-16S

Without CLABSI With CLABSI

Volumes and Patient Flow Volumes and Patient Flow = $$$= $$$

• Patients without HAI are discharged sooner• New patients move into those beds• Assuming fixed costs stay the same (building,

utilities, etc.), available “bed-days” increase volumes and revenue, reimbursement.

• Example: Table 1. shows CABG SSI mean excess LOS = 26 days. *Preventing 10 CABG SSI would open up 260 “bed-days”. If average LOS without complication is 4 days, then 65 new patients could be admitted.

*Modified from: Perencevich, Stone, Wright*Modified from: Perencevich, Stone, Wright

Estimation Estimation MethodsMethods

• Compare costs for patients with infections to patients without infections (matched comparison; like case-control study)

• Problem: are the patients who get infection just like those who do not?

AgeGenderDiabetesSmokingWeight

C.S. Hollenbeak, 2006

Where Can You Start?Where Can You Start?– Select type of infection to estimate; SSI easiest– Use accounting dept to obtain individual costs and

LOS for patients undergoing specific surgical procedure

– List patients who developed SSI. – Use accounting to calculate additional costs:

readmission, return to OR, ICU stay, antibiotics, etc.– Compare cost of patients without SSI to patients

with SSI who had procedure during same time period

– Compare length of hospital stay, including readmission for SSI, for those with infection

Societal Costs of HAISocietal Costs of HAI

Direct cost savings: – No routine ventilator circuit changes– $1M savings across BJC

(equipment/supplies)

Indirect cost savings– Increase in Respiratory Therapist

productivity due to fewer vent circuit changes (focus on reducing VAP)

– 25% increase in flu vaccine (lower RN absenteeism/ agency costs)

Applying Economics….Applying Economics….to IPC Practiceto IPC Practice

Cost (or revenue loss) avoidanceOutbreak of SSI: difference in observed vs. expected SSI rates/excess cost & LOS ($37K & 18 d.)*– Reduced excess cost and LOS (reimbursement

lower after 3-5 days of re-admission for SSI)– Reduce adverse outcomes on CMS list of

“healthcare acquired conditions” that will no longer receive associated excess reimbursement (e.g., CR-BSI; Mediastinitis, Total Joint Replacement; Bariatric SSI; UTI)

Comparison of Endemic vs. Epidemic SSI Rates

BJC Operating unit: Hospital APeriod of increased SSI 6/98 - 12/98Surgical procedure Gastric BypassNumber of procedures performed in 1998 70Reported “benchmark” SSI rate/100 procedures 2.7-5.1Operating unit endemic rate/100 procedures 2.86% (2 SSI / 70 procedures)Operating unit epidemic rate/100 procedures 22.6% (7 SSI / 31 procedures)Average LOS for uninfected vs. infected 4 days vs. 22 daysMean excess LOS per SSI 18 daysAverage cost for uninfected vs. infected $7,816 vs. $44,963Mean excess cost per SSI $37,147Rate reduced to baseline/ benchmark (date) 3.0% (4/99 through 4/2000)Projected # procedures 2000 70 casesExpected # SSI based on endemic (3.0) rate 2 SSIExpected # SSI based on epidemic (22.6%) rate 16 SSI

# SSI avoided (based on *reduced rate) 14 SSI annually

*Estimated cost avoidance 1999 - 2000 $520,058 ($37,147 x 14)*Estimated cost avoidance is based on the #SSI avoided annually when rates remain at baseline (endemic) compared to epidemic rates.

SAMPLE REPORT

Lost opportunity costs– Fewer CABG SSI resulted in fewer I&D cases in

OR; – Opportunity for more 1st time CABG surgery cases

brought higher reimbursement

Intangible costs– Lessen risk for negative PR (impact on referrals)– Impact on societal trust– Changes in insurance premiums due to high HAI

costs– Impact on status with accreditation and regulatory

agencies

Attributable Cost– Much better estimate of cost attributable to

infection– Use economic modeling to tease out in-pt. cost of

other co-morbidities* diabetes costs include glucose monitoring, insulin CHF costs include Rx with ACE/ARB/beta blocker

– Much easier to do with surgical patients: readmission/ re-operation purely due acquisition of SSI

– Found attributable cost of CABG SSI ~$20K in our study; ($35K deep chest; 15K non-deep SSIs)*

*Source: Hollenbeak CS, Murphy DM, Dunagan WC, Fraser VJ. Chest 2000; 118:397-402.

Personal/Individual Personal/Individual CostsCosts

• Physical pain and discomfort• Mental and financial stress• Increased length of stay in hospital• Prolonged or permanent disability• Disruption to patient and family• Time lost from work for patient

and caregivers • Death

Communicating Communicating Financial ImpactFinancial Impact

– Display cost and LOS data graphically– Approach Clinical Leadership and Senior

Executives to demonstrate financial impact of HAI (avoidable cost, opportunity cost, revenue enhancement)

– Use *literature to show cost-benefit of Infection Prevention – impact of interventions to reduce HAI

– Demonstrate your value!– You then argue for a larger investment in IPC…

*Raising Standards While Watching the Bottom Line: Making a Business Case For Infection Control .

Eli N. Perencevich, MD, MS; Patricia W. Stone, PhD, MPH, RN; Sharon B. Wright, MD, MPH;

Yehuda Carmeli, MD, MPH; David Fishman, MD, MPH; Sarah Cosgrove, MD, MS.

Infect Control Hosp Epidemiol 2007; 28:1121-1133

Getting local information is Getting local information is

powerful powerful but complicated.but complicated.

Pick something, be able to Pick something, be able to explain it, explain it,

then stick to it!then stick to it!

Consider Using the Consider Using the Literature Literature

and Adjusting Dollarsand Adjusting Dollars Healthcare inflation rate has been about 4 -4.5%

annually, so 1985$ ~ adjusting up to 2009$ means multiplying EACH YEAR between 1985-2009 by annual inflation rate.

This is a very crude adjustment. Medical care services increased 5.2% in 2007,

2.6% in 2008 and 3.4% in 2009 A BSI that cost $38,336 in 2007 (36,441 x 1.052

or 5.2%) will cost $39,337. in 2008 (38,336 x 1.026 or 2.6%) and $40,674 in 2009 (39,337 x 1.034 or 3.4%)

Or use the CPI “cost calculator! http://www.bls.gov/data/inflation_calculator.htmhttp://www.bls.gov/data/inflation_calculator.htm

Source: D. Murphy, 2006 revised 2011

How about a 5% inflation rate for the sake How about a 5% inflation rate for the sake of adjusting costs in literature?of adjusting costs in literature?

After You’ve Made the After You’ve Made the Business Case…Business Case…

Learned organizational priorities – aligned with them Created the IPC mission, vision, goals and objectives Obtained resources to support effective program Tracking on goals, reducing HAI rates...what next?

“The more you know about executive leadership, the more executive leadership knows about you.”

Wharton School of Business; University of PA

Demonstrate Functional ValueDemonstrate Functional Value

• Eliminating waste/improving productivity through

Wise product selectionAppropriate application of expensive technologySensible policies & proceduresProtection of employees from injury

• Maintaining regulatory compliance• Creating effective collaboration between clinicians and administration• Creating a safer environment for patients and staff, increasing satisfaction; maintain reputation for service

Demonstrate Strategic ValueDemonstrate Strategic Value

Supporting organization’s strategic plan

To grow volumes:To grow volumes: Empty out ICU beds more quickly by reducing

To grow services:To grow services:Show how interventions to reduce HAI rates on specific services can be utilized to plan and design new programs and servicesGastric bypass surgery new for your organization? Use literature and experience of others to build in risk reduction strategies.

To hit target on 100% of quality To hit target on 100% of quality scorecards!scorecards!

Same skills used for outbreak investigation can help PI teams get to root causes of poor performance.

Planning - Planning - StrategiesStrategies

Lay out three year plan with someone who knows how Tactics to meet goals – refine them each year

Focus on the critical few firstFocus on the critical few first Needs assessment –

do one every year; even a *SWOT Analysisuse to create long and short term goalssetting direction based on assessment new goals and priorities

*S*Strengths, WWeaknesses, OOpportunities, TThreats

Planning - Planning - StrategiesStrategies

Evidence-based medicine: as it changes, your interventions must follow: Need system for keeping up, environmental scans, literature search, journal clubs.

Performance Measurement and Improvement basics

Tools, methods, SMART goals and meaningful metrics - with accurate data analysis and reportingTrained facilitators and leadersExecutive and physician championsOutbriefs to educate, engage and gain leadership commitment

Budget / Financial ManagementBudget / Financial Management

Budgeting – take and keep some control Resources vs. what program can/cannot do…just say NO! Role of technology: cost / benefit analysis, use literature, experience of others Executive incentives / Scorecard and dashboards:

exert influence on senior leadership to include HAIs

Board education about HAIs and impact of interventions will help sustain financial support from management

The Business PlanThe Business Plan

Not One and Done, continue demonstrating value and:

Use data to show current state; Highlight successes and ROI Outline short and long term needs Propose IPC expansion aligned with resources Request professional development opportunities Propose technology solutions that have been proven Access to clinical/administrative decision-makers

Action Plans and Action Plans and TacticsTactics

to Drive the Actionto Drive the Action Specific actions to fix broken processes and systems Specific actions to address staff behavior/compliance Responsible parties to drive each tactic or step Timelines Required resources to complete actions Briefings to senior leaders Make performance transparent: briefings/scorecards Watch for barriers in each step of implementation

If Everyone is If Everyone is Responsible…Responsible…

Action Item Who is Responsible

By When

Post screen saver C. Hampton 4/24/08

Communication plan(Publications, Meetings)

J. Gagliardi Upon completion of final

RIE

Place line removal training module on Pathlore (intranet)

V. FerrisA. Dixon

05/16/08

Central line removal pictures

M. SchultzV. Ferris

4/24/08

Sustaining the Sustaining the GainsGains

Accountability through monitoringResponsible parties reporting to key leadersClear expectations and follow upWhat’s in it for those who must change/sustainPerformance management – discuss how to keep people compliant: part of their performance expectations…they are evaluated on patient safety and IPC!

HUMAN FACTORS and impact on compliance!

Demonstrating The Value of Demonstrating The Value of Infection Prevention and Infection Prevention and

ControlControl

Know the Cost of Know the Cost of EffectiveEffective Infection Prevention and Infection Prevention and

ControlControlAnnual Cost(s)

Personnel 0.5 Physician 70,000 1 Nurse 30,000 1 Secretary 15,000

0.5 Computer Programmer 15,000Supplies, fax. Etc. 20,000Fringe benefits and overhead 50,000

Total $200,000*

Wentzel. J Hosp Inf 1995; 31: 79-87; *1992$

*Add computer & adjust for inflation, this cost would be >$315,000 in 2011

:(

Remember, this is 1992 $$

Plan for the Resources You Need!Plan for the Resources You Need!Sample IPC Program BudgetSample IPC Program Budget

Staff = 2 IPs; 1 Secretary; 1 Medical Director

Acct. Desc. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

Salaries (Professional) 7,084 7,084 7,084 7,084 7,084 7,084 7,084 7,084 7,084 7,084 7,084 7,084 125,008

Salary (Clerical) 2,083 2,083 2,083 2,083 2,083 2,083 2,083 2,083 2,083 2,083 2,083 2,083 24,996

Misc. Benefits 2,291 2,291 2,291 2,291 2,291 2,291 2,291 2,291 2,291 2,291 2,291 2,291 37,492

Minor Equip. 1,000 1,000

PCs 5,000 5,000

Software 1,000 1,000

Office Supp. 100 100 100 100 100 100 100 100 100 100 100 100 1,200

Publications 200 200 400

Telephone 72 72 72 72 72 72 72 72 72 72 72 72 864

Education 2,400 2,400 4,800

Postage 10 10 10 10 10 10 10 10 10 10 10 10 120

Travel 100 100 100 100 100 100 100 100 100 100 100 100 1,200

Special Events 584 2920 3504 7,008

Printing Purchased 25 25 25 25 25 25 25 25 25 25 25 25 300

Purchase MD Services 5,417 5,417 5,417 5,417 5,417 5,417 5,417 5,417 5,417 5,417 5,417 5,417 85,004

Lab 416 416 416 416 416 416 416 416 416 416 416 416 5000

2010 BUDGET TOTAL 300,392

Secure Resources to Secure Resources to

Support Effective Support Effective ProgramsProgramsIPC resources should be allocated based

on:– Demographics of population– Most common diagnosis– High risk populations– Services offered– Type and volume of procedures performed– What is NOT BEING DONE due to

inadequate resources THAT SHOULD BE DONE to improve patient care

*O’Boyle C, Jackson MM, Henly SJ. Staffing requirements for infection control programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.

Staffing Staffing Requirements?Requirements?

O’Boyle C, Jackson MM, Henly SJ. Staffing requirements for infection control

programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.

2001 Delphi Study•*0.8 to 1.0 ICP per 100 occupied

beds acute and long-term care• Physician time not measured

How did we get more resources at my hospital?

Constant assessment and relentless annual negotiations.

Looking outside of hospital: contracts for IPC services, grants support temporary resources (students, data collection), Internship program support (MPH, MHA).

Proving our value year after year; increasing visibility of program; focusing on interventions = REDUCING HAIs!

FOCUS ON FOCUS ON INTERVENTIONS!INTERVENTIONS!

What Percent of HAIs What Percent of HAIs

are Preventable? are Preventable? • In 1985 SENIC study estimated 32% of HAIs

preventable if effective IC program in place*

• 1995: British Hospital Infection Working Group stated that about 30% of HAIs could be avoided by better application of existing knowledge**

• 10-70% HAIs preventable with appropriate infection control depending on setting, study design, baseline infection rates and type of infection***

• Concluded at least 20% of all healthcare-associated infections probably preventable***

Sources: Haley, et al. Study on the Efficacy of Nosocomial Infection Control

Am J Epidemiol 1985; 121:159-67, 182-205*

Management and Control of HAI in Acute NHS Trusts in England. Feb 2000**

Harbarth S, et al. J Hosp Infect 2003;54:258-266***

Getting to Zero Getting to Zero HAIHAI

• Targeting zero =culture change

• Strong Sr. Leader support/CHAMPIONS/ multidisciplinary teams

• Bundle approach/EBM• Transparency/data

feedback• Analysis – real time• Personalize HAI• Communication!• Celebrate• Market value of IP

• Critical event analysis• Daily assessment of

device use/reminders to remove

• Board involvement• IPC Liaisons • Weekly Executive

Report• Web-based education• Empowered staff STOP THE LINE• Human Factors training

What’s Standard?What’s Standard? What’s Different?What’s Different?

Development costs:6 IPs @ $23/2 hrs./12 mos. =$3,312Graphics & printing =$1,300 $4,612Implementation costs:20 ICPs @ $23/16hrs. = $12,000600 RNs @ $23/1hr. = $13,800100 PCTs @ $12/1hr. = $ 1,20052 MDs @ $100/1hr. = $ 5,200 $32,200Development & Implementation costs = Development & Implementation costs = $36,812$36,812

Cost Benefit Cost Benefit AnalysisAnalysis

IPC BSI

Example: Intervention Modules to Prevent CLABSI – 2 ICUs @ BJC

Cost Benefit Analysis Cost Benefit Analysis (continued)(continued)

CLABSIs prevented (in 2 ICUS) in 2000

Expected BSI = 90 (based on previous two years rates)Observed BSI = 45BSI prevented post intervention = 45Estimated cost savings = $4,500 x 45 = $202,500

Cost Savings - Intervention Costs = Net Savings $202,500 - $36,812 = $165,688

So what’s mySo what’s myreal return onreal return oninvestment?investment?

NOTE: Once our value was established, we didn’t have to keep proving it NOTE: Once our value was established, we didn’t have to keep proving it to executives (in dollars saved!) We changed the way they think about IPC! to executives (in dollars saved!) We changed the way they think about IPC!

We just have to keep reducing infections!We just have to keep reducing infections!

BJC HealthCare – BJC HealthCare – Impact of InterventionsImpact of Interventions to Decrease HAIs to Decrease HAIs

CABG Surgical Site Infections (SSI) 2000 2001 Impact of Interventions#SSI 116 86 -30%SSI 5.21% 4.26% -26%Excess Cost $2,440,000 $1,737,945 -$801,340Spinal Surgical Site Infections (SSI)#SSI 64 58 -6%SSI 1.7% 1.5% -10%Excess Cost $716,345 $659,394 -$90,000Bloodstream Infections (BSI)#BSI 564 542 -22BSI/1,000 patient days 3.5/1,000 3.4/1,000 -4%Excess Cost $2,639,520 $2,639,540 -$107,140

#VAP 294 160 -134VAP/1,000 ventilator days 7.5/1,000 3.9/1,000 -46%

Excess Cost $2,449,020 $1,385,600 -$1,160,440

Total Cost of All HAI tracked $8,244,885 $6,422,479 -$2,158,920

Ventilator Associated Pneumonia (VAP)

Barnes-Jewish HospitalBarnes-Jewish HospitalExcess Cost of HAIExcess Cost of HAI

2000 to 2007

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

$8,000,000

$9,000,000

2000 2001 2002 2003 2004 2005 2006 YTD 2007

Exc

ess

Co

st

Barnes-Jewish HospitalBarnes-Jewish HospitalExcess LOS Associated with HAIExcess LOS Associated with HAI

2000 to 2007

0

500

1000

1500

2000

2500

3000

3500

4000

2000 2001 2002 2003 2004 2005 2006 YTD 2007

Ex

ce

ss

Le

ng

th o

f S

tay

(D

ay

s)

Main Line Health System Cost of Infections July 2008 - December 2010

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

July-Sept08

Oct-Dec08

Jan-Mar09

Apr-June09

July-Sept09

Jan-Mar10

Apr-Jun10

Jul-Sep10

Oct-Dec10

Co

st o

f In

fect

ion

s

CA UTI

SSI

VAP

CLABSI

What impresses leaders the What impresses leaders the most?most?

Let’s look at the Let’s look at the Chief Financial OfficersChief Financial Officers

Presentation of Presentation of achievements at theachievements at the

MLH Annual Leadership MLH Annual Leadership MeetingMeeting

Main Line Health (Critical Care Main Line Health (Critical Care Units) Units)

CLABSI (#) April 2008 - March CLABSI (#) April 2008 - March 20112011

65

4

2

12

4 6

10

9

7

1

3

Apr-Jun2008

Jul-Sep Oct-Dec

Jan-Mar

2009

Apr-Jun Jul-Sep Oct-Dec

Jan-Mar

2010


Jan-Mar

2011

Data Source: NHSN via DMA Infection Control Database

83% decrease from second quarter of 2008 to first quarter 2011

Trend line: p< .005, R2 = 0.59

Main Line Health Main Line Health (*All (*All Patients)Patients)

CLABSI (#) April 2008 - March CLABSI (#) April 2008 - March 20112011

28

22

12

97

10

7

17

2623

18

10

Apr-Jun2008

Jul-Sep Oct-Dec

Jan-Mar

2009


Jan-Mar

2010


Jan-Mar

2011

*All Patients = all patients in house with central line



Trend line: p< .001, R2 = 0.71

Main Line Health (Med/Surg/Tele Main Line Health (Med/Surg/Tele Units) Units)

CAUTI (#) April 2008 - March CAUTI (#) April 2008 - March 20112011


22

26

16

11

7

1113

10

13

8

7

10

Apr-Jun'08

Jul-Sep Oct-Dec Jan-Mar'09

Apr-Jun Jul-Sep Oct-Dec Jan-Mar'10

Apr-Jun Jul-Sep Oct-Dec Jan-Mar'11


Trend line: not significant, R2 = 0.29

Main Line Health (Critical Care Main Line Health (Critical Care Units) Units)

Ventilator Associated Ventilator Associated Pneumonia (#)Pneumonia (#)

April 2008 through March April 2008 through March 20112011

18

30

4 3

63

6

3

15

2 5

5

Apr-Jun2008

Jul-Sep Oct-Dec

Jan-Mar

2009


Jan-Mar

2010


Jan-Mar

2011


Trend line: p< .05, R2 = 0.45


A few other pearls…A few other pearls…

Your IPC CultureYour IPC Culture

Culture is the set of beliefs and values, learned organizational behaviors, the way we do things around here

Can you describe the culture of the IPC program?

Service culture? Safety culture? What do customers want from you and your program? How do you get others to embrace IPC culture

PartnershipsPartnerships

Champions, partners, facilitators – actively seek them out, work to keep them: WIIF them?

Patient Safety/Risk Management; Performance/Quality Improvement Data management and analysis Information Technology Occupational Health Accounting and finance

Financial impactIPC program and intervention investment ROI

Marketing – celebrate successes widely

Managing Your BossManaging Your BossMake sure you understand your boss and his or her context, including:Goals and objectivesPressuresStrengths, weaknesses, blind spotsPreferred work style

Assess yourself and your needs, including:Strengths and weaknessesPersonal stylePredisposition toward dependence on authority figures

Develop and maintain a relationship that:Fits both your needs and stylesIs characterized by mutual expectationsKeeps your boss informedIs based on dependability and honestySelectively uses your boss’s time and resources

Source: Harvard Business Review (checklist) May-Jun 1993

59

Thanks for your time and attention!Thanks for your time and [email protected]@mlhs.org

the business case for infection prevention and control: educating yourself and your exe c utives

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