6

Exploring a Business Case for Investing Entities: Reflections and Next Steps

To delve more deeply into the issues surrounding continuing professional development (CPD) that were discussed at the workshop, the participants were divided into four breakout groups. Each group focused on a different case study of an intervention and a different investing entity: governments, workplaces, professional associations, or philanthropic organizations. Each group was asked to consider the investing entity’s perspective on CPD and to explore the business case for the specific intervention: who are the stakeholders, what are the costs, what are the benefits, who pays, and what are the incentives?

In addition to this charge to the groups, Lucy Savitz asked workshop participants to keep in mind the importance of partnerships, relationships, and goodwill between stakeholders. Recalling the lessons learned from Simon Kitto’s attempted CPD consortium in Canada, Savitz urged participants to consider the value of relationships when building a business case. Karahanna concurred, noting that a business case should anticipate that stakeholders may have disincentives to participate, and it should try to identify and mitigate these disincentives. Savitz added that stakeholders may have very different goals, but that through discussion and alignment of goals, stakeholders can agree to collaborate. For example, an insurance company may want to undertake an initiative to reduce future expenses, a public health entity may undertake the same initiative in order to improve population health, and a delivery system may do it to improve patient satisfaction and return rate. Thorough discussion and understanding of these motivations can increase the likelihood of a successful collaboration, said Savitz.

The groups met simultaneously, and afterward, the facilitators of each group presented their summary of the group’s discussions to the entire audience.¹ Participants in each breakout group used the case studies to discuss, react to, and explore ideas for building a business case within a specific investing entity. The reports of the facilitators noted below are based on their interpretation of these conversations.

EXPLORING A BUSINESS CASE FOR GOVERNMENTS

Marilyn DeLuca, New York University

After presenting the case study for expanding the role of Namibian nurses in treating patients infected with human immunodeficiency virus

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¹ The following sections are the reports from the individual facilitators, and should not be viewed as a consensus of the groups or of the workshop participants. Furthermore, while these case studies are based on real-life examples, data for the case studies were at times estimated in an effort to encourage more focused discussions among the group members and should not be considered definitive.

(HIV) (see Box 6-1), Marilyn DeLuca laid out her argument for taking action that was informed by the participants in her small group discussion. In 2014, she said, Region A enrolled 1,715 new patients in antiretroviral treatment (ART), but given trends in prevalence and population growth, it is estimated that by 2018, more than 14,000 new patients will need to be enrolled in ART. With only 282 physicians in the entire country, it would be “impossible to achieve” this without allowing nonphysicians to prescribe ART and manage HIV patients. The nurse-initiated antiretroviral treatment model (NIMART) offers one way to accomplish this.

DeLuca added that implementing the NIMART model in Namibia

would require “many frequent walks in the woods” to fully engage all the stakeholders and identify and address roadblocks, concerns, and perspectives. She then reported on the many stakeholders that would be involved in a transition to NIMART. Stakeholders would include patients, families, physicians, nurses, pharmacists, community health workers, laboratory staff, pharmaceutical manufacturers, government, employers, the educational system, nongovernmental organizations (NGOs), and philanthropic funders. She specifically called out tribal leaders as critical stakeholders because they so often hold the keys to community buy-in. She then acknowledged the risk of tension between stakeholders. For example, doctors may be sensitive to nurses “taking” their duties, while patients may not feel comfortable with a nonphysician treating them.

Next, DeLuca reported on looking at the costs of implementing NIMART in Region A. The estimated costs of salaries, medication, and training were $1.5 million. She identified a number of less obvious costs or risks to implementation, including

• movement of health workers to HIV/AIDS from other critical areas such as chronic diseases;
• overburdened nurses pushing back because of increased workload;
• costs of educating patients, families, and communities;
• increased future medication costs as more patients are enrolled;
• costs of developing the training and performing monitoring and quality assurance;
• cost of scaling NIMART up to an entire country if it is successful;
• costs in changing policy and regulations and implementing new certifications; and
• possible conflict and competition with the broader AIDS strategy.

The stated benefits of NIMART—such as an increased number of patients with viral load suppressed by ART, or reduced transmission of HIV—are fairly obvious and quantifiable. However, other benefits were also identified that are a likely result of the program, including

• fewer AIDS orphans and less disruption to families;
• empowered and aware health care workforce;
• increased productivity of workers and increase in gross domestic product;
• improved education and empowerment of patients, families, and communities; and
• interprofessional team practice that can benefit other areas of health care.

DeLuca noted that the NIMART model is not merely a way to expand access to ART but a way of improving the overall health care system. The model encourages interdisciplinary team practice and allows nurses to “function and practice at the full level of their . . . training and education.” Additionally, the NIMART model frees up physicians to focus on enrolling and managing the most critically ill patients.

Looking at the example as a business case to accept or reject, DeLuca based her decision to move forward with the implementation of NIMART on the discussions she heard within her breakout group session. The benefits accrue to the HIV patients themselves as well as to the community and the health care workers, she explained. These benefits outweigh the costs of the program. In addition, the costs of not moving forward—increased HIV infection, morbidity, and mortality—are too great. However, this endorsement of the business case was accompanied by a caveat that engaging stakeholders and working collaboratively are critical to the success of the program. DeLuca said that the changes cannot simply occur in clinics; there must be a shift in the ecosystem. For example, the source of the funding would be transparent, and there would be buy-in from the local communities. Health care workers would be partners in the shift to NIMART, and attention would be paid to how and when the workers were trained. Patients and families would be made aware of the changes and assured that they were receiving appropriate treatment. Finally, NIMART would only be a part of a holistic nationwide effort to address all aspects of HIV/AIDS, including awareness, prevention, testing, self-care, and stigma.

EXPLORING A BUSINESS CASE FOR WORKPLACES

Stuart Gilman, Veterans Health Administration
Lucy Savitz, Intermountain Healthcare

Gilman began his summary with a brief synopsis of the case study looking at emergency department use at the Veterans Health Administration (see Box 6-2). He then summarized his view of the breakout group’s discussions, starting with a list of identified stakeholders:

• Patients
• Clinical institution senior management
• Clinical institution middle management
• Frontline clinicians
• Frontline staff
• Academic affiliates
• Veterans Affairs Central Office academic affiliations
• Community representatives

This led Gilman to his discussion of the complex choices that must be made when designing a CPD program such as the one outlined in this case study. First, the entity desiring change would determine what problem to tackle, asking “what is the opportunity for improvement that is more important” than other potential opportunities to improve? Then it would determine the type of results it wanted from the program. This could be a short- or long-term improvement, it could involve only changes to processes, or it could entail substantial changes in outcomes. Gilman noted, “You want to measure what matters, and what usually matters involves patients.” This comment came with a caveat: There are a huge variety of measures that could be used, he said, including clinical outcomes, educational outcomes, and team knowledge and skills. The last choice to make involves determining the type of instructional design to use to accomplish the desired results.

Gilman identified a number of development and operation costs and benefits for the program based on his group’s input (see Table 6-1). After some discussion, he realized that the clinical environment and the learning environment for workplace-based educational interventions must be thought of as separate but interrelated elements. For example, there is one set of development costs for an educational activity and another set of costs on the delivery side for setting up clinical activities. After the activi-

TABLE 6-1 Workplace Education Costs and Benefits

SOURCE: Presented by Stuart Gilman and Lucy Savitz, April 7, 2017.

ties begin, there are operational events for the educational component of the intervention that may be discrete from the operational events of the clinical component. What is important to note is that such processes may not operate in parallel and are likely to be intentionally out of phase. For example, the education development may occur and then proceed to the education operation, which then initiates the clinical development. For those in charge, figuring out the right sequence for these events can be a real challenge.

EXPLORING A BUSINESS CASE FOR PROFESSIONAL ASSOCIATIONS

Silvia Rabionet, University of Puerto Rico and Nova Southeastern University
Michael Rouse, Accreditation Council for Pharmacy Education
Elena Karahanna, University of Georgia

Rabionet summarized the first case study that the group looked at (see Box 6-3), an American Pharmacists Association program that trained more than 280,000 pharmacists to provide immunizations. Rabionet said that the program was spurred by the “identified need for higher rates of immunizations to achieve national targets, and [the] need for easier access of immunization services by patients.” The program focuses not only on giving the pharmacists the skills to immunize but also on teaching the

basics of immunology and how to serve as the primary source of information about vaccines. In addition to workforce training, a program like this requires changes in the scope of practice law and acceptance by patients.

Rabionet then described the costs and benefits of the program, saying that, while the cost of training the pharmacists was almost $500 million, the savings of doing the immunizations in the pharmacy rather than elsewhere was $2.4 billion. This resulted in a net benefit of $1.9 billion. The expansion in the pharmacists’ scope of practice had a “substantial impact on the cost of immunization,” she said. However, she also brought forward a comment from her breakout group saying that, while the program reduced costs, it did not result in improved vaccination rates.

The case study presented by Rouse focused on training pharmacists to help manage asthma patients (see Box 6-4). With the sponsorship of the Turkish Pharmacists’ Association (TPA), more than 3,500 pharmacists in Turkey have been trained, and there was a measurable effect on patient outcomes, with improvements in peak flow rate and asthma control tests, reduced salbutamol use as a result of improved inhaler technique, and improved patient quality of life and habits. In addition, said Rouse, pharmacists had enhanced competence and confidence, and the TPA gained a stronger reputation. An analysis of the economic effect of the program has not yet been performed, said Rouse.

Professional Associations Investing in CPD

Breakout group participants considered both of the case studies outlined above when engaging in discussions about professional associations as an investing entity for CPD. Rabionet presented the group’s discussions, beginning with the following list of 13 stakeholders that had been identified (she emphasized the top 6 stakeholders, pointing out that professional associations—the investing entity—were also viewed as key stakeholders):

1. Professional associations (main plus other related)
2. Health professionals
3. Providers of CPD
4. Employers of health professionals
5. Patients
6. Federal and state lawmakers and legislative bodies
7. Credentialing and accrediting agencies
8. Association members
9. Accrediting agencies of continuing education bodies
10. Educational institutions
11. Funding agencies

12. Insurance companies
13. Industry

Rabionet then went through the identified costs and benefits for a professional association to invest in CPD. Development costs may include costs associated with needs assessment and research, content development, course development, training the trainer, advocacy for necessary legal changes, and development of record keeping systems. Operational costs include the costs of delivering the training, promotion costs, the cost of materials, and the costs of assessment, testing, and accreditation. Despite these costs, Rabionet reported a number of substantial benefits to the professional association:

• Increase in membership of the association (which could increase revenue)
• Better recruitment to that profession at schools
• Advancing the profession
• Enhancing the public image, reputation, and credibility of the profession
• Revenue from “tuition” for CPD
• Increased nondues revenue opportunities (conferences, publications, scholarship)
• Having “control” or influence over CPD standards and quality
• Improved alignment between practice and education, thereby fulfilling the obligation of responding to the profession as a whole
• Encouraging company sponsorship
• Centralized data repository to demonstrate outcomes

Given these costs and benefits, the group discussed why a professional association would want to be an investing entity in CPD, Rabionet said. The decision to invest is likely not motivated purely by financial reasons. Every professional organization will have a different perspective on whether and how to invest in CPD based on the mission of the organization, the potential value of CPD for the members and the association, and the justification for investing money in a program that is unlikely to result in financial benefit to the organization. Rabionet recounted a number of justifications for investing in CPD offered by individual participants of her group. First, the mission of advancing the profession is unique to the professional association, and CPD represents an opportunity to advance the profession in an organized, consistent, and standardized way. CPD also gives the association an opportunity to add value for its members, their employers, and ultimately patients through lifelong learning. However, as was pointed out by one participant, lifelong learning is not just for an individual professional but for the profession as a whole. In summary, said Rabionet, professional

associations want to invest in CPD to help health professionals practice using the full scope of their education and training while assuring growth, development, credibility, and the survival of the profession.

EXPLORING A BUSINESS CASE FOR PHILANTHROPIC ORGANIZATIONS WORKING WITH HIGHER EDUCATION

Darlene Curley, Jonas Center for Nursing and Veterans Healthcare
Paul Mazmanian, Virginia Commonwealth University

Before presenting the case study, Curley remarked on several disconnections that the breakout group had identified during their discussion about philanthropists and higher education working on CPD. The first involved the term business case. Some wondered whether it might be inappropriate for philanthropic organizations to consider a business case, noting that philanthropies are mission driven, and groups seeking their support must aim to align their proposals with the mission of the organization. Curley agreed that grant seekers must do their “homework about what kind of philanthropic organization [they] are speaking to and what their mission is and what their values are.” However, she noted, the mindset that philanthropists may not see “things from a business case point of view” is changing with organizations such as the Gates Foundation and the Chan Zuckerberg Initiative. Curley said that her organization, the Jonas Center for Nursing and Veterans Healthcare (Jonas Center), requires a business case for any grant proposal. She needs “an eight-point one-pager” to present to the Jonas family and the advisory board in order to get an initial decision on whether to move forward. She noted that the anticipated return on investment is a critical piece of a proposal, despite the fact that the Jonas Center itself will not be the entity that profits from the investment. While the Jonas Center does look at nonmonetary outcomes, such as quality improvement, the financial return on investment is always part of the discussion.

Curley’s point prompted comments from her small group participants. One came from a participant who believed the phrase business case might be a cultural barrier outside of the United States. It may make it difficult to keep the patient as the focus of health interventions, he said, in a community where businessmen are seen as corrupt and exploitative of the poor. This led several individual participants in the breakout group to describe alternatives to the phrase business case that included alignment (ensuring that scarce resources are being used to further the priorities of everyone involved) and accountability (holding grantees accountable for the wise use of resources and showing funders what happened as a result of their investment).

Another participant suggested there may be a mismatch between the

goals of philanthropic organizations that provide the money and the higher education institutions that carry out the CPD programs. Mazmanian, who was a co-leader of the small group, agreed that the perspectives are slightly different, saying that higher education wants funding that is sufficient, sustainable, and in line with the values of its institution. Curley said the goals of the funder and the funding recipient do not need to be the same, but “they cannot be in conflict.” Despite potential mismatches, Mazmanian said, there are many benefits for higher education institutions working with philanthropic organizations on CPD programs, including the following:

• Doing meaningful work that produces a high-quality CPD program with high-value outcomes that address the mission of the funding organization as well as the mission of the educational institution
• Demonstrating rapid success and solving immediate problems more quickly by involving health care practitioners currently in the workforce, as opposed to waiting for those at earlier stages of training in the health professions education pipeline
• Building capacity for carrying out future similar work in CPD
• Learning to specify measurable objectives for describing progress and determining relative success
• Building new relationships with partners, patients, health systems, and communities
• Building evidence and tracking performance over an extended period of time, along with helping to identify or explore causal linkages that may go undetected using other designs
• Paying the bills of the CPD enterprise itself

Curley and Mazmanian both emphasized that sustainability is a critical component of a successful program. From the funder’s point of view, the initial funding is intended to create a program that will continue past the point that the money ends; the project may be considered a “failure” if it does not. Grantees generally share this view, and hope to use the initial funding to build capacity to continue the funded program and expand upon success.

Moving from a general discussion into the case study, Curley gave a brief synopsis of the Jonas Center’s Vision Care program (see Box 6-5), which has the goal of eliminating children’s blindness. Curley said that pediatricians are not routinely trained in ophthalmology, and that most states do not require vision tests for children. The program is designed to increase the number of providers who are trained in children’s vision and to double the number of children receiving vision care by 2021.

For Donald Jonas—the living funder of the Jonas Center—this program started as a personal passion. Jonas has a genetic retinal disease and is

legally blind, said Curley. In his years of caring for this disease, he visited vision centers and found that there were a great number of children who were blind. Although this personal experience sparked his desire to do something, the Jonas Center conducted 3 years of research about the topic and about how an investment could have the greatest effect. In addition to these personal reasons, Curley listed a number of other reasons why a philanthropic organization such as the Jonas Center would invest in this type of program. First, the focus on CPD means that it is easier and faster to see a return on investment, unlike, for example, focusing on training people

coming up through the pipeline. Second, the money that is invested in this specific CPD program also builds capacity for other CPD programs. Finally, by training and supporting health care providers and scholars in pediatric ophthalmology, the program builds capacity and potential for research into children’s vision problems.

Regarding the issue of sustainability, Curley noted that it is a 5-year grant program, but there is the expectation that the grantee will generate revenue with the program, and this revenue will be sufficient to run the program for at least an additional 5 years. Curley emphasized again that, for philanthropic organizations, “sustainability is one of the first questions on the business case at the very beginning.”

REFERENCE