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Turning data into action:
Using HSOPS and SSI data as part of a meaningful change
Sallie Weaver, PhD & Deb Hobson, RN; Julius Pham, MD, PhD & Terry Tsai, PhD
January 13 & January 15, 2014
DRAFT-Final pending AHRQ approval
Agenda
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SUSP timeline: Where are we now?
Interpreting safety culture survey data (HSOPS) and using results for improvement
1. Accessing & interpreting HSOPS Score reports
2. Debriefing & using your team’s data
High level description of the 2 new features of the SSI data registry
1. SSI rate reports o App Performance Monitor o Trend Graph
2. Missing data reports
Next steps
How to use data to effect changeQuestions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
SUSP: Where are you now?
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October 2013 SUSP Kickoff
Conduct SUSP pre-mortem exercise Administer HSOPS
November 2013 Watch Science of Patient Safety video Administer PSSA
December 2013 Schedule monthly executive safety rounds for the year Complete HSOPS administration
January 2014 Share HSOPS and PSSA results with your team during monthly
executive safety roundsQuestions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
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Interpreting Safety Culture Survey Data (HSOPS) and Using Results for
Improvement
Presented by:
Deborah B. Hobson, RN
& Sallie J. Weaver, PhD
DRAFT-Final pending AHRQ approval
If your team has completed the HSOPS or uploaded HSOPS data…
Your survey coordinator can download a copy of your aggregate survey report from the SUSP Online Portal
https://armstrongresearch.hopkinsmedicine.org/susp
How to find your team’s HSOPS results
DRAFT-Final pending AHRQ approval
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How to find your team’s HSOPS results
Select “My Reports” from the “My Network” drop down menu
DRAFT-Final pending AHRQ approval
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2. Tool: Select “HSOPS for SUSP”
How to find your team’s HSOPS results
DRAFT-Final pending AHRQ approval
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JHH-Colorectal Team- OR
3. Network: Select your Unit (typing the first letter of its name will bring you to that part of the alphabetized list)
4. Report: Select “HSOPS Report”
How to find your team’s HSOPS results
DRAFT-Final pending AHRQ approval
The same HSOPS Report can also be downloaded from your HSOPS App Dashboard after your survey period closes.
How to find your team’s HSOPS results
9 DRAFT-Final pending AHRQ approval
IMPORTANT NOTE:
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Your survey coordinator will only be able to download HSOPS reports AFTER your survey period has CLOSED
– If you survey is still open (i.e., if you are still actively collecting responses online or are in the process of uploading previously collected HSOPS data) you will NOT be able to download an HSOPS report
– Cohort 4 HSOPS survey period closing dates:
Cohort 4: December 16, 2013
Cohort 4-Extension group 4a: December 30, 2013
Cohort 4-Extension group 4b: January 17, 2013
How to find your team’s HSOPS results
DRAFT-Final pending AHRQ approval
HSOPS Aggregate Report (.pdf)
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Who participated in the survey? (p. 4-6, 29-34)
Johns Hopkins HospitalJohns Hopkins Hospital
Interpreting your team’s HSOPS results
DRAFT-Final pending AHRQ approval
Composite Score Charts (p. 7-8)Scores = Percentage (%) of responses that were positive
71% of team members who responded to the survey felt positively about the teamwork within their work area
Only 16% of team members felt that there was clearly a non-punitive response to error in their work area
Interpreting your team’s HSOPS results
DRAFT-Final pending AHRQ approval
Individual Question Scores are also displayed (p. 9-26)
Percent positive = GreenPercent neutral = YellowPercent negative = Red
Interpreting your team’s HSOPS results
DRAFT-Final pending AHRQ approval
Question scores provide more detail:For positively worded questions, more green is better
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Interpreting your team’s HSOPS results
NOTE: Due to rounding totals may not add exactly to 100%
For negatively worded questions (*), more RED is better
DRAFT-Final pending AHRQ approval
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Debrief survey results with your work area leaders and team members
Debriefing is…– A semi-structured conversation among frontline clinicians
and staff that is usually led by a designated facilitator
Purpose…
1. Encourage open communication, transparency, and interactive discussion about the survey results
Across all levels of the work area and between disciplines
2. To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area
How can we use our HSOPS data in a meaningful way?
DRAFT-Final pending AHRQ approval
Why debrief?Work areas/units that debrief around safety culture perform better
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Data is data
– Debriefing turns data into information
Debriefing accelerates improvement
Units who did not debrief survey results2.2% Reduction in Infection Rates
Units who used semi-structured debriefing of
culture survey 10.2% Reduction in
Infection Rates
Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):509-14.
How can we use our HSOPS data in a meaningful way?
CUSP Culture Check-Up Tool
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How Do I Use this Tool?
– Share culture results with everyone on the unit during a survey debriefing
Bring together team members from your work area
Follow your debriefing plan
– Take notes and recognize recurring themes
– Purpose = Open, honest discussion about ideas to make the culture of your work area the best it can be
– Focus on identifying system issues that the group can work on improving together instead of individuals
NOT used to point fingers at specific individuals
– Use the tool to structure meetings and guide conversation
– As a group, complete all steps in this worksheet
How can we use our HSOPS data in a meaningful way?
DRAFT-Final pending AHRQ approval
CUSP Culture Check-Up Tool: A tool to use during HSOPS Debriefings
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What is the Purpose of this Tool?– Understand the culture of the unit– Use teammates’ feedback to predict barriers to change and avoid them– Use feedback to make the most of the team’s strengths
Who Should Use this Tool? – Safety culture debriefing facilitators
Use this tool to help guide the discussion and record group decisions
Where can I Find this Tool?
How can we use our HSOPS data in a meaningful way?
https://armstrongresearch.hopkinsmedicine.org/susp/hsops/resources.aspx
DRAFT-Final pending AHRQ approval
Steps in CUSP Culture Check-Up Tool
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STEP 1: Your team identifies the general strengths and weaknesses of your unit culture.
STEP 2: Your team identifies the specific behaviors and attitudes that make up those strengths and weaknesses.
STEP 3: Debriefing facilitator encourages group reflection. Your team chooses opportunities for growth, understanding that cultural strengths can help fix cultural weaknesses.
STEP 4: Your team identifies a strategy for fixing the opportunities selected in step three.– AHRQ recommends creating ‘safety briefings’ – short updates for frontline teammates about
patient safety issues in the work are. For more ideas, go to: http://www.ahrq.gov/qual/patientsafetyculture/hospimpdim.htm.
STEP 5: Your team works out the details of putting strategy into action.
STEP 6: Your team evaluates your plans. Be sure to meet again and check in on progress at your SUSP team meetings
How can we use our HSOPS data in a meaningful way?
DRAFT-Final pending AHRQ approval
The “Culture Check Up Tool” = Word Document that Debriefing Facilitator can use to guide conversation & improvement planning
DRAFT-Final pending AHRQ approval
DRAFT-Final pending AHRQ approval
Some points to cover in your debriefing plan
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Decision points for project team Debriefing plan How many debriefing sessions will be held?
Who will facilitate each debriefing session?
When will debriefing(s) be held?
Where will debriefing(s) be held?
Who is responsible for taking notes and recording ideas from each session?
If you conduct more than one debriefing session, who is responsible for collating notes and ideas for improvement from the different sessions?
How will the CUSP team ensure there is follow-up on the action items from the debriefing session(s)?
How can we use our HSOPS data in a meaningful way?
DRAFT-Final pending AHRQ approval
In Sum
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1. Review the survey report for your participating work areas
2. Can be helpful to distill the report down into 3-5 key slides
3. Decide when, how, and where to debrief your teammates (and leaders) on these results
Be prepared to listen
Ask for feedback
Ask teammates to help come up with solutions
4. Gather a small group together and use the “culture debriefing tool” to examine the roots of problem areas and begin to formulate strategies for improvement
Questions?
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Using the SSI data registry to turn SSI data into action
Learn how to create SSI reports to share with your SUSP team!
Questions? Contact the SUSP helpdesk! ([email protected])
Who can access the SSI data registry?
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SUSP Facilitators:
– Coordinating Entity
– SUSP Data Lead (“Hospital Administrator”)
Anyone who has “administrator” access to the hospital level and team (NHSN and/or NSQIP) networks in SUSP portal
– If your name was on your hospitals’ SUSP Portal Registration Form, you have “administrator” access!
Questions? Contact the SUSP helpdesk! ([email protected])DRAFT-Final pending AHRQ approval
What can you do in the SSI data registry?
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Generate
– Two different reports that give you real-time performance feedback
SSI app performance monitor report
SSI trend graph reports at CE and hospital level
– SSI missing data report
Goal: Data in SSI data registry by mid-February!
Manual:
Questions? Contact the SUSP helpdesk! ([email protected])DRAFT-Final pending AHRQ approval
How to access the SSI Data Registry?https://armstrongresearch.hopkinsmedicine.org/susp.aspx
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Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
My Tools homepage
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Questions? Contact the SUSP helpdesk! ([email protected])
• “SSI app” = SUSP: Improving Surgical Care through TRiP and CUSP• Click the actual words, SUSP: Improving Surgical Care through TRiP and CUSP,
not your hospital name underneath
DRAFT-Final pending AHRQ approval
SSI Data Registry homepage
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Questions? Contact the SUSP helpdesk! ([email protected])
If it says REGISTER instead of REPORTS, please contact the NPT ([email protected])!
DRAFT-Final pending AHRQ approval
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How to generate SSI performance monitor reports:
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
SUSP SSI app performance monitor homepageMonitor your SSI rates and generate reports to share with your team!
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Questions? Contact the SUSP helpdesk! ([email protected])
Click here to generate your SSI app performance monitor report:
DRAFT-Final pending AHRQ approval
Example: SSI App Performance Monitor Report
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Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
How to generate SSI trend graph reports:SUSP SSI app performance monitor homepage VIEW CHART
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Questions? Contact the SUSP helpdesk! ([email protected])
Click here to generate your SSI trend graph report:
DRAFT-Final pending AHRQ approval
Example: Hospital level trend graph report
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Compare your hospital’s SSI rate to:1. All SUSP NSQIP (or NHSN) participants2. All hospitals in your cohort3. All hospitals in your CE4. All hospitals who are working on same surgical line (e.g. colorectal)
SSI rate = (# SSIs/total # cases)*100
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
SSI missing data reports
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Who can generate them?– SUSP hospital administrators, Coordinating Entities and the
National Project Team
When? – Monthly, yearly, quarterly
Why?– To monitor hospital team’s SSI data upload into the SSI data
registry
Manual:
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
How to generate an SSI missing data report:https://armstrongresearch.hopkinsmedicine.org/susp.aspx
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Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
How to generate an SSI missing data report:
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Surgical Site Infections- NHSN or NSQIP
SUSP
Select hospital level
Missing Data Report
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
Example: Hospital level missing data report
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Different ways to interpret NO:
1.The CE has not yet uploaded data into the portal
2.CE uploaded data, but hospital has not yet submitted data for that month
3.CE and hospital uploaded data, but the hospital did not have any (for example) colorectal cases that month
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
Next steps
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NPT and CEs will: Collect outstanding DUAs (very few left)
NSQIP users: ACS will send NSQIP addendum to hospital admin
Register your team in the SSI Data Registry CE and NPT will transfer your NHSN and NSQIP data into the SSI
data registry
Once data is in registry, SUSP teams can generate their performance monitor and trend graph reports!
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
Using data to drive Quality Improvement
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Generate monthly reports
Share reports with teams
Use events to initiate investigations
Questions? Contact the SUSP helpdesk! ([email protected])
DRAFT-Final pending AHRQ approval
Questions?
42 DRAFT-Final pending AHRQ approval
Questions? Tools? Data?
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Reminder…You can access all slides, call recordings, and project tools and data discussed today on the SUSP Online Portal
https://armstrongresearch.hopkinsmedicine.org/susp
DRAFT-Final pending AHRQ approval
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How is your team planning to share and use your data?
What hurdles might come up?
DRAFT-Final pending AHRQ approval
Team Brainstorm…
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Ideas, tips, or advice to mitigate or manage these potential hurdles?
DRAFT-Final pending AHRQ approval
Project Call evaluation
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https://www.surveymonkey.com/s/SUSP_Cohort4
DRAFT-Final pending AHRQ approval