Turning data into action: Using HSOPS and SSI data as part of a meaningful change

1. 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 ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY July 21st and July 23rd , 2014 DRAFT-Final pending AHRQ approval

2. Agenda • SUSP timeline: Where are we now? • Interpreting safety culture survey data (HSOPS) and using results for improvement • Accessing & interpreting HSOPS Score reports • Debriefing & using your team’s data • High level description of new SSI data registry features • SSI rate reports (App Performance Monitor & Trend Graph) • Missing data reports • Next steps • How to use data to effect change Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

3. SUSP: Where are you now? April 2014 • SUSP Kickoff and conduct SUSP pre-mortem exercise • Administer HSOPS May 2014 • Watch Science of Patient Safety video • Administer PSSA June 2014 • Schedule monthly executive safety rounds for the year • Complete HSOPS administration July 2014 • Share HSOPS and PSSA results with your team duringmonthly executive safety rounds DRAFT-Final pending AHRQ approval

4. 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

5. How To Find Your Team’s HSOPS Results For completed 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 DRAFT-Final pending AHRQ approval

6. How To Find Your Team’s HSOPS Results Select “My Reports” from the “My Network” drop down menu DRAFT-Final pending AHRQ approval

7. How To Find Your Team’s HSOPS Results Project: Select “SUSP” Tool: Select “HSOPS for SUSP” DRAFT-Final pending AHRQ approval

8. How To Find Your Team’s HSOPS Results Network: Select your Unit Report: Select “HSOPS Report” JHH-Colorectal Team- OR DRAFT-Final pending AHRQ approval

9. How To Find Your Team’s HSOPS Results The same HSOPS Report can also be downloaded from your HSOPS App Dashboard after your survey period closes. DRAFT-Final pending AHRQ approval

10. How To Find Your Team’s HSOPS Results IMPORTANT NOTE: • Your survey coordinator will only be able to download HSOPS reports AFTER your survey period has CLOSED • HSOPS report downloads are not available for OPEN surveys • If actively collecting responses online • If uploading previously collected HSOPS data • Cohort 5 HSOPS survey period closing dates: July 15, 2014 DRAFT-Final pending AHRQ approval

11. Interpreting Your Team’s HSOPS Results HSOPS Aggregate Report Survey response rate (Pages4-6, 29-34) Johns Hopkins Hospital Johns Hopkins Hospital DRAFT-Final pending AHRQ approval

12. Interpreting Your Team’s HSOPS Results Composite score (Page 7-8) • Interpreting Composite Scores: • The big picture view • Higher is better 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 DRAFT-Final pending AHRQ approval

13. Interpreting Your Team’s HSOPS Results Individual Question Scores (Pages9-26) Percent positive = GreenPercent neutral = YellowPercent negative = Red DRAFT-Final pending AHRQ approval

14. Interpreting Your Team’s HSOPS Results Questions provide a deeper dive NOTE: Due to rounding totals may not add exactly to 100% Tip: For positively worded items, more GREEN is better. DRAFT-Final pending AHRQ approval

15. Interpreting Your Team’s HSOPS Results Questions provide a deeper dive NOTE: Due to rounding totals may not add exactly to 100% Tip: For negatively worded items, more RED is better.

16. What is Debriefing? Debrief survey results with all your team members • Debriefing isasemi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator • Encourages open communication, transparency, and interactive discussion • across all levels of the work area • between disciplines • Engages clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area

17. Making HSOPS Data Meaningful Work units that debrief around safety culture perform better • Data is data. Debriefing turns data into information. • Debriefing accelerates improvement.1 YES NO Units who used semi-structured debriefing of culture survey achieved 10.2% Reduction in Infection Rates Units who did not debrief survey results achieved 2.2% Reduction in Infection Rates

18. Making HSOPS Data Meaningful How do I use the CUSP culture check-up 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 • Encourage open, honest discussion about making the culture of your work area the best it can be

19. Making HSOPS Data Meaningful How do I use the CUSP culture check-up tool? • Focus on identifying system issues that the group can work on improving together instead of as individuals. • Don’t use it to point fingers at specific individuals • Use the tool to structure meetings and guide conversation. • As a group, complete all steps in this worksheet.

20. Making HSOPS Data Meaningful HSOPS debriefings with CUSP culture check-up tool What is the Purpose of this Tool? • Understand the unit culture • Use teammates’ feedback to predict and avoid barriers • Use feedback to leverage the team’s strengths Who Should Use this Tool? • Safety culture debriefing facilitators • Helps to guide the discussion and record group decisions

21. How can we use our HSOPS data in a meaningful way? CUSP Culture Check-Up Tool: A tool to use during HSOPS Debriefings • Where can I Find this Tool? • https://armstrongresearch.hopkinsmedicine.org/susp/hsops/resources.aspx DRAFT-Final pending AHRQ approval

22. Steps in CUSP Culture Check-Up Tool • Identifies general strengths and weaknesses of your unit culture • Get specific about behaviors and attitudes that make up those strengths and weaknesses • Select opportunities for growth • Develop a strategy for addressing growth opportunities • Put plan into action • Evaluate results and share progress during SUSP team meetings

23. Culture Check Up Tool • Culture Check Up Tool is a document used by Debriefing Facilitator to guide conversation and improvement planning • Download from either to SUSP project page or the AHRQ website • Tip: Download the Culture Check Up Tool at either • https://armstrongresearch.hopkinsmedicine.org/susp OR • www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/culturecheckup.html

24. Culture Check Up Tool Brainstorming culture discussion items

25. Debriefing Plan Highlights

26. What’s Next? • Review the survey report for your clinical areas • Distill the information into 3-5 key slides • Plan debriefing strategy to share results with team • Be prepared to listen • Ask for feedback • Ask teammates to help come up with solutions • 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

27. Questions?

28. Using the SSI data registry to turn SSIdata into action Learn how to create SSI reports to share with your SUSP team!

29. Who Can Access The SSI Data Registry? • 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! DRAFT-Final pending AHRQ approval

30. What Can You Do in SSI Data Registry? Generate reports • Reports that provide real-time performance feedback • SSI app performance monitor report • SSI trend graph reports at CE and hospital level • SSI missing data report DRAFT-Final pending AHRQ approval

31. Access the SSI Data Registry Project Site: https://armstrongresearch.hopkinsmedicine.org/susp.aspx DRAFT-Final pending AHRQ approval

32. My Tools Homepage • “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

33. SSI Data Registry Homepage TIP: If button reads REGISTER instead of REPORTS, please contact us at SUSP@Jhmi.edu. DRAFT-Final pending AHRQ approval

34. Generating SSI Performance Reports TIP: Use the manual! SUSP Generating reports using the SSI data registry DRAFT-Final pending AHRQ approval

35. Generating SSI Performance Reports SUSP SSI app performance monitor homepage Click here to generate your SSI app performance monitor report: DRAFT-Final pending AHRQ approval

36. Generating SSI Performance Reports Example: SSI App Performance Monitor Report DRAFT-Final pending AHRQ approval

37. Generating SSI Trend Reports SSI trend graph reports Click here to generate your SSI trend graph report: DRAFT-Final pending AHRQ approval

38. Generating SSI Trend Reports Example: Hospital level trend graph report Compare your hospital’s SSI rate to: All SUSP NSQIP (or NHSN) participants All hospitals in your cohort All hospitals in your CE All hospitals who are working on same surgical line (e.g. colorectal) SSI rate = (# SSIs/total # cases)*100 DRAFT-Final pending AHRQ approval

39. Generating SSI Missing Data Reports • Who can generate them? • Coordinating Entities and any one who has access to the portal • When? • Monthly, quarterly, yearly • Why? • To monitor hospital team’s SSI data upload into the SSI data registry • For assistance, download the manual “SUSP Generating Missing Data Reports” at https://armstrongresearch.hopkinsmedicine.org/susp.aspx DRAFT-Final pending AHRQ approval

40. Generating SSI Missing Data Reports https://armstrongresearch.hopkinsmedicine.org/susp.aspx DRAFT-Final pending AHRQ approval

41. Generating SSI Missing Data Reports SUSP Surgical Site Infections- NHSN or NSQIP Select hospital level Missing Data Report DRAFT-Final pending AHRQ approval

42. Generating SSI Missing Data Reports Example: Hospital level missing data report Different ways to interpret NO: • The CE has not yet uploaded data into the portal • CE uploaded data, but hospital has not yet submitted data for that month • CE and hospital uploaded data, but the hospital did not have any (for example) colorectal cases that month DRAFT-Final pending AHRQ approval

43. Next Steps Hospitals: • Confer your NHSN rights to your CE (reminder for Independent, California hospitals) • NSQIP hospitals- return NSQIP addendum to ACS NPT and CEs: • CE and NPT will continue or begin transferring 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! DRAFT-Final pending AHRQ approval

44. Using Data To Drive Quality Improvement • Generate monthly reports • Share reports with teams • Use events to initiate investigations DRAFT-Final pending AHRQ approval

45. Questions? DRAFT-Final pending AHRQ approval

46. Resources https://armstrongresearch.hopkinsmedicine.org/susp Reminder… You can access all slides, call recordings, and project tools and data discussed today on the SUSP Online Portal DRAFT-Final pending AHRQ approval

47. How is your team planning to share and use your data? What hurdles might come up? DRAFT-Final pending AHRQ approval

48. Team Brainstorm… Ideas, tips, or advice to mitigate or manage these potential hurdles? DRAFT-Final pending AHRQ approval

49. References • 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. JtComm J Qual Patient Saf. 2011 Nov;37(11):509-14.