Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012 Safe Surgery Surgical Site Infection K-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

Objectives Review reporting requirements Review K-HEN recommended measures Review the specifications for monitoring data (Inclusion and exclusion criteria) Discuss requirements for baseline data Define data entry and submission timeline Identify measures that may be pulled from other systems where data is currently being entered

Reporting Requirements For each topic area chosen, hospitals are required to submit data for at least One process measure AND One outcome measure Hospitals are strongly encouraged to report on the K-HEN recommended measures Additional outcome and/or process measures may be selected and reported as desired

K-HEN Recommended Measures Purpose—standardize reporting on the same measures across the state for robust benchmarking capability Measures selected based on polling data from the KHA Quality Conference in March 2012 Have continued to evolve with your feedback (Keep it coming! )

HRET HEN Encyclopedia of Measures Lists all measures available in the CDS Defines the numerator and denominator for each measure Provides a link to the source of the measure http://www.k-hen.com/Portals/16/Documents/HRET_HEN_Encyclopedia_of_Measures_v1.pdf

SSI: Outcome Measure Preferred measure: #89 Surgical site infection rate within 30 days after procedure Alternate measure: #88 Surgical site infection rate (In-hospital) (CDC NHSN subset) (abdominal hysterectomy and colon surgery)

#89 SSI Criteria Numerator—The number of surgical site infections based on CDC NHSN definition occurring within 30 days after operative procedure Denominator—All patients having any of the procedures included in the selected NHSN operative procedure categories Equation—(Number of SSI occurring within 30 days after the operative procedure/ Number specific operative procedures) * 100 Source: CDC NHSN SSI

#88 SSI Criteria Numerator—The number of surgical site infections based on CDC NHSN definition. All patients having any of the procedures included in the selected NHSN operative procedure categories are monitored for signs of SSI. The SSI form (CDC 57.120) is completed for each patient found to have an SSI. Denominator—All patients having any of the procedures included in the selected NHSN operative procedure categories Equation—(Number of SSI / Number specific operative procedures) * 100

SSI Process Measure Preferred Measure: #83 Prophylactic antibiotic received within one hour prior to surgical incision (SCIP-Inf-1) Source: TJC Specifications Manual for National Hospital Inpatient Quality Measures

#83 SCIP Inf-1 Criteria CMS Core Measure Numerator—Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision Denominator—All selected surgical patients with no evidence of prior infection Source: TJC Specifications Manual for National Hospital Inpatient Quality Measures

Baseline Data Only submitted one time For all topic areas except Readimissions: Baseline data is from 2011 prior to January 1, 2012 May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) Enter your specific period beginning and ending dates Readmission Baseline Data Preferably CY 2011 May use Jan – Jun 2012 if 2011 data is not available If no baseline data is available, do not enter anything for baseline—begin with monitoring data

Complete baseline data entry by August 15! SSI Baseline Data Complete baseline data entry by August 15! NHSN data will be extracted once rights are conferred Data should be entered on a monthly basis as much as possible

2012 SSI Monthly Data Entry Schedule Monitoring Month Data Entry Available Data Entry Complete January Immediately As soon as possible* February March April May June July September 1, 2012 September 30, 2012 August October 1, 2012 October 31, 2012 September November 1, 2012 November 30, 2012 October December 1, 2012 December 31, 2012 November January 1, 2013 January 31, 2013 December February 1, 2013 February 28, 2013 *If data is available

Comprehensive Data System (CDS) Link to HRET training webinar for CDS located on K-HEN website under Data Page https://www.hretcds.org/Login.aspx Data coordinator receives initial login and creates hospital’s users At least two data administrators As many data entry users as needed

Measure Selection Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected

Measure Enrollment Enroll in the measures that you are reporting Select Admin  Measure Enrollment Select the topic area Select/deselect and save the measures that you will be reporting on This will narrow your choices for data entry to only those selected You may reselect those measures at a later time if desired

Data Collection & Entry Review the numerator and denominator criteria for the measures selected Collect and compile the data Sign on to the CDS Select Data Entry tab Select the topic from the drop  Select Next Find the appropriate measure  Select Enter Data

Baseline Data Entry Defaults to the Baseline tab Enter the Measurement start and end dates  Select ‘Add’ Under ‘Data Entry’ column, Select ‘Go’ Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit Save holds data in ‘temporary’ area and is not available for reporting within the CDS Data may be edited by the hospital until it is submitted

Monitoring Data Entry Select the Monitoring tab Under the Data Entry column, Select ‘Go’ for the appropriate month Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS Data may be edited by the hospital until it is submitted

Data Tidbits Each month should have data entered or a reason it was not collected Additional training will be provided after data has been entered and reporting is available

Monthly Progress Report Due to K-HEN by the 10th of each month Use template provided One report per topic area Report template and sample complete report located on K-HEN website (www.k-hen.com) under Tools and Resources

Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here> Aim Statement Run Charts Lessons Learned Aim?: (Including your How Good and By When statement) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) (Enter summary here) Why is this project important?: Recommendations and Next Steps Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) Recommendations Next steps for testing Changes being Tested, Implemented or Spread (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) © 2012 Institute for Healthcare Improvement

Sample Completed Report

Project Assessment Scale http://www.k-hen.com/Portals/16/Documents/HRETHENProjectAssessmentScale.pdf

Homework Set up CDS users for your site Collect and enter baseline data by Aug 15 Enter monitoring data for Jan - Jun 2012 as available and time permits Enter monitoring data for Jul 2012 by Aug 31 Complete July progress report by Aug 10 and email to info@k-hen.com

Questions