DRAFT – final pending AHRQ approval Kristina Weeks, MHS, DrPH(c) January 13, 2015 Designing and Using Scorecard for SUSPtainability 1

Quick Administrative Announcements 2 Dial into the conference line: – Dial in Number: – Passcode: 5403 – Webinar URL: – Please contact your Coordinating Entity for these slides We will make a recording of this webinar available. Interact with us today – Type comments in the chat box – Or even better, speak up Sustainbability:Scorecard

Polling Question 3 What is your role in your clinical area?  Surgeon  Quality Improvement practitioner  Infection preventionist  OR nurse  OR technician  Anesthesiologist  OR manager  Coordinating Entity  Educator  Other  Sustainbability:Scorecard

Follow-up from Learning from Defects 4 Review the Learning from Defects tool with your team Review a defect in your operating rooms Select one defect per quarter Consider applying to surgical morbidity and mortality conferences Post the stories of reduced risks (include data!) Celebrate your success Action Plan Sustainbability:Scorecard

Learning Objectives 5 Assess objectively your unit’s current stage in SUSP implementation Describe how to design a scorecard to measure performance as part of your sustainability efforts Identify and give examples of adaptive and technical indicators to include on a performance scorecard Sustainbability:Scorecard

Evaluating Performance 6 When we performed, I felt nervous and excited at the same time. My stomach was doing flip flops. I learned don’t be nervous. Forget about the crowd and just do what you are supposed to be doing and you will do a great job. Source: Sustainbability:Scorecard

Take Stock by Checking Your Progress Create collective awareness of what’s working and what’s not working Celebrate what makes the team strong and effective Tackle remaining barriers proactively 7 Sustainbability:Scorecard

Take stock of team variables every six months 8 VARIABLESQUESTIONS FrequencyDoes your team meet enough to achieve goals? AttendanceDoes your team have sufficient participation to facilitate group goals? TrainingIs entire staff trained in Science of Safety? DefectsAre you learning from defects? Are any of your improvement plans driven by data? StabilityHas turnover in key positions affected your progress? Safety CultureHow many safety climate responses are positive? Does the staff know you are hearing them? Scorecard Parameters Sustainbability:Scorecard

9 Measure Within The Past Six Months (Circle One) Below Target Okay On Target FREQUENCY How many SUSP meetings held in past 6 months? How many SUSP subgroup meetings held in past 6 months? (based on 1 monthly subgroup) ATTENDANCE Number of meetings attended by a SUSP Team Lead in past 6 months? Number of meetings attended by the senior executive in past 6 months? Number of meetings attended by the surgeon champion in past 6 months? Number of meetings attended by nurse champion in past 6 months? TRAINING How much of staff has received Science of Safety training within 2 years?<80%80-90%>90% DEFECTS How many defects have you learned from in past 6 months? How many of your improvement goals to address these defects are data-driven? >1 SAFETY CULTURE Average percent positive scores for Safety Climate Domain from most recent HSOPS? What is the unit response rate for the latest HSOPS? <60% 60-80% >80% SUSPtainability Scorecard Sustainbability:Scorecard

10 Measure (Circle One) Below Target Okay On Target Insert surgery related indicator* Insert surgery related indicator SSI Prevention Activities Scorecard *An example would be the percentage of time made for: SSI Rate Time out procedure Briefings Debriefings Sustainbability:Scorecard

Polling Question 11 Do you have SUSP team “subgroups”?  Yes  No  Sustainbability:Scorecard

Polling Question 12 How often do these subgroup meet?  Once per month  Once per quarter  A couple of times per year  Sustainbability:Scorecard

Polling Question 13 Do you have a participating senior executive actively involved with the SUSP team (attending SUSP meetings?)  Yes  No  Sustainbability:Scorecard

Polling Question How does your team receive your SSI data reports in your clinical area? (select all that apply)  Through the SUSP/SSI Data Portal  NHSN portal  NSQIP portal  Infection control administrator in my hospital  My CE sends reports to me  We get data but I don’t where it comes from Sustainability: Scorecard 14

15 Revisit your pre-SUSP safety culture assessment and action plan Share results and progress with your frontline staff Validate the hard work of your frontline staff Keeping an Eye on Culture Sustainbability:Scorecard

SUSP Activities Still Open for Participation 16 Resources still available to you through August 2015 Cohort 4 sustainability phase calls begin in June 2015 Affinity group calls SUSP webpage (webinars, toolkits, etc.) SUSP data portal – HSOPS reports – SSI reports Medconcert SUSP help desk Cohort 3 SUSP project ends in February 2015 Sustainbability:Scorecard

Where to find the old webinars? 17 Sustainbability:Scorecard

HSOPS Re-Administration Announcement Sustainability:Scorecard 18 HSOPS survey administration date has been extended to accommodate your schedule The new close date for HSOPS re-administration is now February 3, 2015 at 12 noon (ET) If you have any questions related to HSOPS re-administration, please contact the SUSP help desk at

Next SCIP Affinity Group Call Sustainbability:Scorecard 19 The next SCIP affinity group call will be held on Thursday, February 12, 2015 at 4PM (EST) Leader Telephone number: Passcode: Webinar:

Thank you for your willingness to participate and learn together on how to prevent surgical site infections. The journey continues….. 20 Sustainbability:Scorecard

It’s the soil, not the seed. --Louis Pasteur 21 Nurture your safety culture.