DRAFT – final pending AHRQ approval Kristina Weeks, MHS, DrPH(c) June 3, 2014 Designing and Using Scorecard for SUSPtainability

DRAFT – final pending AHRQ approval Polling Question 2 What is your role in your clinical area? –Surgeon –Quality Improvement practitioner –Infection preventionist –OR nurse –OR technician –Anesthesiologist –OR manager

DRAFT – final pending AHRQ approval 3 Review the Learning from Defects tool with your team Review a defect in your operating rooms Select one defect per month or quarter Consider applying in surgical morbidity and mortality conferences Post the stories of reduced risks (include data!) Share with others Action Plan Follow-up from Learning from Defects

DRAFT – final pending AHRQ approval Learning Objectives 4 Asses 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

DRAFT – final pending AHRQ approval Evaluating Performance 5 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:

DRAFT – final pending AHRQ approval 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

DRAFT – final pending AHRQ approval Take stock of team variables every six months 7 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? Safety CultureHow many safety climate responses are positive? Does the staff know you are hearing them? Scorecard Parameters

DRAFT – final pending AHRQ approval 8 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 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? Do you have improvement plans that 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

DRAFT – final pending AHRQ approval 9 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: Time out procedure Briefings Debriefings

DRAFT – final pending AHRQ approval Polling questions 10 Do you have SUSP team “subgroups”? -Yes -No How often do these subgroup meet? -Once per month -Once per quarter -A couple of times per year Do you have a participating senior executive actively involved with the SUSP team (attending SUSP meetings?) -Yes -No

DRAFT – final pending AHRQ approval Revisit your pre-SUSP safety culture assessment and action plan Celebrate successes Share with your frontline staff Let frontline staff know their voices have been heard 11 Keeping an Eye on Culture

DRAFT – final pending AHRQ approval What’s next? 12 HSOPS re-administration will open on July 1 st. The final project call for cohorts 1 and 2 is scheduled for July 1 st. We will be contacting a sample of units for an SSI project feedback opportunity on the project. We will be contacting those teams about this within the next couple of months.

DRAFT – final pending AHRQ approval 13 It’s the soil, not the seed. --Louis Pasteur Nurture your safety culture.

DRAFT – final pending AHRQ approval Content Call Evaluation 14 We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: If you are not able to reach the link from the slide, please cut & paste the URL into your browser.