1. 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

2. 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

3. 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

4. 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! )

5. 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

6. 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)

7. #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

8. #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 ) 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

9. 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

10. #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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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 ( under Tools and Resources

22. 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

23. Sample Completed Report

24. Project Assessment Scale

25. 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 to

26. Questions