1. How to Use the SUSP Online Portal A training call for SUSP facilitators May 12, 2014 Sallie Weaver, PhD & Erin Hanahan, MPH Armstrong Institute for Patient Safety and Quality May 14, 2014 Laura Vail, MS

2. You enable SUSP teams’ success At the end of this webinar, you should be able to: Identify the roles and responsibilities of SUSP facilitators Explain the SUSP Portal registration process Locate HSOPS data registry ‘apps’ in the SUSP Portal Discuss the SSI data transfer and HSOPS administration processes 2

3. How we’ve structured this call Start high level Then go into details (not too far!) Point you to step-by-step resources for training on specific skills 3 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

4. SUSP Portal Main page Bookmark it! 4 https://armstrongresearch.hopkinsmedicine.org/susp.aspx

5. Why use the Portal? The Power of Data Frontline clinicians often don’t have access to hospitals’ performance data Through the SUSP Portal, you can put two types of project data in their hands: –Hospital Survey on Patient Safety (HSOPS), or “patient safety culture” survey data –Surgical site infection (SSI) data 5 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

6. The SUSP Portal is your project data resource You can get real-time safety culture and SSI data through the Portal –The HSOPS ‘app’ will generate a report of your safety culture scores 24 hours after the survey period closes Cohort 5 Baseline HSOPS survey period: May 14 to July 7, 2014 –SSI Data Registry will generate SSI reports for unadjusted data every month Once data has been entered into system 6 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

7. SUSP Facilitators All Work as a Team Coordinating Entity HSOPS Survey Coordinator SUSP Data Lead (“Hospital Administrator”) 7 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

8. SUSP Facilitator Responsibilities Coordinating Entity –Connects hospitals and the National Project Team (NPT) –Facilitates networking and improvement work HSOPS Survey Coordinator –Leads HSOPS administration (or data upload) at the hospital level SUSP Data Lead (“Hospital Administrator”) –Leads the process of connecting frontline staff to hospital SSI data 8 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

9. SUSP PORTAL REGISTRATION Your first step to accessing SUSP project data 9

10. High Level SUSP Online Team Registration form is a crucial first step to optimizing your participation in this project We use your registration info to create “networks” in the SUSP Portal –Networks ensure that your hospital team sees the right SSI and HSOPS data 10 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

11. In the Weeds We sent all registered SUSP users an email with temporary log-in information –If you have not yet received this information, please email the SUSP help desk (SUSP@jhmi.edu)SUSP@jhmi.edu OR Try logging in using these instructions: 11 Log in here: https://armstrongresearch.hopkinsmedicine.org/Default.aspx Use these credentials: Username: Your complete email address (e.g. john.smith@hospital.org)john.smith@hospital.org) Default Password: Your last name and first initial, capitalized (e.g. John Smith would use “SmithJ”) Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

12. HSOPS ADMINISTRATION Measure your perioperative area’s safety culture 12

13. Safety Culture Matters Safety culture is related to outcomes –Patient outcomes –Clinician outcomes Safety culture influences the effectiveness of other safety and quality interventions –Can enhance or inhibit effects of other interventions Safety culture can change through intervention –Best evidence so far is for culture interventions that use multiple components 13 Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011. Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

14. The SUSP Model to Improve Care 14 http://www.hopkinsmedicine.org/armstrong_institute

15. Do I have to upload or collect HSOPS data to participate in this project? No –No formal requirement to collect fresh HSOPS data or to upload previously collected data BUT! Safety culture data is a value-add for your SUSP work –Helps diagnose areas where culture might be hindering reliable use of evidence-based practices –Can help to understand why clinicians and staff are engaged (or not engaged) in safety efforts 15

16. Two Options for Safety Culture Data Collection Yes, we have previously collected HSOPS data Upload perioperative HSOPS data to the HSOPS App in the SUSP Portal https://armstrongresearch.hopkinsmedicine.org/MyTools. aspx https://armstrongresearch.hopkinsmedicine.org/MyTools. aspx No, we have not previously collected HSOPS data, or we would like to collect new data for the work areas participating in this project Collect new HSOPS data using the HSOPS App in the SUSP Portal https://armstrongresearch.hopkinsmedicine.org/MyT ools.aspxhttps://armstrongresearch.hopkinsmedicine.org/MyT ools.aspx 16 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

17. The HSOPS App is Located on the SUSP Portal https://armstrongresearch.hopkinsmedicine.org/MyTools.aspx You can only access the HSOPS Data App with a SUSP Portal login and password The HSOPS Data App will be functional within a specific time period of HSOPS “open” and “close” dates Cohort 5 Open Date: May 14, 2014 Cohort 5 Close Date: July 7, 2014 17 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

18. Survey coordinators will use the HSOPS App to… 1.Collect new HSOPS data or upload previous HSOPS data –Send invitation emails to survey participants –Emails contain a unique link that participants will click on to complete the survey 2.Check on the response rate for their work areas –Goal = 60% response rate –Stretch goal = 80% response rate or higher 3.Download a pdf report that summarizes survey results for their work area(s) –Reports will be available after the survey closes 18 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

19. Locating the HSOPS App Log in with your Username and Password https://armstrongresearch.hopkinsmedicine.org/susp.as px (bookmark it!) https://armstrongresearch.hopkinsmedicine.org/susp.as px Select My Tools 19 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

20. Accessing the HSOPS App Click Manage 20 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

21. 21

22. Accessing Your HSOPS Report 22 Available after Cohort 5 Survey “Closes” on July 7, 2014 Download aggregate report to obtain results of the HSOPS for your work area, including charts and graphs Use the aggregate report to debrief results with frontline staff and clinicians The purpose of the debriefing discussion(s) are to identify strengths and areas to improve using CUSP

23. Key Steps: If collecting fresh HSOPS data 1.Determine whom to survey 2.Compile email lists (Pre-op, OR, PACU) 3.Log on to the SUSP Portal https://armstrongresearch.hopkinsmedicine.org/susp.aspx https://armstrongresearch.hopkinsmedicine.org/susp.aspx 4.Upload a list of survey participant email addresses for participating work area(s) 5.The app will send each study participant an email which contains a unique link to the survey. 6.Check survey response rate weekly 7.After survey closes, download pdf report Based on your survey debriefing plan, share with project team, leadership, and frontline staff members 23 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

24. Is your email list up to date? 24 Make sure your list is up to date, check for: Staff on administrative or extended sick leave, Staff who appear in more than one staffing category or hospital area/unit, Staff who have moved to another hospital area/unit, Staff who no longer work at the hospital, and Other changes that may affect the accuracy of your list email addresses Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

25. Thinking about uploading existing HSOPS data? Some important questions Has data about the safety culture in our work area been collected in the last 12 months? If yes: -When was this data collected and how (e.g., online survey, paper survey, in person interviews)? Who has access to this data? -What aspects of culture were measurement/what data were captured? -Is it possible to obtain copies of the raw data (e.g., an excel file of responses) or only reports (e.g., pdf file with charts and graphs). 25 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

26. How to upload previously collected HSOPS data for your surgical work area 1.Find all HSOPS Resources at https://armstrongresearch.hopkinsmedicine.org/susp/hsops/reso urces.aspx https://armstrongresearch.hopkinsmedicine.org/susp/hsops/reso urces.aspx 2.Format your HSOPS data excel file as described in “HSOPS data formatting & definition guide” 3.Upload your correctly formatted HSOPS excel file to the HSOPS App 4.Check to make sure file uploaded correctly 5.Download report after survey closes –Based on your survey debriefing plan, share with project team, leadership, and frontline staff members 26 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

27. Aim for a response rate of 60% or higher Response rate = Number of respondents who completed the online survey divided by the total number of unit members who were invited to complete the survey Safety culture reflects the shared perceptions among unit members –Response rate of 60% is minimum necessary for a relatively representative sample –Important for validity and reliability of your results 27 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

28. Effective surveys… Are confidential and anonymous Have a clear reason and motivation to complete them Are publically supported by both formal and informal unit leaders 28 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

29. Thinking ahead: Creating a Debriefing Plan for your Survey Results Debriefing is… A semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Purpose… Encourage open communication, transparency, and interactive discussion about the survey results across all levels To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area 29 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

30. HSOPS Tools & Resources https://armstrongresearch.hopkinsmedicine.org/susp/h sops/resources.aspx Planning and Preparing HSOPS Quick Reference Guide Survey coordinator role and responsibilities Debriefing & using your HSOPS results for meaningful change Example results report Debriefing plan template Culture check up tool Improving patient safety in hospitals: resource list 30 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

31. HSOPS Tools & Resources https://armstrongresearch.hopkinsmedicine.org/susp/hs ops/resources.aspx If collecting fresh HSOPS data: –“Video guide: Collecting fresh HSOPS data” –“HSOPS Manual: Planning and preparing for your survey” –“Example survey pre-notification materials” –“Example email to participants from HSOPS App” –Template Email list “Send Emails” 31 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

32. HSOPS Tools & Resources https://armstrongresearch.hopkinsmedicine.org/susp/h sops/resources.aspx If uploading previously collected HSOPS data: –Video guide: Uploading previously collected HSOPS data –HSOPS data formatting & definition guide –HSOPS data upload template 32 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

33. References Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct- Dec;34(4):300-11. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print]. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004. van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9. Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011. Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press. 33

34. SSI DATA TRANSFER Use the SUSP Portal to get performance data in the hands of your frontline staff. 34

35. SSI data transfer steps NHSN 1.Return SUSP Data Use agreement ASAP! 2.If you haven’t already done so, confer rights to your CE’s NHSN group  All hospitals need to have conferred rights by Friday 5/30 3.That’s it! Coordinating Entities will do the rest! NSQIP 1.Return SUSP Data Use agreement ASAP! 2.Return ACS NSQIP addendum (these will be sent out by 5/16)  Return by Friday, 5/30 3.That’s it! ACS and the National Project Team will do the rest! 35 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

36. Example: Hospital level trend graph report 36 SSI rate = (# SSIs/total # cases)*100 Compare your hospital’s SSI rate to: 1.All SUSP NSQIP (or NHSN) participants 2.All hospitals in your cohort 3.All hospitals in your CE 4.All hospitals who are working on same surgical line (e.g. colorectal)

37. We have manuals to help you! Found online here: https ://armstrongresearch.hopkinsmedicine.org/susp/resources.aspx https ://armstrongresearch.hopkinsmedicine.org/susp/resources.aspx SSI Data Transfer Fast Facts –Provides a high-level overview of “who does what, when” and points you to additional training resources For Coordinating Entities: –NHSN Unadjusted SSI Exporting and Uploading Data Manual –NHSN SIR SSI Exporting and Uploading Data Manual –(Video) January 2014 CE Call: NHSN Data Transfer Process 37 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

38. Next Steps All hospitals –Begin HSOPS administration or upload (opens 5/14) Read the HSOPS fast fact sheet and HSOPS manuals for further instruction NHSN hospitals –Confer rights to your CEs NHSN group by 5/30 NSQIP hospitals –Return NSQIP addendum to ACS by 5/30 All: Attend the next training call on on July 21 st or 23 rd call –Debriefing your HSOPS report –Generating SSI reports 38 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

39. JOIN SUSP MEDCONCERT Connect Nationally with your Peers!

40. What is Medconcert? A secure social networking site where SUSP teams can learn from and collaborate with other SUSP hospitals Share strategies and successes Post questions for the experts on the National Project Team 40 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

41. How to join Medconcert 41 1. Click on the icon at the bottom of the SUSP Portal homepagePortal homepage 2. This will take you to MedConcert (the vendor). Click on the ‘Locate Me’ button Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

42. How to join Medconcert 3. The first time you log in, click under the ‘Don’t see your name?’ button 42 4. Complete your profile information Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

43. Congratulations! You can now connect with and learn from other SUSP hospitals 43 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

44. Next Call 44

45. What questions do you have? Remember, you have a support network –You can ask questions during coaching calls –You can contact the SUSP helpdesk 45 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)