1. Measurement for SHN! – Submitting Data January 31, 2006 Virginia Flintoft, RN MSc Project Manager, SHN! Central Measurement Team

2. Measurement Strategies – SHN! When to send Where to Send How to send What to send Privacy

4. Measurement - When to Send? Plan to receive data in all forms by end of February Teams to retain data until CEO signed consent for CMT to receive Teams will be notified by email when to send and contact information Teams report monthly on their work

5. Measurement – Where to Send? Data to be sent directly to SHN! Central Measurement Team (CMT) at University of Toronto Data to be received on secure server or by fax in locked office both at UofT

6. Mechanics for Data Collection

7. Measurement – How to Send? Data to be sent to Central Measurement Team at University of Toronto by: Facsimile Hardcopy of Measurement Worksheet or Spreadsheet Use SHN! Fax cover sheet Fax number TBA Web Transfer Electronic version of Measurement Worksheet or Spreadsheet Link to secure web transfer site from SHN website and CoP Email Attachment Not recommended Teams send data by email attachment at your own risk

8. Measurement – What to Send? Data to be sent to Central Measurement Team at University of Toronto includes: Hardcopy of Measurement Worksheet or Spreadsheet Containing only aggregate data OR Electronic version of Measurement Spreadsheet or Worksheet Containing only aggregate data OR Do NOT send individual identifiable patient information

9. Data Collection Tool - Measurement Worksheet - SSI

10. Data Collection Tool – SSI Measurement Worksheet - Completed 3.0 Percent of Clean Surgery Patients with Surgical Infection – Measurement Worksheet Prevention of Surgical Site Infection (SSI) Intervention: Reducing Surgical Site Infection Definition: Rate of infection in patients undergoing clean surgery (NNIS Class 3 or 4 wound class: Appendix C) Goal: Goal may be set by individual organizations/teams however, IHI recommends a reduction of 50% Data Collection Details Hospital Name: A - LARGE - MANITOBA - HOSPITAL Health Region: X NA or Specify Region: Year: Indicate the year for which the data was collected:  2004  2005 X 2006  2007  Other (specify): ____ Collection Method: X Concurrent  Retrospective Month: Indicate the month for which the data was collected:  Jan. X Feb.  Mar.  Apr.  May  June  July  Aug.  Sept.  Oct.  Nov.  Dec. Implementation Stage:  Baseline stage X Early implementation stage  Full implementation stage (Pre-intervention)(Some team members in selected unit(s)(All team members on selected unit(s) are have begun implementing AMI bundle)consistently implementing AMI bundle) Patient Sample: 1 worksheet/sample Indicate the “clean” surgical procedure you have selected to monitor by placing a  in the corresponding box. We recommend you use separate sheets for monitoring individual procedures, however if you choose to monitor more than one surgical procedure at once please indicate your selection by placing a  in the corresponding boxes for all procedures. Surgical Procedure:  CABG  Cardiac Surgery X Hip arthroplasty  Knee arthroplasty  Colon surgery  Hysterectomy  Vascular Surgery

11. Data Collection Tool – SSI Measurement Worksheet - Completed Calculation of Denominator FormulaAnswer 3.1 What is the total number of patients during the previous month who had an inpatient surgical procedure of the type indicated above? If more than one surgical procedures are performed during a single index hospitalization include data from the first surgical procedure only (CCI related codes: Appendix B) 25 3.2 What is the total number of patients in # 3.1 whose age was less than 18 yrs on admission to hospital? Exclude from patient list for calculating Percentage of “clean” surgery patients with surgical infection. 3 3.3 Subtract the total of # 3.2 from the total of # 3.1 and enter here. (3.1 - 3.2 = ) 22 3.4 What is the total number of patients with an existing infectious process at the same site as the surgical procedure or surgeries that are classified as wound class 3 or 4? 1 3.5Subtract the total of # 3.4 from the total of # 3.3 and enter here. (3.3 - 3.4 = ) 21 Calculation of Numerator – Retrospective FormulaAnswer 3.6 What is the total number of patients in # 3.5 (wound classification 1 & 2) who developed a post-operative wound infection / nosocomial infection as defined by NNIS (www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf) - see Appendix C. 15 Final Calculation FormulaAnswer 3.7Divide # 3.6 by #3.5. Multiply by 100.(3.6 / 3.5) x 100 71 %

12. Data Collection Tool – Sample Excel SS & Run Chart

14. Sources for Help with Measurement and Submission Help for teams in measurement Safety & Improvement Advisors (SIAs) Conference calls on interventions Communities of Practice National Learning Series workshops and Local meetings coordinated by Nodes

15. Measurement – Privacy Each participating hospital / health region will give CMT permission to receive, store, analyze and report data Secure data transfer and storage assured REB (UofT) and Privacy Consultant’s approval of process to act as agents for Ontario Health Information Custodians Policies consistent with Ontario PHIPA

16. Data Privacy Data privacy strategies will include: Anonymized data; Technological measures including maintaining data on a secure system accessible only by the measurement team using passwords and data encryption. Individual hospitals results will not be identified without consent Data collected for QI and may be used for research

17. Questions or More Information Virginia Flintoft 416.946.8350 virginia.flintoft@utoronto.ca G. Ross BakerPeter Norton 416.978.7804403.210.9236 ross.baker@utoronto.ca norton@ucalgary.ca