1. DRAFT – final pending AHRQ approval 1 Deep-Rooting Your Data Liza Wick, MD Deb Hobson, RN

2. DRAFT – final pending AHRQ approval Learning Objectives 2 Define SSI data sources and determine which SSI data source fits you Describe process vs outcome data Create a plan to share your SSI data to communicate your progress and obtain the needed resources for your project. Define groups with whom you will be sharing your data Describe the barriers to making your SSI data a routine component of your quality improvement efforts. Develop an action plan to address barriers to sustaining the use of SSI data for quality improvement efforts.

3. DRAFT – final pending AHRQ approval Polling Question 3 What is your role in your clinical area? –Surgeon –Quality Improvement practitioner –Infection preventionist –OR nurse –OR technician –Anesthesiologist –OR manager

4. DRAFT – final pending AHRQ approval 4 SSI Data Sources for Surgical Site Infections

5. DRAFT – final pending AHRQ approval Polling Question 5 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

6. DRAFT – final pending AHRQ approval Polling Question 6 What kinds of SSI data do you receive in your clinical area? (select all that apply)  Risk-adjusted NSQIP data  NSQIP raw data  SIR NHSN  NHSN raw data  I don’t know

7. DRAFT – final pending AHRQ approval SSI Data Sources for Surgical Site Infections 7 There are several places where you can download your SSI data and get summary reports -SUSP/SSI data portal -NSHN and NSQIP sites It’s important to understand what each of these resources provide and what you need to consider as you develop a plan for sustainability. –Which platform will you use to get your reports?

8. DRAFT – final pending AHRQ approval Polling Question 8 Have you generated an SSI data report that shows your SSI data compared to other units?  Yes  No  I don’t know what a comparative report is If yes, please share comments in chat box about what reactions to the comparison were

9. DRAFT – final pending AHRQ approval Processes vs. Outcomes Data 9 Processes lead to outcomes Prioritize what you need to focus on in your data -Process data: What are we doing? -Outcome data: Did it make a difference? How do we know which one we should focus on? InputProcessoutputsoutcomes

10. DRAFT – final pending AHRQ approval Process data 10 What process data is collected in the surgical unit? Where is process data documented?

11. DRAFT – final pending AHRQ approval More Process Measure Examples Process Measure proper hair removal correct skin preparation in O.R. proper use of antimicrobial prophylaxis avoid incisional hematomas correct colon preparation avoid elective operation if remote site infection proper incisional protection proper sterilizer function in O.R. proper perioperative metabolic management adequate FiO 2

12. DRAFT – final pending AHRQ approval Interpreting the Denominator 12 The denominator dilemma –If you have a low # of cases, delve into your process data Monthly report vs. quarterly reports

13. DRAFT – final pending AHRQ approval 13 Data Sharing

14. DRAFT – final pending AHRQ approval Polling Question 14 Who currently is responsible for downloading and distributing your SSI data reports  It varies-whoever is available  Our quality representative  Our SUSP team lead  Our CE sends it to us  We don’t distribute SSI data reports.  Other (please explain in chat box)

15. DRAFT – final pending AHRQ approval Develop a Data Sharing Plan 15 Assign a role for these tasks  Downloading SSI data  Extraction and compiling SSI data  Distribute SSI data reports

16. DRAFT – final pending AHRQ approval Create an Orientation to the Data Summary 16 The data that you present should be tailored to your audience  Explain the data in ways that make sense to your audience  Describe what specialties or surgeons the data includes e.g. colectomy can cross specialties  Describe data for Internal vs external audience  Decide on detailed data vs summary data  Ask “what is the focus?” and “How do I gage my audience?”

17. DRAFT – final pending AHRQ approval Leverage Your Data 17 Package your data reports, framing it to your audience Create a business case, using your data Create a strategy to share your data reports to leverage what you need for your project

18. DRAFT – final pending AHRQ approval SSI Opportunity Estimator 18 SSI Opportunity Estimator –Estimate lost revenue from patients with infections using SUSP web-based calculator

19. DRAFT – final pending AHRQ approval SSI Opportunity Estimator 19

20. DRAFT – final pending AHRQ approval Business Case for enhanced recovery protocol to decrease length of stay 20 Outcome Additional Revenue Expense

21. DRAFT – final pending AHRQ approval Barriers to Deep-Rooting Your Data 21 Staff turnover Throughput as a distraction (e.g. OR delays) Competing priorities Perception/believability the data (SSI cases aggregated)

22. DRAFT – final pending AHRQ approval Develop a Sustainable Action Plan to Deep-Root Your Data 22

23. DRAFT – final pending AHRQ approval To Do Checklist-A Summary of Action Items 23  Define roles  Confirm SSI data source  Define report type  Develop a data sharing plan  Create a data sharing feedback mechanism

24. DRAFT – final pending AHRQ approval Polling Questions 24 Would your hospital be interested in joining the Enhanced Recovery Protocol affinity group? -Yes -No What affinity groups would your hospital be interested in joining (you can select more than one)? –Enhanced Recovery Protocol –Bowel prep/oral antibiotics, glucose control –OR traffic, environmental, sterile technique (environmental issues) –Skin prep, abx, normothermia (SCIP measures)

25. DRAFT – final pending AHRQ approval Content Call Evaluation 25 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: https://www.research.net/s/SUSP_C1_2_Content_Eval