1. DRAFT – final pending AHRQ approval CUSP for Safe Surgery: The Surgical Unit-Based Safety Program SUSP/Cohort 3 One Year Review Sean Berenholtz, MD, MHS, FCCM February 11, 2014

2. DRAFT – final pending AHRQ approval First Year Review The SUSP vision Where the project is right now Next Steps 2

3. DRAFT – final pending AHRQ approval Many ideas grow better when transplanted into another mind than the one where they sprang up. —Oliver Wendell Holmes The power of collective wisdom

4. DRAFT – final pending AHRQ approval The goals of the SUSP Project To achieve significant reductions in surgical site infection and surgical complication rates To achieve significant improvements in safety culture 4

5. DRAFT – final pending AHRQ approval Why is Your SUSP Work Important? 1 in 25 people will undergo surgery 7 million (25%) in-patient surgeries followed by complication 1 million (0.5 – 5%) deaths following surgery 50% of all hospital adverse events are linked to surgery AND are avoidable 5 http://www.who.int/patientsafety/challenge/safe.surgery/en/

6. DRAFT – final pending AHRQ approval 6 A study that retrospectively examined a random sample of records for 61,523 hospitalized patients across 4,372 hospitals. Patients examined were those with acute myocardial infarction, congestive heart failure, pneumonia, and those with conditions requiring surgery. Adverse event-rates has declined significantly from 2005-2011 for those with myocardial infarction and congestive heart failure. Adverse event rates remained steady for those patients that had conditions that required surgery; rates of infection-related and post-procedural adverse events increased among patients who required surgery. * * N Engl J Med; 370;4:341-351. (January 23, 2014)

7. DRAFT – final pending AHRQ approval Wrong-patient, Wrong-site, Wrong-procedure Events Reviewed by The Joint Commission * 7 * The Joint Commission, Sentinel Event Data; http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29.

8. DRAFT – final pending AHRQ approval Polling Question Has increased compliance in SCIP measures reduced SSI rates in your organization? Why might this be? 8

9. DRAFT – final pending AHRQ approval Key concepts: Adaptive and Technical Work 9 Technical Work Adaptive Work Sweet Spot

10. DRAFT – final pending AHRQ approval 10 Technical WorkAdaptive Work Procedural components of work, like performing skin prep The ‘intangible’ components of work, like ensuring an OR team holds each other accountable for quality skin prep Work that we know we ‘should’ do, like letting skin prep dry before incision Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they ‘should’ Work that lends itself to checklists or protocols Culture change is not a checklist Key concepts: Adaptive and Technical Work

11. DRAFT – final pending AHRQ approval How is SUSP different? Informed by science Embeds adaptive CUSP work into technical work Led by clinicians and supported by management Guided by measures 11

12. DRAFT – final pending AHRQ approval SUSP can be tailored to your environment No single SSI prevention bundle –Frontline staff identifies local defects –Develop a SSI prevention bundle to address local defects Measure local safety culture using Hospital Survey of Patient Safety (HSOPS) 12

13. DRAFT – final pending AHRQ approval 13 Goal: 15% Quarter 3 Skin preparation protocol Pre-op wash clothes Quarter 4 CUSP kickoff Antibiotic deficiencies addressed Quarter1 Pre-op warming Enhanced sterile technique Intervention checklist Quarter4 Briefing/Debriefing Mechanical bowel prep with oral antibiotics CUSP Works in the OR Colorectal NSQIP SSI Rate at Hopkins (Wick 2012) * Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. J Am Coll Surg. 2012; 215 (2). *

14. DRAFT – final pending AHRQ approval WHERE IS SUSP NOW & WHERE ARE WE GOING? Armstrong Institute for Patient Safety and Quality Where Is SUSP Now & Where Are We Going?

15. DRAFT – final pending AHRQ approval Where Is SUSP Now? State and hospital enrollment SSI data update HSOPS completion Our path forward 15

16. DRAFT – final pending AHRQ approval SUSP Enrollment by Coordinating Entity 16 Armstrong Institute for Patient Safety & Quality Hawaii Safer Care SUSP Collaborative Arkansas Hospital Association Iowa Healthcare Collaborative (HEN) Colorado Hospital Association Maryland Hospital Association Connecticut Hospital Association Michigan Health & Hospital Association (HEN) Florida Hospital Association Nevada Health Insight (HEN) Georgia Hospital Association (HEN) Tennessee Hospital Association (HEN) Premier Healthcare Alliance (HEN) Massachusetts Hospital Association SUSP Enrollment by Coordinating Entity

17. DRAFT – final pending AHRQ approval SUSP Enrollment by Coordinating Entity and Cohort 17 Coordinating EntityNumber of Hospitals Enrolled Armstrong Institute32 Arkansas Hospital Association10 Colorado Hospital Association8 Connecticut Hospital Association7 Florida Hospital Association11 Georgia Hospital Association14 Hawaii14 HealthInsight Nevada4 Iowa Healthcare Collaborative13 Maryland Hospital Association18 Massachusetts Hospital Association8 Michigan Health & Hospital Association46 Premier Healthcare Alliance8 Tennessee Hospital Association10 Total Enrollment Cohort 110 Cohort 2103 Cohort 347 Cohort 442 Total202

18. DRAFT – final pending AHRQ approval A big THANK YOU to all of our Cohort 3 SUSP Teams! Coordinating Entity: Connecticut Hospital Association Danbury Hospital Coordinating Entity: Georgia Hospital Association Gwinnett Medical Center – Lawrenceville Gwinnett Medical Center- Duluth Liberty Regional Medical Center Spalding Regional Hospital Atlanta Medical Center Upson Regional Medical Center Hamilton Medical Center Medical Center of Central Georgia Habersham Medical Center Floyd Medical Center Tift Regional Medical Center Ty Cobb Regional Medical Center Emory 18 Coordinating Entity: Maryland Hospital Association Calvert Memorial Hospital Carroll Hospital Center Harford Memorial Hospital MedStar Franklin Square Medical Center MedStar Harbor Hospital MedStar Montgomery Medical Center MedStar St. Mary's Hospital MedStar Union Memorial Hospital Mercy Medical Center Sinai Hospital of Baltimore The Johns Hopkins Hospital Upper Chesapeake Medical Center Bon Secours Baltimore Health System Holy Cross Hospital Laurel Regional Hospital Prince George's Hospital Center University of Maryland St. Joseph Medical Center Western Maryland Health System Coordinating Entity: Armstrong Institute for Patient Safety & Quality Canton-Potsdam Hospital Cooper Health Indiana University Health - Arnett Lehigh Valley Health - Cedar Crest Lehigh Valley Health- Muhlenburg Sanford USD Medical Center Southwest General Health Center Ochsner Medical Center Indiana University Health - Ball Memorial Hospital Coordinating Entity: Iowa Healthcare Collaborative Alegent Creighton Health Immanuel Medical Center Alegent Creighton Health Lakeside Alegent Creighton Health Mercy BLUFFS? Hospital Alegent Creighton Health Midlands Hospital Bergan Mercy Medical Center Creighton University Medical Center

19. DRAFT – final pending AHRQ approval Team Calls and Resources Check out the SUSP website for great resources https://armstrongresearch.hopkinsmedicine.org/susp.aspx SUSP Tools CUSP Tools HSOPS Toolkit Recordings and Slide Presentations for SUSP Webinars -Using SUSP Audit tools -Executive Partnerships -Learning from Defects -Briefings and Debriefings -Optional SUSP Tools -HICPAC Guidelines 19

20. DRAFT – final pending AHRQ approval John Muir Video 20 SUSP Teams Are Engaged: Video submissions

21. DRAFT – final pending AHRQ approval SUSP Teams Are Engaged: MedConcert Teams have initiated discussion via MedConcert: Susan Overman– Wound classification documentation practices Heidi LePard- Literature pertaining to c-section SSI’s Dana Bonistalli– Forced air warming practices MedConcert Link: https://www.medconcert.com/ 21

22. DRAFT – final pending AHRQ approval Polling Question What technical processes are you currently working on? (multi answer) -Skin preparation -Antibiotic timing/selection/re-dosing -Normothermia -Enhanced sterile techniques -OR Traffic -Glucose control -Hyperoxia -Other (type in the chat box) 22

23. DRAFT – final pending AHRQ approval Summary of SSI Data Submission 23 Total # of cohort 3 hospitals 47 SSI data available NHSN Hospitals 3919 NSQIP Hospitals 65 NHSN & NSQIP 2 Undeclared data source 0 Questions? Email the SUSP help desk! SUSP@jhmi.edu

24. DRAFT – final pending AHRQ approval 24 Your Data to Date *SSI rate (%) = (# of SSIs / Total # of cases) 13-Feb13-Mar13-Apr13-May13-Jun13-Jul13-Aug13-Sep13-Oct13-Nov13-Dec NHSN: Cohort 36 (10/155)5 (8/142)5 (10/179)5 (11/185)5 (10/193)5 (10/168)2 (4/185)4 (9/181)4 (7/153)2 (3/113)0 (0/27) NHSN: Total hospitals 19 NSQIP: Cohort 315 (8/51)6 (3/44)8(5/60)3(2/54)6 (3/50)3(2/51)11 (1/9) 0 (0/1) NSQIP: Total hospitals 455555211

25. DRAFT – final pending AHRQ approval Timely data reports guide your project improvement work Hospital teams can generate monthly SSI data reports after the CE transfers data files from NHSN Currently, data submission rates are low because: -Competing priorities -Challenges with DUA’s -Hospital teams are less familiar with SUSP data reporting capabilities Summary of plan to get more data into the portal -State Coordinators tracking the data transfer process -Plan to educate teams on generating SSI data reports during upcoming state coaching calls 25

26. DRAFT – final pending AHRQ approval How are you using your data to drive progress? Is your hospital downloading progress reports to view your current SSI rates? How have you used your SSI data to foster engagement with project stakeholders? What can we do to help you be successful in sharing your data? 26

27. DRAFT – final pending AHRQ approval Polling Question What tools/strategies have you been using to address adaptive challenges in your SUSP work? -Educate staff on the Science of Safety -Staff Safety assessment -Debrief HSOPS results with front line teams and leadership -Executive partnership -Learning from defects/investigating SSI -Briefing and debriefing tools -Others 27

28. DRAFT – final pending AHRQ approval Why Safety Culture Matters Safety culture is related to outcomes –Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors –Clinician outcomes Incident reporting, burnout, turnover 28 Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

29. DRAFT – final pending AHRQ approval Why Safety Culture Matters 2.Safety culture influences the effectiveness of other safety and quality interventions –Can enhance or inhibit effects of other interventions 3.Safety culture can change through intervention –Best evidence so far for culture interventions that use multiple components 29 Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

30. DRAFT – final pending AHRQ approval SUSP HSOPS Baseline Results CohortTime Phase# Hospitals Submitted Data Total Hospitals Date Submission Rates 110/15/2012-12/1/1271164% 21/18/13-3/18/13325459% 34/9/2013 – 6/8/2013364678% 410/28/2013- 2/16/2013374288% Total11215373% 30

31. DRAFT – final pending AHRQ approval CohortStart DateClose Date 17/1/20148/15/2014 27/1/20148/15/2014 310/1/201411/15/14 44/1/20155/16/2015 31 Follow-up (Approximately 16 months after baseline administration) HSOPS Re-Administration Schedule

32. DRAFT – final pending AHRQ approval HSOPS Review and Debriefing Have you reviewed your HSOPS results? What have you uncovered? Have you discussed these results with your SUSP team and staff? Have the HSOPS results driven your approach to your SUSP project? 32

33. DRAFT – final pending AHRQ approval What will this next year look like? Project calls -A combination of technical topics and hospital team presentations Re-administering HSOPS -Survey will open in October 2014 Select interviews -The NPT will be conducting quarterly interviews to learn more about your SUSP project. On-going monthly state level coaching calls 33

34. DRAFT – final pending AHRQ approval DateTopicCohortPresenter Tuesday, February 11 @4PM (EST)Annual Update3Sean Berenholtz Tuesday, March 11 @4PM (EST)Blood Management3Steven Frank Tuesday, April 8 @4PM (EST)Hospital Team Experiences3Hospital Teams 1. 2. Tuesday, May 13 @4PM (EST)Re-op Optimization3Tom Varghese Tuesday, June 10 @4PM (EST)Hospital Team Experiences3Hospital Teams 1. 2. Tuesday, July 8 @4PM (EST)(pending) Surgeon Technique/Videotaping 3Caprice Greenberg Tuesday, August 12 @4PM (EST)Hospital Team Experiences3Hospital Teams 1. 2. CUSP for Safe Surgery (SUSP) Project Call Schedule Implementation Phase

35. DRAFT – final pending AHRQ approval Horizontal Learning Initiative Medconcert professional networking site Peer to peer sharing and collaboration -Hospital team presentations during cohort 3 project calls -State coaching calls -Other ideas 35

36. DRAFT – final pending AHRQ approval Additional Resources Armstrong Institute Training Opportunities –http://www.hopkinsmedicine.org/armstrong_institute/training_services /cusp_offerings/http://www.hopkinsmedicine.org/armstrong_institute/training_services /cusp_offerings/ AHRQ CUSP Toolkit –http://www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/http://www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/ Armstrong Institute CUSP Tools –http://www.hopkinsmedicine.org/armstrong_institute/training_services /cusp_offerings/cusp_guidance.htmlhttp://www.hopkinsmedicine.org/armstrong_institute/training_services /cusp_offerings/cusp_guidance.html 36

37. DRAFT – final pending AHRQ approval Share your Story! We would like to spend some time hearing from you— What have been your breakthroughs? What are your hopes and expectations for the coming year? 37

38. DRAFT – final pending AHRQ approval Content Call Evaluation 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_Cohort3 If you are not able to reach the link from the slide, please cut & paste the URL into your browser. 38