1. 1 Turning data into action: Using HSOPS and SSI data as part of a meaningful change Sallie Weaver, PhD & Deb Hobson, RN Julius Pham, MD, PhD ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY July 21 st and July 23 rd, 2014 DRAFT-Final pending AHRQ approval

2. Agenda 2 SUSP timeline: Where are we now? Interpreting safety culture survey data (HSOPS) and using results for improvement 1.Accessing & interpreting HSOPS Score reports 2.Debriefing & using your team’s data High level description of new SSI data registry features 1.SSI rate reports (App Performance Monitor & Trend Graph) 2.Missing data reports Next steps How to use data to effect change Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

3. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. SUSP: Where are you now? 3 April 2014 SUSP Kickoff and conduct SUSP pre-mortem exercise Administer HSOPS May 2014 Watch Science of Patient Safety video Administer PSSA June 2014 Schedule monthly executive safety rounds for the year Complete HSOPS administration July 2014 Share HSOPS and PSSA results with your team during monthly executive safety rounds DRAFT-Final pending AHRQ approval

4. 4 Interpreting Safety Culture Survey Data (HSOPS) and Using Results for Improvement Presented by: Deborah B. Hobson, RN & Sallie J. Weaver, PhD DRAFT-Final pending AHRQ approval

5. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. For completed or uploaded HSOPS data Your survey coordinator can download a copy of your aggregate survey report from the SUSP Online Portal https://armstrongresearch.hopkinsmedicine.org/susp How To Find Your Team’s HSOPS Results DRAFT-Final pending AHRQ approval 5

6. 6 Select “My Reports” from the “My Network” drop down menu DRAFT-Final pending AHRQ approval How To Find Your Team’s HSOPS Results

7. 7 1.Project: Select “SUSP” 2.Tool: Select “HSOPS for SUSP” 1.Project: Select “SUSP” 2.Tool: Select “HSOPS for SUSP” DRAFT-Final pending AHRQ approval How To Find Your Team’s HSOPS Results

8. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 8 JHH-Colorectal Team- OR 3.Network: Select your Unit 4.Report: Select “HSOPS Report” 3.Network: Select your Unit 4.Report: Select “HSOPS Report” DRAFT-Final pending AHRQ approval How To Find Your Team’s HSOPS Results

9. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. The same HSOPS Report can also be downloaded from your HSOPS App Dashboard after your survey period closes. 9 DRAFT-Final pending AHRQ approval How To Find Your Team’s HSOPS Results

10. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. IMPORTANT NOTE: 10 Your survey coordinator will only be able to download HSOPS reports AFTER your survey period has CLOSED HSOPS report downloads are not available for OPEN surveys –If actively collecting responses online –If uploading previously collected HSOPS data Cohort 5 HSOPS survey period closing dates: July 15, 2014 DRAFT-Final pending AHRQ approval How To Find Your Team’s HSOPS Results

11. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. HSOPS Aggregate Report 11 Survey response rate (Pages 4-6, 29-34) Johns Hopkins Hospital Interpreting Your Team’s HSOPS Results DRAFT-Final pending AHRQ approval

12. Composite score (Page 7-8) 71% of team members who responded to the survey felt positively about the teamwork within their work area Only 16% of team members felt that there was clearly a non-punitive response to error in their work area DRAFT-Final pending AHRQ approval Interpreting Your Team’s HSOPS Results Interpreting Composite Scores: The big picture view Higher is better

13. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Individual Question Scores (Pages 9-26) Percent positive = Green Percent neutral = Yellow Percent negative = Red DRAFT-Final pending AHRQ approval Interpreting Your Team’s HSOPS Results

14. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Questions provide a deeper dive 14 NOTE: Due to rounding totals may not add exactly to 100% DRAFT-Final pending AHRQ approval Interpreting Your Team’s HSOPS Results Tip: For positively worded items, more GREEN is better.

15. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Questions provide a deeper dive 15 Tip: For negatively worded items, more RED is better. NOTE: Due to rounding totals may not add exactly to 100% Interpreting Your Team’s HSOPS Results

16. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Debrief survey results with all your team members Debriefing is a semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Encourages open communication, transparency, and interactive discussion –a cross all levels of the work area –between disciplines Engages clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area What is Debriefing? 16

17. Work units that debrief around safety culture perform better Data is data. Debriefing turns data into information. Debriefing accelerates improvement. 1 Units who did not debrief survey results achieved 2.2% Reduction in Infection Rates Units who used semi- structured debriefing of culture survey achieved 10.2% Reduction in Infection Rates YES NO 17 Making HSOPS Data Meaningful

18. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. How do I use the CUSP culture check-up tool? 18 Share culture results with everyone on the unit during a survey debriefing –Bring together team members from your work area –Follow your debriefing plan Take notes and recognize recurring themes Encourage open, honest discussion about making the culture of your work area the best it can be Making HSOPS Data Meaningful

19. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 19 Focus on identifying system issues that the group can work on improving together instead of as individuals. –Don’t use it to point fingers at specific individuals Use the tool to structure meetings and guide conversation. As a group, complete all steps in this worksheet. Making HSOPS Data Meaningful How do I use the CUSP culture check-up tool?

20. HSOPS debriefings with CUSP culture check-up tool 20 What is the Purpose of this Tool? Understand the unit culture Use teammates’ feedback to predict and avoid barriers Use feedback to leverage the team’s strengths Who Should Use this Tool? Safety culture debriefing facilitators Helps to guide the discussion and record group decisions Making HSOPS Data Meaningful

21. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. CUSP Culture Check-Up Tool: A tool to use during HSOPS Debriefings 21 Where can I Find this Tool? How can we use our HSOPS data in a meaningful way? https://armstrongresearch.hopkinsmedicine.org/susp/hsops/resources.aspx DRAFT-Final pending AHRQ approval

22. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 1.Identifies general strengths and weaknesses of your unit culture 2.Get specific about behaviors and attitudes that make up those strengths and weaknesses 3.Select opportunities for growth 4.Develop a strategy for addressing growth opportunities 5.Put plan into action 6.Evaluate results and share progress during SUSP team meetings Steps in CUSP Culture Check-Up Tool 22

23. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Tip: Download the Culture Check Up Tool at either https://armstrongresearch.hopkinsmedicine.org/susphttps://armstrongresearch.hopkinsmedicine.org/susp OR www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/toolkit/culturecheckup.html Tip: Download the Culture Check Up Tool at either https://armstrongresearch.hopkinsmedicine.org/susphttps://armstrongresearch.hopkinsmedicine.org/susp OR www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/toolkit/culturecheckup.html Culture Check Up Tool Culture Check Up Tool is a document used by Debriefing Facilitator to guide conversation and improvement planning Download from either to SUSP project page or the AHRQ website 23

24. Brainstorming culture discussion items Statement To Be Discussed Unit Safety Assessment Score % What does this statement mean to you? How accurately does the unit score reflect your experience on this unit? Share examples. How would it look (what behaviors or processes would we see) in this unit if 100% of staff responded “agree strongly” with this item? Identify at least one actionable idea to improve unit results in this area. What are the next steps and how will we accomplish them? Culture Check Up Tool 24

25. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 25 Debriefing Plan Highlights Decision Points For Project TeamDebriefing Plan How many debriefing sessions will be held? Who will facilitate each debriefing session? When will debriefing(s) be held? Who is responsible for taking notes and recording ideas from each session? If you conduct more than one debriefing session, who is responsible for collating notes and ideas for improvement from the different sessions? How will the CUSP team ensure there is follow-up on the action items from the debriefing session(s)?

26. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. What’s Next? 1.Review the survey report for your clinical areas 2.Distill the information into 3-5 key slides 3.Plan debriefing strategy to share results with team –Be prepared to listen –Ask for feedback –Ask teammates to help come up with solutions 4.Gather a small group together and use the “culture debriefing tool” to examine the roots of problem areas and begin to formulate strategies for improvement 26

27. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Questions? 27

28. 28 Using the SSI data registry to turn SSI data into action Learn how to create SSI reports to share with your SUSP team!

29. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Who Can Access The SSI Data Registry? 29 Anyone who has “administrator” access to the hospital level and team (NHSN and/or NSQIP) networks in SUSP portal –If your name was on your hospitals’ SUSP Portal Registration Form, you have “administrator” access! DRAFT-Final pending AHRQ approval

30. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Generate reports 30 Reports that provide real-time performance feedback –SSI app performance monitor report –SSI trend graph reports at CE and hospital level SSI missing data report DRAFT-Final pending AHRQ approval What Can You Do in SSI Data Registry?

31. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Access the SSI Data Registry 31 DRAFT-Final pending AHRQ approval Project Site: https://armstrongresearch.hopkinsmedicine.org/susp.aspx

32. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. My Tools Homepage 32 “SSI app” = SUSP: Improving Surgical Care through TRiP and CUSP Click the actual words, SUSP: Improving Surgical Care through TRiP and CUSP, not your hospital name underneath DRAFT-Final pending AHRQ approval

33. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. SSI Data Registry Homepage 33 TIP: If button reads REGISTER instead of REPORTS, please contact us at SUSP@Jhmi.edu. DRAFT-Final pending AHRQ approval

34. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 34 TIP: Use the manual! SUSP Generating reports using the SSI data registrySUSP Generating reports using the SSI data registry DRAFT-Final pending AHRQ approval Generating SSI Performance Reports

35. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. SUSP SSI app performance monitor homepage 35 Click here to generate your SSI app performance monitor report: DRAFT-Final pending AHRQ approval Generating SSI Performance Reports

36. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Example: SSI App Performance Monitor Report 36 DRAFT-Final pending AHRQ approval Generating SSI Performance Reports

37. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. SSI trend graph reports 37 Click here to generate your SSI trend graph report: DRAFT-Final pending AHRQ approval Generating SSI Trend Reports

38. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Example: Hospital level trend graph report 38 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) 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) SSI rate = (# SSIs/total # cases)*100 DRAFT-Final pending AHRQ approval Generating SSI Trend Reports

39. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 39 Who can generate them? –Coordinating Entities and any one who has access to the portal When? –Monthly, quarterly, yearly Why? –To monitor hospital team’s SSI data upload into the SSI data registry For assistance, download the manual “SUSP Generating Missing Data Reports” at https://armstrongresearch.hopkinsmedicine.org/susp.aspx https://armstrongresearch.hopkinsmedicine.org/susp.aspx DRAFT-Final pending AHRQ approval Generating SSI Missing Data Reports

40. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. https://armstrongresearch.hopkinsmedicine.org/susp.aspx 40 DRAFT-Final pending AHRQ approval Generating SSI Missing Data Reports

41. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 41 Surgical Site Infections- NHSN or NSQIP SUSP Select hospital level Missing Data Report DRAFT-Final pending AHRQ approval Generating SSI Missing Data Reports

42. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Example: Hospital level missing data report 42 Different ways to interpret NO: 1.The CE has not yet uploaded data into the portal 2.CE uploaded data, but hospital has not yet submitted data for that month 3.CE and hospital uploaded data, but the hospital did not have any (for example) colorectal cases that month DRAFT-Final pending AHRQ approval Generating SSI Missing Data Reports

43. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Next Steps 43 Hospitals:  Confer your NHSN rights to your CE (reminder for Independent, California hospitals)  NSQIP hospitals- return NSQIP addendum to ACS NPT and CEs:  CE and NPT will continue or begin transferring your NHSN and NSQIP data into the SSI data registry Once data is in registry, SUSP teams can generate their performance monitor and trend graph reports! DRAFT-Final pending AHRQ approval

44. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Using Data To Drive Quality Improvement 44 Generate monthly reports Share reports with teams Use events to initiate investigations DRAFT-Final pending AHRQ approval

45. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Questions? 45 DRAFT-Final pending AHRQ approval

46. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. https://armstrongresearch.hopkinsmedicine.org/susp 46 Reminder… You can access all slides, call recordings, and project tools and data discussed today on the SUSP Online Portal DRAFT-Final pending AHRQ approval Resources

47. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. 47 How is your team planning to share and use your data? What hurdles might come up? DRAFT-Final pending AHRQ approval

48. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. Team Brainstorm… 48 Ideas, tips, or advice to mitigate or manage these potential hurdles? DRAFT-Final pending AHRQ approval

49. Questions? Contact the SUSP helpdesk at SUSP@jhmi.edu. References 49 1.Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):509-14.