1. © 2009 On the CUSP: STOP BSI Data We Can Count On

2. © 2009 Learning Objectives To understand the data collection and entry requirements for the STOP-BSI initiative. To understand the importance of accurate data collection and entry.

3. © 2009 Importance of “Good” Data We must ensure that the data we collect are accurate, complete and in the required format. The data we collect and enter are the ultimate proof of our success & de-identified, aggregated data will be shared broadly (i.e., they will influence care and policy).

4. © 2009 Roles of Data Baseline – Tells us where we are at the start. On-going – Tells us whether and how we are changing our outcomes and performance. Overall – Tells us what impact we (i.e., the project and its initiatives) have on the goal of reducing/eliminating CLABSIs.

5. © 2009 Data Flow Data transcribed onto form Data entered into web-based tool, Care Counts Quality checks completed Data stored in database Reports Manuscripts

6. © 2009 Required Data Technology & Exposure Survey Baseline Administrative Baseline CLABSI Monthly CLABSI Monthly Team Checkup Tool Health Survey on Patient Safety Culture (HSOPS)

7. On the CUSP Data Collection FormFrequency of Completion How to submitReports generated Technology & Exposure surveyOnceSurvey Monkey (Link will be sent via email) Descriptive Culture assessment (AHRQ Hospital Survey on Patient Safety Culture) Baseline and 18 months HSOPS administered via MHA Care Counts or thru existing process such as Press Ganey (will accept surveys within 6 month window from state administration date, but will not be able to provide comparison data) Unit reports and comparative reports from Westat CLABSI*Monthlywww.mhacarecounts.orgComparative Available in MHA Care Counts Team Check-Up Form*Monthlywww.mhacarecounts.orgAvailable in MHA Care Counts Staff Safety Assessment survey ‘How is the next patient going to be harmed’ Baseline and biannualNot submittedNo report Learning From DefectsMonthlyNot submittedNo report * Due by the 15th of the Month following data collection. (Ex: January MTCT is due by February 15)

8. © 2009 Central Line Technology Survey State leader will send link & instructions Developed using SurveyMonkey.com Collects information on the types of central line technologies used in each participating clinical area (e.g., biopatch, needleless systems, etc.) Should be completed by the team leader

9. © 2009 Exposure Tool State leader will send link & instructions Developed using SurveyMonkey.com Collects information on the clinical area team’s prior exposure to elements of the STOP BSI initiative and methods Should be completed by the team leader

10. © 2009 Data Entry Web-based data entry tool. Tool provides for data entry and reporting Baseline data entered prior to work with STOP BSI checklist and methods. Monthly data entered by the 15 th of each month. Users can edit monthly data. Rolling 6-month lock on the data. Data quality checks built into the system.

11. © 2009 CLABSI Data Baseline: entered once at start of project. Usually for the year preceding the start of the immersion calls. Monthly: entered by the 15 th of the month. For example, January’s data is due for entry by February 15th. Total number of CLABSIs in the unit for the period of interest (baseline or month). Numerator Total number of central line days in the unit for the period of interest(baseline or month). Denominator

12. © 2009 Sources of CLABSI Data Often these data are available from the infectious disease control practitioners in your hospital. Team leader needs to arrange to obtain the data from infection control for baseline and monthly thereafter. Need to establish a pathway and process for resolving problems, questions with data.

13. © 2009 Monthly Team Checkup Completed monthly by team leader. Data entry completed by the 15 th of the month. Form provides a snapshot of team activity during the month. Allows team leaders, executives, collaborative sponsor and faculty to identify strengths and weaknesses of teams. Help teams who need help and identify teams who might mentor other teams.

14. MHA Care Counts Log-In

15. © 2009 Team Checkup Tool 4

16. © 2009 CLABSI Data Entry 1 2

17. 1 2 3 4 Data Validation Checks Must enter last month Verify if denominator is same as last month Verify if numerator is >2SD from last 3-12 months

18. © 2009 MTCT Data Entry

19. © 2009 MTCT cont’d

20. © 2009 CLABSI Report

21. MTCT Report 1 2 3 4

22. MTCT Common Barriers

23. © 2009 MTCT: Team Activities

24. © 2009 Data Status Report

25. © 2009 Action Items Complete the Central Line Technology Survey Complete the Exposure Tool Identify HOW and from WHOM CLABSI data (numerator & denominator) will be obtained Determine the process for completing the Monthly Team Checkup Tool Identify WHO will be responsible data entry in your ICU. Ensure that everyone involved in data entry is trained & understands what they need to do Develop a process for ensuring compliance with data quality control