1. The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Data We Can Count On Lisa H. Lubomski, PhD April 8, 2011 Immersion Call

2. Slide 2 Learning Objectives To understand the importance of accurate data collection and entry. To understand the data collection and entry requirements for the CSTS. To outline next steps towards implementing data collection activities as part of CSTS.

3. Slide 3 Immersion call Schedule TitleDate /Time 13:00 EST Presented by Program Overview Feb 18, 2011Peter Pronovost MD PhD Science Of Safety February 25, 2011Jill Marsteller, PhD, MPP Comprehensive Unit-Based Safety Program CUSP March 4, 2011Christine Goeschel MPA MPS ScD RN Central Line Blood Stream Infection Elimination March 11, 2011David Thompson DNSC, MS Surgical Site Infection Elimination March 18, 2011Elizabeth Martinez, MD, MHS Ventilator-Associated Pneumonia Reduction March 25, 2011Sean Berenholtz, MD Hand-Offs: Transitions in Care April 1, 2011Ayse Gurses, PhD Data We Can Count On April 8, 2011Lisa Lubomski, PhD. Team Building April 15, 2011Jill Marsteller, PhD, MPP Physician Engagement April 22, 2011Peter Pronovost, MD, PhD

4. Slide 4 CSTS Timeline Planned Roll-out – CLABSI Prevention interventions and monthly data collection: June, 2011 – SSI Prevention interventions and monthly data collection: approximately September 2011 – VAP Prevention interventions and monthly data collection: after December 2011

5. Slide 5 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).

6. Slide 6 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 Healthcare Associated Infections (CLABSI, SSI, VAP).

7. Slide 7 Data Flow Collect Data Enter data into web- based tool Complete quality checks Store data in database Data analysis and Reporting

8. Slide 8 Required Data Safety Culture Assessment – HSOPS (Hospital Survey On Patient Safety culture) Baseline CLABSI (Baseline and Monthly) Team Checkup Tool (Monthly) Subsequent SSI and VAP as these initiatives roll out.

9. Slide 9 Data Elements FormFrequency of Completion How to submitReports generated Safety Culture assessment AHRQ’s HSOPS (Hospital Survey on Patient Safety Culture) CV-OR ICU Floor Baseline and 18 months HSOPS administered CSTS data entry system. Unit reports and comparative reports CLABSI ICU Floor *MonthlyWeb-based data entry system (under development) Available in CSTS data entry system Clinical Area Team Check-Up Tool CV-OR ICU Floor *MonthlyWeb-based data entry system (under development) Available in CSTS data entry system * Due by the 15th of the Month following data collection. (Ex: June CLABSI and TCT are due by July 15)

10. Slide 10 Data Entry Web-based data entry tool. Tool provides for data entry and reporting Baseline data entered prior to work with CSTS 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. Web-based system will send reminders of data due & overdue

11. Slide 11 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, June’s data is entered by July 5th. 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. Slide 12 Sources of CLABSI Data Often these data are available from the infection preventionists (IPs) 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. Slide 13 Entering CLABSI Data Identify 1 or more people to complete data entry. Good to have a back up in case of illness, vacation, etc. Make sure IPs know to whom data should be sent each month

14. Slide 14 Monthly Team Checkup (MTCT) Each clinical area has a relevant MTCT: CV-OR; ICU; Floor Completed monthly – Completed on paper at a meeting with quorum of team members present; – Completed on paper by team members & forwarded to team leader for synthesis

15. Slide 15 MTCT 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.

16. Slide 16 Measuring Culture AHRQ’s Hospital Survey on Patient Safety (HSOPS) – A 51 item survey instrument – Approximately 10 minutes to complete – Most of the items use Agree/Disagree or Never/Always response categories

17. Slide 17 HSOPS What can teams do with results from the HSOPS? – Raise staff awareness about patient safety. – Diagnose and assess the current status of patient safety culture. – Identify strengths and areas for patient safety culture improvement. – Examine trends in patient safety culture change over time. – Evaluate the cultural impact of patient safety initiatives and interventions.

18. Slide 18 HSOPS Collection will be web-based Methods will be discussed on a future call and supported by documentation HSOPS will be completed by all clinical area staff members (both clinical & non-clinical) Reporting will be anonymous

19. Slide 19 Additional Data Surgical Site Infections Ventilator-Associated Pneumonia

20. Slide 20 Summary Teams will collect & enter data monthly. CLABSI data will be collected first with SSI & VAP rolled out in the future. All teams complete a MTCT Ensuring data quality is of utmost importance. A web-based data entry system is being developed for use in entry & reporting. Training will take place during May meeting Watch for information & training on HSOPS, SSI, VAP

21. Slide 21 Action Items  Identify HOW and from WHOM monthly CLABSI data (numerator & denominator) will be obtained.  Determine the process for completing the Team Checkup Tool monthly for your clinical area.  Identify WHO will be responsible for data entry in your clinical area.  Ensure that everyone involved in data entry is trained & understands what they need to do.  Develop a process for ensuring data quality control.