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 & Terry Tsai, PhD January 13 & January 15, 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 the 2 new features of the SSI data registry 1.SSI rate reports o App Performance Monitor o 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. SUSP: Where are you now? 3 October 2013 SUSP Kickoff Conduct SUSP pre-mortem exercise Administer HSOPS November 2013 Watch Science of Patient Safety video Administer PSSA December 2013 Schedule monthly executive safety rounds for the year Complete HSOPS administration January 2014 Share HSOPS and PSSA results with your team during monthly executive safety rounds Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) 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. If your team has completed the HSOPS 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

6. 6 How to find your team’s HSOPS results Select “My Reports” from the “My Network” drop down menu DRAFT-Final pending AHRQ approval

7. 7 2. Tool: Select “HSOPS for SUSP” How to find your team’s HSOPS results DRAFT-Final pending AHRQ approval

8. 8 JHH-Colorectal Team- OR 3. Network: Select your Unit (typing the first letter of its name will bring you to that part of the alphabetized list) 4. Report: Select “HSOPS Report” 3. Network: Select your Unit (typing the first letter of its name will bring you to that part of the alphabetized list) 4. Report: Select “HSOPS Report” How to find your team’s HSOPS results DRAFT-Final pending AHRQ approval

9. The same HSOPS Report can also be downloaded from your HSOPS App Dashboard after your survey period closes. How to find your team’s HSOPS results 9 DRAFT-Final pending AHRQ approval

10. IMPORTANT NOTE: 10 Your survey coordinator will only be able to download HSOPS reports AFTER your survey period has CLOSED –If you survey is still open (i.e., if you are still actively collecting responses online or are in the process of uploading previously collected HSOPS data) you will NOT be able to download an HSOPS report –Cohort 4 HSOPS survey period closing dates: Cohort 4: December 16, 2013 Cohort 4-Extension group 4a: December 30, 2013 Cohort 4-Extension group 4b: January 17, 2013 How to find your team’s HSOPS results DRAFT-Final pending AHRQ approval

11. HSOPS Aggregate Report (.pdf) 11 Who participated in the survey? (p. 4-6, 29-34) Johns Hopkins Hospital Interpreting your team’s HSOPS results DRAFT-Final pending AHRQ approval

12. Composite Score Charts (p. 7-8) Scores = Percentage (%) of responses that were positive 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 Interpreting your team’s HSOPS results DRAFT-Final pending AHRQ approval

13. Individual Question Scores are also displayed (p. 9-26) Percent positive = Green Percent neutral = Yellow Percent negative = Red Interpreting your team’s HSOPS results DRAFT-Final pending AHRQ approval

14. Question scores provide more detail: For positively worded questions, more green is better 14 Interpreting your team’s HSOPS results NOTE: Due to rounding totals may not add exactly to 100% For negatively worded questions (*), more RED is better DRAFT-Final pending AHRQ approval

15. Debrief survey results with your work area leaders and team members Debriefing is… –A semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Purpose… 1.Encourage open communication, transparency, and interactive discussion about the survey results Across all levels of the work area and between disciplines 2.To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area 15 How can we use our HSOPS data in a meaningful way? DRAFT-Final pending AHRQ approval

16. Why debrief? Work areas/units that debrief around safety culture perform better 16 Data is data –Debriefing turns data into information Debriefing accelerates improvement Units who did not debrief survey results 2.2% Reduction in Infection Rates Units who used semi- structured debriefing of culture survey 10.2% Reduction in Infection Rates 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. How can we use our HSOPS data in a meaningful way?

17. CUSP Culture Check-Up Tool 17 How Do I Use this Tool? –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 –Purpose = Open, honest discussion about ideas to make the culture of your work area the best it can be –Focus on identifying system issues that the group can work on improving together instead of individuals NOT used to point fingers at specific individuals –Use the tool to structure meetings and guide conversation –As a group, complete all steps in this worksheet How can we use our HSOPS data in a meaningful way? DRAFT-Final pending AHRQ approval

18. CUSP Culture Check-Up Tool: A tool to use during HSOPS Debriefings 18 What is the Purpose of this Tool? –Understand the culture of the unit –Use teammates’ feedback to predict barriers to change and avoid them –Use feedback to make the most of the team’s strengths Who Should Use this Tool? –Safety culture debriefing facilitators Use this tool to help guide the discussion and record group decisions 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

19. Steps in CUSP Culture Check-Up Tool 19 STEP 1: Your team identifies the general strengths and weaknesses of your unit culture. STEP 2: Your team identifies the specific behaviors and attitudes that make up those strengths and weaknesses. STEP 3: Debriefing facilitator encourages group reflection. Your team chooses opportunities for growth, understanding that cultural strengths can help fix cultural weaknesses. STEP 4: Your team identifies a strategy for fixing the opportunities selected in step three. –AHRQ recommends creating ‘safety briefings’ – short updates for frontline teammates about patient safety issues in the work are. For more ideas, go to: http://www.ahrq.gov/qual/patientsafetyculture/hospimpdim.htm. http://www.ahrq.gov/qual/patientsafetyculture/hospimpdim.htm STEP 5: Your team works out the details of putting strategy into action. STEP 6: Your team evaluates your plans. Be sure to meet again and check in on progress at your SUSP team meetings How can we use our HSOPS data in a meaningful way? DRAFT-Final pending AHRQ approval

20. The “Culture Check Up Tool” = Word Document that Debriefing Facilitator can use to guide conversation & improvement planning DRAFT-Final pending AHRQ approval

22. Some points to cover in your debriefing plan 22 How can we use our HSOPS data in a meaningful way? DRAFT-Final pending AHRQ approval

23. In Sum 23 1.Review the survey report for your participating work areas 2.Can be helpful to distill the report down into 3-5 key slides 3.Decide when, how, and where to debrief your teammates (and leaders) on these results 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

24. Questions? 24

25. 25 Using the SSI data registry to turn SSI data into action Learn how to create SSI reports to share with your SUSP team! Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

26. Who can access the SSI data registry? 26 SUSP Facilitators: –Coordinating Entity –SUSP Data Lead (“Hospital Administrator”) 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! Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

27. What can you do in the SSI data registry? 27 Generate –Two different reports that give you real-time performance feedback SSI app performance monitor report SSI trend graph reports at CE and hospital level –SSI missing data report Goal: Data in SSI data registry by mid-February! Manual: Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

28. How to access the SSI Data Registry? https://armstrongresearch.hopkinsmedicine.org/susp.aspx 28 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

29. My Tools homepage 29 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) “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

30. SSI Data Registry homepage 30 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) If it says REGISTER instead of REPORTS, please contact the NPT (SUSP@Jhmi.edu)! DRAFT-Final pending AHRQ approval

31. 31 How to generate SSI performance monitor reports: Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

32. SUSP SSI app performance monitor homepage Monitor your SSI rates and generate reports to share with your team! 32 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) Click here to generate your SSI app performance monitor report: DRAFT-Final pending AHRQ approval

33. Example: SSI App Performance Monitor Report 33 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

34. How to generate SSI trend graph reports: SUSP SSI app performance monitor homepage  VIEW CHART 34 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) Click here to generate your SSI trend graph report: DRAFT-Final pending AHRQ approval

35. Example: Hospital level trend graph report 35 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 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

36. SSI missing data reports 36 Who can generate them? –SUSP hospital administrators, Coordinating Entities and the National Project Team When? –Monthly, yearly, quarterly Why? –To monitor hospital team’s SSI data upload into the SSI data registry Manual: Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

37. How to generate an SSI missing data report: https://armstrongresearch.hopkinsmedicine.org/susp.aspx 37 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

38. How to generate an SSI missing data report: 38 Surgical Site Infections- NHSN or NSQIP SUSP Select hospital level Missing Data Report Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

39. Example: Hospital level missing data report 39 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 Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

40. Next steps 40 NPT and CEs will:  Collect outstanding DUAs (very few left)  NSQIP users: ACS will send NSQIP addendum to hospital admin  Register your team in the SSI Data Registry  CE and NPT will transfer 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! Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

41. Using data to drive Quality Improvement 41 Generate monthly reports Share reports with teams Use events to initiate investigations Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) DRAFT-Final pending AHRQ approval

42. Questions? 42 DRAFT-Final pending AHRQ approval

43. Questions? Tools? Data? 43 Reminder… You can access all slides, call recordings, and project tools and data discussed today on the SUSP Online Portal https://armstrongresearch.hopkinsmedicine.org/susp DRAFT-Final pending AHRQ approval

44. 44 How is your team planning to share and use your data? What hurdles might come up? DRAFT-Final pending AHRQ approval

45. Team Brainstorm… 45 Ideas, tips, or advice to mitigate or manage these potential hurdles? DRAFT-Final pending AHRQ approval

46. Project Call evaluation 46 https://www.surveymonkey.com/s/SUSP_Cohort4 DRAFT-Final pending AHRQ approval