1. Deep-rooting your data CUSP FOR SAFE SURGERY: SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP) Elizabeth Wick, MD November 11, 2014

2. Polling Question 2 What is your role in your clinical area?  Surgeon  Quality Improvement practitioner  Infection preventionist  OR nurse  OR technician  Anesthesiologist  OR manager  Educator  Coordinating Entity  Other DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 2

3. Polling Question Have your surgical safety efforts been refocused for Ebola?  Yes  No

4. HSOPS Re-Administration Announcement Deep-Rooting Your Data 4 DRAFT-Pending AHRQ Final Approval HSOPS survey administration date has been extended to accommodate teams who have been working on Ebola preparation The new close date for HSOPS re-administration is now January 15 th at 12 noon (ET) We are also offering office call hours for teams who have questions or need guidance on HSOPS administration OFFICE HOURS Nasir Mohd will be available to accept calls on November 12 th from 2:30-5:30P M (ET) #410-637-6282

5. Learning Objectives 5 Define SSI data sources and determine which SSI data source fits you Describe process vs outcome data Create a plan to share your SSI data to communicate your progress and obtain the needed resources for your project. Define groups with whom you will be sharing your data Describe the barriers to making your SSI data a routine component of your quality improvement efforts. Develop an action plan to address barriers to sustaining the use of SSI data for quality improvement efforts. DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 5

6. SSI DATA SOURCES FOR SURGICAL SITE INFECTIONS Deep-rooting Your Data 6 DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 6

7. Polling Question 7 How does your team receive your SSI data reports in your clinical area? (select all that apply)  Through the SUSP/SSI Data Portal  NHSN portal  NSQIP portal  Infection control administrator in my hospital  My CE sends reports to me  We get data but I don’t where it comes from DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 7

8. Polling Question 8 What kinds of SSI data do you receive in your clinical area? (select all that apply)  Risk-adjusted NSQIP data  NSQIP raw data  SIR NHSN  NHSN raw data  I don’t know DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 8

9. SSI Data Sources for Surgical Site Infections Deep-Rooting Your Data 9 There are several places where you can download your SSI data and get summary reports (Important to know who has access) -SUSP/SSI data portal -NSHN and NSQIP sites It’s important to understand what each of these resources provide and what you need to consider as you develop a plan for sustainability. – Which platform will you use to get your reports? DRAFT-Pending AHRQ Final Approval

10. Polling Question Deep-rooting Your Data 10 Have you generated an SSI data report that shows your SSI data compared to other hospitals?  Yes  No  I don’t know what a comparative report is If yes, please share comments in chat box about what reactions to the comparison were DRAFT-Pending AHRQ Final Approval

11. Processes vs. Outcomes Data Deep-rooting Your Data 11 Processes lead to outcomes Prioritize what you need to focus on in your data -Process data: What are we doing? -Outcome data: Did it make a difference? How do we know which one we should focus on? InputProcessoutputsoutcomes DRAFT-Pending AHRQ Final Approval

12. Process Data 12 What process data is collected in the surgical unit? Where is process data documented? DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 12

13. More Process Measure Examples DRAFT-Pending AHRQ Final Approval Deep-Rooting Your Data 13 Standard hair removal Standard skin preparation in the OR Standard use of antimicrobial prophylaxis Avoid post operative hemorrhages Standard colon preparation If infection is present at remote site, avoid elective surgery Standard wound protection Avoid flashing of instruments in the OR Maintenance of perioperative glycaemia

14. Interpreting the Denominator Deep-rooting Your Data 14 The denominator dilemma-- If you have a low # of cases, delve into your process data Monthly report vs. quarterly reports DRAFT-Pending AHRQ Final Approval May-12Jun-12Jul-12Aug-12Sep-12Oct-12Nov-12Dec-12Jan-13Feb-13Mar-13Apr-13May-13Jun-13 % SSIs for colon surgery0.0%33.3%0.0%50.0%0.0% 28.6%0.0%100.0%20.0%0.0%50.0%28.6% Total Cases13525307335027 #SSI Infections01010002031012 Example of a Monthly Report

15. Interpreting the Denominator Deep-rooting Your Data 15 DRAFT-Pending AHRQ Final Approval Example of a Quarterly Report CY11 Q1CY11 Q2CY11 Q3CY11 Q4CY12 Q1CY12 Q2CY12 Q3CY12 Q4CY13 Q1CY13 Q2 % SSIs for colon surgery16.7%20.0%16.7%0.0%20.0%46.7%18.2%10.5%28.6%15.0% Total Cases3020125251522191420 #SSI Infections5420574243

16. DATA SHARING Deep-rooting Your Data Deep-rooting Your Data 16 DRAFT-Pending AHRQ Final Approval

17. Polling Question Deep-rooting Your Data 17 Who currently is responsible for downloading and distributing your SSI data reports  It varies-whoever is available  Our quality representative  Our SUSP team lead  Our CE sends it to us  We don’t distribute SSI data reports.  Other (please explain in chat box) DRAFT-Pending AHRQ Final Approval

18. Develop a Data Sharing Plan Deep-rooting Your Data 18 Assign a role for these tasks Downloading SSI data Extraction and compiling SSI data Distribute SSI data reports DRAFT-Pending AHRQ Final Approval

19. Orienting the Audience to the Data Deep-rooting Your Data 19 The data that you present should be tailored to your audience Explain the data in ways that make sense to your audience Describe what specialties or surgeons the data includes e.g. colectomy can cross specialties Describe data for Internal vs external audience Decide on detailed data vs summary data Ask “what is the focus?” and “How do I gage my audience?” DRAFT-Pending AHRQ Final Approval

20. Leverage Your Data Deep-rooting Your Data 20 Package your data reports, framing it to your audience Create a business case, using your data Create a strategy to share your data reports to leverage what you need for your project DRAFT-Pending AHRQ Final Approval

21. Example Graph to Report Quarterly SSI Rates Deep-rooting Your Data 21 DRAFT-Pending AHRQ Final Approval

22. Example-30 Day Post Operative Occurrence Summary Deep-rooting Your Data 22 DRAFT-Pending AHRQ Final Approval

23. Example-Post Operative Occurrence Patient Detail List Deep-rooting Your Data 23 DRAFT-Pending AHRQ Final Approval

24. SSI Opportunity Estimator Deep-rooting Your Data 24 SSI Opportunity Estimator – Estimate lost revenue from patients with infections using SUSP web-based calculator DRAFT-Pending AHRQ Final Approval

25. SSI Opportunity Estimator Deep-rooting Your Data 25 DRAFT-Pending AHRQ Final Approval

26. Business Case for Enhanced Recovery Protocol to Decrease Length of Stay Deep-rooting Your Data 26 Outcome Additional Revenue Expense DRAFT-Pending AHRQ Final Approval

27. Barriers to Deep-Rooting Your Data Deep-rooting Your Data 27 Staff turnover Throughput as a distraction (e.g. OR delays) Competing priorities Perception/believability the data (SSI cases aggregated) DRAFT-Pending AHRQ Final Approval

28. DEVELOP A SUSTAINABLE ACTION PLAN TO DEEP-ROOT YOUR DATA Deep-rooting Your Data Deep-rooting Your Data 28 DRAFT-Pending AHRQ Final Approval

29. To Do Checklist A Summary of Action Items Deep-rooting Your Data 29  Define roles  Confirm SSI data source  Define report type  Develop a data sharing plan  Create a data sharing feedback mechanism DRAFT-Pending AHRQ Final Approval