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,

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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

Agenda

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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 changeQuestions? Contact the SUSP helpdesk! ([email protected])


SUSP: Where are you now?

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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 roundsQuestions? Contact the SUSP helpdesk! ([email protected])


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Interpreting Safety Culture Survey Data (HSOPS) and Using Results for

Improvement

Presented by:

Deborah B. Hobson, RN

& Sallie J. Weaver, PhD


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




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Select “My Reports” from the “My Network” drop down menu


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2. Tool: Select “HSOPS for SUSP”



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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”



The same HSOPS Report can also be downloaded from your HSOPS App Dashboard after your survey period closes.


9 DRAFT-Final pending AHRQ approval

IMPORTANT NOTE:

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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



HSOPS Aggregate Report (.pdf)

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Who participated in the survey? (p. 4-6, 29-34)

Johns Hopkins HospitalJohns Hopkins Hospital

Interpreting your team’s HSOPS results


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



Individual Question Scores are also displayed (p. 9-26)

Percent positive = GreenPercent neutral = YellowPercent negative = Red



Question scores provide more detail:For positively worded questions, more green is better

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NOTE: Due to rounding totals may not add exactly to 100%

For negatively worded questions (*), more RED is better


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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

How can we use our HSOPS data in a meaningful way?


Why debrief?Work areas/units that debrief around safety culture perform better

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Data is data

– Debriefing turns data into information

Debriefing accelerates improvement

Units who did not debrief survey results2.2% 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.


CUSP Culture Check-Up Tool

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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



CUSP Culture Check-Up Tool: A tool to use during HSOPS Debriefings

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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?


https://armstrongresearch.hopkinsmedicine.org/susp/hsops/resources.aspx


Steps in CUSP Culture Check-Up Tool

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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.

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



http://www.ahrq.gov/qual/patientsafetyculture/hospimpdim.htm

The “Culture Check Up Tool” = Word Document that Debriefing Facilitator can use to guide conversation & improvement planning



Some points to cover in your debriefing plan

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Decision points for project team Debriefing plan How many debriefing sessions will be held?

Who will facilitate each debriefing session?

When will debriefing(s) be held?

Where 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)?



In Sum

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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

Questions?

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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! ([email protected])

Who can access the SSI data registry?

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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! ([email protected])DRAFT-Final pending AHRQ approval

What can you do in the SSI data registry?

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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! ([email protected])DRAFT-Final pending AHRQ approval

How to access the SSI Data Registry?https://armstrongresearch.hopkinsmedicine.org/susp.aspx

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My Tools homepage

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• “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


SSI Data Registry homepage

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If it says REGISTER instead of REPORTS, please contact the NPT ([email protected])!


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How to generate SSI performance monitor reports:



SUSP SSI app performance monitor homepageMonitor your SSI rates and generate reports to share with your team!

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Click here to generate your SSI app performance monitor report:


Example: SSI App Performance Monitor Report

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How to generate SSI trend graph reports:SUSP SSI app performance monitor homepage VIEW CHART

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Click here to generate your SSI trend graph report:


Example: Hospital level trend graph report

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Compare your hospital’s SSI rate to:1. All SUSP NSQIP (or NHSN) participants2. All hospitals in your cohort3. All hospitals in your CE4. All hospitals who are working on same surgical line (e.g. colorectal)

SSI rate = (# SSIs/total # cases)*100



SSI missing data reports

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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:



How to generate an SSI missing data report:https://armstrongresearch.hopkinsmedicine.org/susp.aspx

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How to generate an SSI missing data report:

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Surgical Site Infections- NHSN or NSQIP

SUSP

Select hospital level

Missing Data Report



Example: Hospital level missing data report

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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



Next steps

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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!



Using data to drive Quality Improvement

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Generate monthly reports

Share reports with teams

Use events to initiate investigations



Questions?

42 DRAFT-Final pending AHRQ approval

Questions? Tools? Data?

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Reminder…You can access all slides, call recordings, and project tools and data discussed today on the SUSP Online Portal





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How is your team planning to share and use your data?

What hurdles might come up?


Team Brainstorm…

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Ideas, tips, or advice to mitigate or manage these potential hurdles?


Project Call evaluation

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https://www.surveymonkey.com/s/SUSP_Cohort4




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,

Documents

hsops reports

hsops survey period

share hsops

hsops reportcohort

hsops reporthow

uploaded hsops data

teams hsops resultsselect

hsops app dashboard