Turning data into action: Using HSOPS and SSI data as part of a meaningful change

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Turning data into action: Using HSOPS and SSI data as part of a

meaningful changeSallie Weaver, PhD & Deb Hobson, RN

Julius Pham, MD, PhD

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITYJuly 21st and July 23rd , 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 improvement1. Accessing & interpreting HSOPS Score reports2. Debriefing & using your team’s data

High level description of new SSI data registry features1. SSI rate reports (App Performance Monitor & Trend Graph)2. Missing data reports

Next steps How to use data to effect change

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


Questions? Contact the SUSP helpdesk at [email protected].

SUSP: Where are you now?

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April 2014 SUSP Kickoff and conduct SUSP pre-mortem exercise Administer HSOPS

May 2014 Watch Science of Patient Safety video Administer PSSA

June 2014 Schedule monthly executive safety rounds for the year Complete HSOPS administration

July 2014 Share HSOPS and PSSA results with your team during monthly

executive safety rounds


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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



For completed 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 approval5

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



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1. Project: Select “SUSP”

2. Tool: Select “HSOPS for SUSP”




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JHH-Colorectal Team- OR

3. Network: Select your Unit

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

HSOPS report downloads are not available for OPEN surveys

– If actively collecting responses online

– If uploading previously collected HSOPS data

Cohort 5 HSOPS survey period closing dates: July 15, 2014




HSOPS Aggregate Report

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Survey response rate (Pages 4-6, 29-34)

Johns Hopkins HospitalJohns Hopkins Hospital

Interpreting Your Team’s HSOPS Results


Composite score (Page 7-8)

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 Composite Scores: • The big picture view• Higher is better


Individual Question Scores (Pages 9-26)Percent positive = GreenPercent neutral = YellowPercent negative = Red




Questions provide a deeper dive

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



Tip: For positively worded items, more GREEN is better.


Questions provide a deeper dive

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Tip: For negatively worded items, more RED is better.

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



Debrief survey results with all your team members

Debriefing is a semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitatorEncourages open communication, transparency, and interactive discussion– across all levels of the work area– between disciplinesEngages clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area

What is Debriefing?

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Work units that debrief around safety culture perform better

Data is data. Debriefing turns data into information.

Debriefing accelerates improvement.1

Units who did not debrief survey results achieved2.2% Reduction in Infection Rates

Units who used semi-structured debriefing of

culture survey achieved 10.2% Reduction in

Infection Rates

YES NO

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Making HSOPS Data Meaningful


How do I use the CUSP culture check-up tool?

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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

Encourage open, honest discussion about making the culture of your work area the best it can be



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Focus on identifying system issues that the group can work on improving together instead of as individuals.

– Don’t use it 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 do I use the CUSP culture check-up tool?

HSOPS debriefings with CUSP culture check-up tool

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What is the Purpose of this Tool?

Understand the unit cultureUse teammates’ feedback to predict and avoid barriers Use feedback to leverage the team’s strengths

Who Should Use this Tool?

Safety culture debriefing facilitatorsHelps to guide the discussion and record group decisions



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

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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



1. Identifies general strengths and weaknesses of your unit culture

2. Get specific about behaviors and attitudes that make up those strengths and weaknesses

3. Select opportunities for growth

4. Develop a strategy for addressing growth opportunities

5. Put plan into action

6. Evaluate results and share progress during SUSP team meetings

Steps in CUSP Culture Check-Up Tool

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Tip: Download the Culture Check Up Tool at eitherhttps://armstrongresearch.hopkinsmedicine.org/susp OR

www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/

culturecheckup.html

Culture Check Up Tool

Culture Check Up Tool is a document used by Debriefing Facilitator to guide conversation and improvement planning

Download from either to SUSP project page or the AHRQ website

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http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/culturecheckup.html



Brainstorming culture discussion itemsStatement To Be Discussed

Unit Safety Assessment Score %What does this statement mean to you?How accurately does the unit score reflect your experience on this unit? Share examples.How would it look (what behaviors or processes would we see) in this unit if 100% of staff responded “agree strongly” with this item?Identify at least one actionable idea to improve unit results in this area.What are the next steps and how will we accomplish them?

Culture Check Up Tool

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Debriefing Plan Highlights

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?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)?


What’s Next?

1. Review the survey report for your clinical areas

2. Distill the information into 3-5 key slides

3. Plan debriefing strategy to share results with team– 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

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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!


Who Can Access The SSI Data Registry?

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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!



Generate reports

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Reports that provide real-time performance feedback– SSI app performance monitor report– SSI trend graph reports at CE and hospital level

SSI missing data report


What Can You Do in SSI Data Registry?


Access the SSI Data Registry


Project Site: https://armstrongresearch.hopkinsmedicine.org/susp.aspx


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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TIP: If button reads REGISTER instead of REPORTS, please contact us at [email protected].



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TIP: Use the manual! SUSP Generating reports using the SSI data registry


Generating SSI Performance Reports

https://cdn.community360.net/app/jh/SUSP_Content/Toolkits_&_Resources/Additional_Resources/SUSP_Generating%20reports%20using%20the%20SSI%20data%20registry_final.docx


SUSP SSI app performance monitor homepage

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Click here to generate your SSI app performance monitor report:




Example: SSI App Performance Monitor Report




SSI trend graph reports

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Click here to generate your SSI trend graph report:


Generating SSI Trend Reports


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


Generating SSI Trend Reports


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Who can generate them?– Coordinating Entities and any one who has access to the portal

When? – Monthly, quarterly, yearly

Why?– To monitor hospital team’s SSI data upload into the SSI data

registry

For assistance, download the manual “SUSP Generating Missing Data Reports” at https://armstrongresearch.hopkinsmedicine.org/susp.aspx


Generating SSI Missing Data Reports


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




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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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Hospitals: Confer your NHSN rights to your CE (reminder for Independent, California

hospitals) NSQIP hospitals- return NSQIP addendum to ACS

NPT and CEs: CE and NPT will continue or begin transferring 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?



https://armstrongresearch.hopkinsmedicine.org/susp

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


Resources


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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?



References

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1. 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.

Turning data into action: Using HSOPS and SSI data as part of a meaningful change

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