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

Deep-rooting your data

CUSP FOR SAFE SURGERY:SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP)

Elizabeth Wick, MDNovember 11, 2014

Polling Question

2

What is your role in your clinical area?SurgeonQuality Improvement practitionerInfection preventionistOR nurseOR technicianAnesthesiologistOR managerEducatorCoordinating EntityOther

DRAFT-Pending AHRQ Final Approval

Deep-Rooting Your Data 2

Polling Question

Have your surgical safety efforts been refocused for Ebola?YesNo

HSOPS Re-Administration Announcement



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 15th at 12 noon (ET)

We are also offering office call hours for teams who have questions or need guidance on HSOPS administration

OFFICE HOURSNasir Mohd will be available to accept calls on November 12th from

2:30-5:30P M (ET)#410-637-6282

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.



SSI DATA SOURCES FOR SURGICAL SITE INFECTIONS

Deep-rooting Your Data

6



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



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



SSI Data Sources for Surgical Site Infections


• 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?


Polling Question

Deep-rooting Your Data 10

Have you generated an SSI data report that shows your SSI data compared to other hospitals?

YesNoI don’t know what a comparative report is

If yes, please share comments in chat box about what reactions to the comparison were


Processes vs. Outcomes Data


• 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?

Input Process outputs outcomes


Process Data

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• What process data is collected in the surgical unit?• Where is process data documented?



More Process Measure Examples



• 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

Interpreting the Denominator


The denominator dilemma--If you have a low # of cases, delve into your process data• Monthly report vs. quarterly reports


May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-130.05.0

10.015.020.025.030.035.040.045.050.0

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Total Cases#SSI Infections% SSIs for colon surgery

May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13% SSIs for colon surgery 0.0% 33.3% 0.0% 50.0% 0.0% 0.0% 0.0% 28.6% 0.0% 100.0% 20.0% 0.0% 50.0% 28.6%Total Cases 1 3 5 2 5 3 0 7 3 3 5 0 2 7#SSI Infections 0 1 0 1 0 0 0 2 0 3 1 0 1 2

Example of a Monthly Report

Interpreting the Denominator

Deep-rooting Your Data 15DRAFT-Pending AHRQ Final Approval

Example of a Quarterly Report

CY11 Q1 CY11 Q2 CY11 Q3 CY11 Q4 CY12 Q1 CY12 Q2 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2% SSIs for colon surgery 16.7% 20.0% 16.7% 0.0% 20.0% 46.7% 18.2% 10.5% 28.6% 15.0%Total Cases 30 20 12 5 25 15 22 19 14 20#SSI Infections 5 4 2 0 5 7 4 2 4 3

CY11 Q1 CY11 Q2 CY11 Q3 CY11 Q4 CY12 Q1 CY12 Q2 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q20

5

10

15

20

25

30

35

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Total Cases#SSI Infections% SSIs for colon surgery

DATA SHARINGDeep-rooting Your Data



Polling Question


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)


Develop a Data Sharing Plan


Assign a role for these tasks• Downloading SSI data• Extraction and compiling SSI data • Distribute SSI data reports


Orienting the Audience to the Data


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

Leverage Your Data


• 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


Example Graph to Report Quarterly SSI Rates


Example-30 Day Post Operative Occurrence Summary


Example-Post Operative OccurrencePatient Detail List


SSI Opportunity Estimator


SSI Opportunity Estimator– Estimate lost revenue from patients with infections using SUSP web-

based calculator


SSI Opportunity Estimator



Business Case for Enhanced Recovery Protocol to Decrease Length of Stay


Outcome

Additional RevenueExpense


Barriers to Deep-Rooting Your Data


• Staff turnover• Throughput as a distraction (e.g. OR delays)• Competing priorities• Perception/believability the data (SSI cases

aggregated)


DEVELOP A SUSTAINABLE ACTION PLAN TO DEEP-ROOT YOUR DATA

Deep-rooting Your Data



To Do ChecklistA Summary of Action Items


Define roles

Confirm SSI data source

Define report type

Develop a data sharing plan

Create a data sharing feedback mechanism


Documents

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