DRAFT – final pending AHRQ approval

Kristina Weeks, MHS, DrPH(c)

June 3, 2014

Designing and Using Scorecard for

SUSPtainability

DRAFT – final pending AHRQ approval

Polling Question

2

What is your role in your clinical area?– Surgeon– Quality Improvement practitioner– Infection preventionist– OR nurse– OR technician– Anesthesiologist– OR manager

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Review the Learning from Defects tool with your team

Review a defect in your operating rooms

Select one defect per month or quarter

Consider applying in surgical morbidity and mortality conferences

Post the stories of reduced risks (include data!)

Share with others

Action Plan

Follow-up from Learning from Defects

4

DRAFT – final pending AHRQ approval

Learning Objectives

Asses objectively your unit’s current stage in SUSP implementation

Describe how to design a scorecard to measure performance as part of your sustainability efforts

Identify and give examples of adaptive and technical indicators to include on a performance scorecard

DRAFT – final pending AHRQ approval

Evaluating Performance

5

When we performed, I felt nervous and excited at the same time. My stomach was doing flip flops.

I learned don’t be nervous. Forget about the crowd and just do what you are supposed to be doing and you will do a great job.

Source: http://dancepulse.org

DRAFT – final pending AHRQ approval

Take Stock by Checking Your Progress

Create collective awareness of what’s working and what’s not working

Celebrate what makes the team strong and effective

Tackle remaining barriers proactively

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Take stock of team variables every six months

7

VARIABLES QUESTIONS

Frequency Does your team meet enough to achieve goals?

Attendance Does your team have sufficient participation to facilitate group goals?

Training Is entire staff trained in Science of Safety?

Defects Are you learning from defects?Are any of your improvement plans driven by data?

Safety Culture

How many safety climate responses are positive?Does the staff know you are hearing them?

Scorecard Parameters

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Measure Within The Past Six Months

(Circle One)

Below

Target

Okay

On Target

FREQUENCY

How many SUSP meetings held in past 6 months?How many SUSP subgroup meetings held in past 6 months? (based on 1 monthly subgroup)

0-30-3

44

5-65-6

ATTENDANCE

Number of meetings attended by the senior executive in past 6 months?

Number of meetings attended by the surgeon champion in past 6 months?

Number of meetings attended by nurse champion in past 6 months?

0-20-20-2

3-43-43-4

5-65-65-6

TRAINING

How much of staff has received Science of Safety training within 2 years?

<80% 80-90% >90%

DEFECTS

How many defects have you learned from in past 6 months?Do you have improvement plans that are data-driven?

00

11

2>1

SAFETY CULTURE

Average percent positive scores for Safety Climate Domain from most recent HSOPS?

What is the unit response rate for the latest HSOPS?

<60%

<60%

60-80%

60-80%

>80%

>80%

SUSPtainability Scorecard

DRAFT – final pending AHRQ approval9

Measure (Circle One)

Below

Target

OkayOn

Target

Insert surgery related indicator*

Insert surgery related indicator

Insert surgery related indicator

SSI Prevention Activities Scorecard

*An example would be the percentage of time made for:Time out procedureBriefingsDebriefings

DRAFT – final pending AHRQ approval

Polling questions

10

Do you have SUSP team “subgroups”?

-Yes

-No

How often do these subgroup meet?

-Once per month

-Once per quarter

-A couple of times per year

Do you have a participating senior executive actively involved with the SUSP team (attending SUSP meetings?)

-Yes

-No

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Revisit your pre-SUSP safety culture assessment and action plan

Celebrate successes

Share with your frontline staff

Let frontline staff know their voices have been heard

Keeping an Eye on Culture

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What’s next?

12

HSOPS re-administration will open on July 1st.

The final project call for cohorts 1 and 2 is scheduled for July 1st.

We will be contacting a sample of units for an SSI project feedback opportunity on the project. We will be contacting those teams about this within the next couple of months.

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It’s the soil, not the seed.

--Louis Pasteur

Nurture your safety culture.

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Content Call Evaluation

We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you

complete a brief evaluation following each call. The evaluation may be found at the following link:

https://www.research.net/s/SUSP_C1_2_Content_Eval

If you are not able to reach the link from the slide, please cut & paste the URL into your browser.