DRAFT – final pending AHRQ approval

Kristina Weeks, MHS, DrPH(c)January 13, 2015

Designing and Using Scorecard for

SUSPtainability

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Quick Administrative Announcements

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• Dial into the conference line:– Dial in Number: 1-800-311-9401– Passcode: 5403– Webinar URL:

https://connect.johnshopkins.edu/susp_3/– Please contact your Coordinating Entity for these slides

• We will make a recording of this webinar available.• Interact with us today

– Type comments in the chat box– Or even better, speak up

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Polling Question

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• What is your role in your clinical area? Surgeon Quality Improvement practitioner Infection preventionist OR nurse OR technician Anesthesiologist OR manager Coordinating Entity Educator Other

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Follow-up from Learning from Defects

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• Review the Learning from Defects tool with your team

• Review a defect in your operating rooms• Select one defect per quarter• Consider applying to surgical morbidity and

mortality conferences• Post the stories of reduced risks (include data!)• Celebrate your success

Action Plan

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Learning Objectives

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• Assess 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

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Evaluating Performance

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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

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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

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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?

Stability Has turnover in key positions affected your progress?

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

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5-65-6

ATTENDANCE

Number of meetings attended by a SUSP Team Lead in past 6 months?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?

0-20-20-20-2

3-43-43-43-4

5-65-65-65-6

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?How many of your improvement goals to address these defects are data-driven?

00

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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

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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:• SSI Rate• Time out procedure• Briefings• Debriefings

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Polling Question

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Do you have SUSP team “subgroups”?YesNo

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Polling Question

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How often do these subgroup meet?Once per monthOnce per quarterA couple of times per year

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Polling Question

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

Polling QuestionHow 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

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• Revisit your pre-SUSP safety culture assessment and action plan

• Share results and progress with your frontline staff

• Validate the hard work of your frontline staff

Keeping an Eye on Culture

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SUSP Activities Still Open for Participation

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Resources still available to you through August 2015

• Cohort 4 sustainability phase calls begin in June 2015• Affinity group calls

• SUSP webpage (webinars, toolkits, etc.)

• SUSP data portal

– HSOPS reports

– SSI reports

• Medconcert

• SUSP help desk (SUSP@jhmi.edu)

Cohort 3 SUSP project ends in February 2015

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Where to find the old webinars?

17https://armstrongresearch.hopkinsmedicine.org/susp

HSOPS Re-Administration Announcement

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HSOPS survey administration date has been extended to accommodate your schedule

The new close date for HSOPS re-administration is now February 3, 2015 at 12 noon (ET)

If you have any questions related to HSOPS re-administration, please contact the SUSP help desk at SUSP@jhmi.edu

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Next SCIP Affinity Group Call

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The next SCIP affinity group call will be held on Thursday, February 12, 2015 at 4PM (EST)

Leader Telephone number: 1-800-680-9685Passcode: 83762

Webinar: https://connect.johnshopkins.edu/affinitygroup/

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Thank you for your willingness to participate and learn together on how to prevent surgical site infections.

The journey continues…..

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It’s the soil, not the seed.

--Louis Pasteur

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Nurture your safety culture.