The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

Data We Can Count On

Lisa H. Lubomski, PhDApril 8, 2011 Immersion Call

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Learning ObjectivesLearning Objectives

• To understand the importance of accurate data collection and entry.

• To understand the data collection and entry requirements for the CSTS.

• To outline next steps towards implementing data collection activities as part of CSTS.

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Immersion call ScheduleImmersion call Schedule

Title Date /Time 13:00 EST

Presented by

Program Overview Feb 18, 2011 Peter Pronovost MD PhD

Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP

Comprehensive Unit-Based Safety Program CUSP

March 4, 2011 Christine Goeschel MPA MPS ScD RN

Central Line Blood Stream Infection Elimination

March 11, 2011 David Thompson DNSC, MS

Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS

Ventilator-Associated Pneumonia Reduction

March 25, 2011 Sean Berenholtz, MD

Hand-Offs: Transitions in Care April 1, 2011 Ayse Gurses, PhD

Data We Can Count On April 8, 2011 Lisa Lubomski, PhD.

Team Building April 15, 2011 Jill Marsteller, PhD, MPP

Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD

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CSTS TimelineCSTS Timeline

• Planned Roll-out

– CLABSI Prevention interventions and monthly data collection: June, 2011

– SSI Prevention interventions and monthly data collection: approximately September 2011

– VAP Prevention interventions and monthly data collection: after December 2011

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Importance of “Good” DataImportance of “Good” Data

• We must ensure that the data we collect are accurate, complete and in the required format.

• The data we collect and enter are the ultimate proof of our success & de-identified, aggregated data will be shared broadly (i.e., they will influence care and policy).

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Roles of DataRoles of Data

• Baseline – Tells us where we are at the start.

• On-going – Tells us whether and how we are changing our outcomes and performance.

• Overall – Tells us what impact we (i.e., the project and its initiatives) have on the goal of reducing/eliminating Healthcare Associated Infections (CLABSI, SSI, VAP).

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Data FlowData Flow

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Required DataRequired Data

• Safety Culture Assessment– HSOPS (Hospital Survey On Patient Safety

culture)

• Baseline CLABSI (Baseline and Monthly)

• Team Checkup Tool (Monthly)

• Subsequent SSI and VAP as these initiatives roll out.

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Data ElementsData Elements

Form Frequency of Completion

How to submit Reports generated

Safety Culture assessment AHRQ’s HSOPS (Hospital Survey on Patient Safety Culture) CV-OR ICU Floor

Baseline and 18 months

HSOPS administered CSTS data entry system.

Unit reports and comparative reports

CLABSI ICU Floor

*Monthly Web-based data entry system (under development)

Available in CSTS data entry system

Clinical Area Team Check-Up Tool CV-OR ICU Floor

*Monthly Web-based data entry system (under development)

Available in CSTS data entry system

*Due by the 15th of the Month following data collection. (Ex: June CLABSI and TCT are due by July 15)

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Data EntryData Entry

• Web-based data entry tool. Tool provides for data entry and reporting

• Baseline data entered prior to work with CSTS checklist and methods. Monthly data entered by the 15th of each month.

• Users can edit monthly data. Rolling 6-month lock on the data.

• Data quality checks built into the system.• Web-based system will send reminders of data

due & overdue

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CLABSI DataCLABSI Data

• Baseline: entered once at start of project. Usually for the year preceding the start of the immersion calls.

• Monthly: entered by the 15th of the month.– For example, June’s data is entered by July 5th.

• Total number of CLABSIs in the unit for the period of interest (baseline or month). Numerator

• Total number of central line days in the unit for the period of interest(baseline or month). Denominator

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Sources of CLABSI DataSources of CLABSI Data

• Often these data are available from the infection preventionists (IPs) in your hospital.

• Team leader needs to arrange to obtain the data from infection control for baseline and monthly thereafter.

• Need to establish a pathway and process for resolving problems, questions with data.

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Entering CLABSI DataEntering CLABSI Data

• Identify 1 or more people to complete data entry. Good to have a back up in case of illness, vacation, etc.

• Make sure IPs know to whom data should be sent each month

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Monthly Team Checkup (MTCT)Monthly Team Checkup (MTCT)

• Each clinical area has a relevant MTCT: CV-OR; ICU; Floor

• Completed monthly– Completed on paper at a meeting with quorum

of team members present;– Completed on paper by team members &

forwarded to team leader for synthesis

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MTCTMTCT

• Form provides a snapshot of team activity during the month.

• Allows team leaders, executives, collaborative sponsor and faculty to identify strengths and weaknesses of teams. Help teams who need help and identify teams who might mentor other teams.

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Measuring CultureMeasuring Culture

• AHRQ’s Hospital Survey on Patient Safety (HSOPS)

– A 51 item survey instrument– Approximately 10 minutes to complete– Most of the items use Agree/Disagree or

Never/Always response categories

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HSOPSHSOPS

• What can teams do with results from the HSOPS?

– Raise staff awareness about patient safety. – Diagnose and assess the current status of patient safety

culture. – Identify strengths and areas for patient safety culture

improvement. – Examine trends in patient safety culture change over

time. – Evaluate the cultural impact of patient safety initiatives

and interventions.

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HSOPSHSOPS

• Collection will be web-based• Methods will be discussed on a future call and

supported by documentation• HSOPS will be completed by all clinical area staff

members (both clinical & non-clinical)• Reporting will be anonymous

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Additional DataAdditional Data

• Surgical Site Infections

• Ventilator-Associated Pneumonia

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SummarySummary

• Teams will collect & enter data monthly.• CLABSI data will be collected first with SSI & VAP

rolled out in the future.• All teams complete a MTCT• Ensuring data quality is of utmost importance.• A web-based data entry system is being

developed for use in entry & reporting. Training will take place during May meeting

• Watch for information & training on HSOPS, SSI, VAP

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Action ItemsAction Items

Identify HOW and from WHOM monthly CLABSI data (numerator & denominator) will be obtained.

Determine the process for completing the Team Checkup Tool monthly for your clinical area.

Identify WHO will be responsible for data entry in your clinical area.

Ensure that everyone involved in data entry is trained & understands what they need to do.

Develop a process for ensuring data quality control.