DRAFT – final pending AHRQ approval1

Deep-Rooting Your Data

Liza Wick, MD

Deb Hobson, RN

DRAFT – final pending AHRQ approval

Learning Objectives

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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.

DRAFT – final pending AHRQ approval

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

DRAFT – final pending AHRQ approval4

SSI Data Sources for Surgical Site Infections

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Polling Question

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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

DRAFT – final pending AHRQ approval

Polling Question

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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

DRAFT – final pending AHRQ approval

SSI Data Sources for Surgical Site Infections

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There are several places where you can download your SSI data and get summary reports

-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?

DRAFT – final pending AHRQ approval

Polling Question

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Have you generated an SSI data report that shows your SSI data compared to other units? Yes No I don’t know what a comparative report is

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

DRAFT – final pending AHRQ approval

Processes vs. Outcomes Data

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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

DRAFT – final pending AHRQ approval

Process data

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What process data is collected in the surgical unit?

Where is process data documented?

DRAFT – final pending AHRQ approval

More Process Measure Examples

Process Measure

proper hair removal

correct skin preparation in O.R.

proper use of antimicrobial prophylaxis

avoid incisional hematomas

correct colon preparation

avoid elective operation if remote site infection

proper incisional protection

proper sterilizer function in O.R.

proper perioperative metabolic management

adequate FiO2

DRAFT – final pending AHRQ approval

Interpreting the Denominator

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The denominator dilemma– If you have a low # of cases, delve into your process data

Monthly report vs. quarterly reports

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Data Sharing

DRAFT – final pending AHRQ approval

Polling Question

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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)

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Develop a Data Sharing Plan

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

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Create an Orientation to the Data Summary

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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 – final pending AHRQ approval

Leverage Your Data

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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

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SSI Opportunity Estimator

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

web-based calculator

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SSI Opportunity Estimator

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Business Case for enhanced recovery protocol to decrease length of stay

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Outcome

Additional RevenueExpense

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Barriers to Deep-Rooting Your Data

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Staff turnover

Throughput as a distraction (e.g. OR delays)

Competing priorities

Perception/believability the data (SSI cases aggregated)

DRAFT – final pending AHRQ approval

Develop a Sustainable Action Plan to Deep-Root Your Data

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DRAFT – final pending AHRQ approval

To Do Checklist-A Summary of Action Items

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Define roles

Confirm SSI data source

Define report type

Develop a data sharing plan

Create a data sharing feedback mechanism

DRAFT – final pending AHRQ approval

Polling Questions

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Would your hospital be interested in joining the Enhanced Recovery Protocol affinity group? 

-Yes

-No

What affinity groups would your hospital be interested in joining (you can select more than one)? 

– Enhanced Recovery Protocol– Bowel prep/oral antibiotics, glucose control – OR traffic, environmental, sterile technique (environmental issues)– Skin prep, abx, normothermia (SCIP measures)

DRAFT – final pending AHRQ approval

Content Call Evaluation

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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