Data Submission and Web-Reporting. for the Maryland Hospital Hand Hygiene Collaborative

Transcription

1 Data Submission and Web-Reporting for the Maryland Hospital Hand Hygiene Collaborative Institutional Setup for the Database--Part I Database developed and supported by Johns Hopkins Medicine. A representative (usually the hospital s Infection Preventionist) from each Maryland hospital will need to register as the Hospital Administrator, who controls all aspects of this application at their hospital. Upon registration, the site administrator can customize the Hand Hygiene Data Collection Form in the following ways: 1. Names of units and services The Hospital Administrator will need to enter the names for all Inpatient and Intensive Care Units, including Medical-Surgical, Pediatrics, Medical and Surgical Intensive Care Units, and Special Care Units (The following units are excluded from the first phase of this Maryland Hospital campaign: Obstetric Service; Newborn Nursery; Psychiatric Service; Emergency Department; PACU; and Operating Rooms).

2 2. Healthcare worker (HCW) type categories for analysis To portray hand hygiene compliance results by healthcare worker type, data should be entered that reflect the HCW discipline. This tool allows the Hospital Administrator to choose how specific the information collected should be and the composition of HCW disciplines to display on the charts. A. Data Collection For the user s convenience, this application includes a default menu which has an exhaustive list of HCW disciplines and roles within each discipline that allows the hospitals to capture detailed data if they choose to. The Hospital Administrator can determine the level of detail that the data would capture by either customizing this list or using it as is. Here is an example of how this works if the hospital administrator decides to use this detailed menu as is: if an observer happens to know the exact type of nurse they are observing (e.g. registered nurse vs. nurse student), they can designate that. If not, they can enter data as Nurse-any. Over time, the Hospital Administrator can analyze hand hygiene compliance data by disciplines or roles within each discipline, and determine which a specific population of hospital s staff, e.g. nursing students, requires additional training on hand hygiene adherence. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

3 B. Data reporting For the hospital s web reports, the Hospital Administrator can customize how he/she would like to categorize the data. Categorization of data should occur by HCW disciplines, which should include nursing discipline, provider/prescriber discipline, environmental services, etc. The application gives the Hospital Administrator the option to choose the number and composition of those disciplines to best match hospital policies and procedures. E.g. one can choose to enter compliance of physician assistants within the provider/prescriber category or within the other category. 3. Observation measures In compliance with the Maryland Hand Hygiene Core Dataset, hospitals must measure EXIT from a patient environment. Hospitals also may choose (and are encouraged to) monitor a number of additional opportunities for hand hygiene. Please take note that it is important to guide/instruct the observers on how to collect data on the hospital s other chosen measures, so data continue to be reliable. ENTRY to patient environment is the only other measure that is currently included in the Standardized Training for Hand Hygiene Observers Course.

4 Institutional Set-Up for the Database--Part II After the Hospital Administrator registers the hospital, members of the hospital can register and request for a specific access level. The Hospital Administrator then will need to go to the User Administration section, and assign/edit the access request with one of the three user access levels: User Administrator: This role is a helper role for the Hospital Administrator. This user can Approve User Access Requests, manage the Hospital Services, Units and Employee types, and view Charts of Data. A hospital can provide multiple users with User Administrator access. Observer: This role is for hand hygiene observers who will perform the hand hygiene observations and submit the hand hygiene observation data. An observer can also view their hospital s hand hygiene compliance charts. A hospital can provide multiple users with Observer access. View Only User: This user will have no administrative privileges. This user can login and view their hospital s Hand Hygiene compliance charts. A hospital can provide multiple users with View Only User access.

5 Data Entry For data entry, the Observer will need to log into the database and access the web-based data collection form. Hand hygiene observers can use a paper data collection tool, and then enter the information into the online database. Alternatively, handheld internet-enabled devices (e.g., iphones and blackberries) can be utilized to more efficiently collect the data and automatically download this information into the database. The Observer has the ability to review his own data submitted, and correct any mistakes within a one week period (or till hospital administrator approves data, whichever occurs first). At least once a month, the Hospital Administrator should view all data submissions and approve the hospital data. Previous month s data must be submitted/ approved by the 10 th day of the following month. After the Hospital Administrator approves the data, the data will then become available for web-reporting. Hospital Administrator also has the ability to download the data for each month as an excel spreadsheet, and can therefore combine the copy of these data with existing internal databases the hospital may already keep.

6 Web-Reporting After data is approved by the Hospital Administrator, the web-reporting function of the database will generate monthly hand hygiene compliance charts at the hospital, service, and unit levels, and by healthcare worker (HCW) disciplines. Sample Hand Hygiene Compliance Charts 1.Click here on hospital bar to get to your Hospital Level Graphs Hospital overtime Hospital services compliance Hospital Level Graphs 2.Click here on service bar to get to your Service Level Graphs Service Level Graphs Hospital units compliance Service overtime Compliance by HCW type Service Units compliance 3. Click on your unit bar from the hospital or service graphs to get to your Unit Level Graphs Compliance by HCW type Unit Level Graphs Unit overtime Compliance by HCW type

7 Frequently Asked Questions on Data Submission and Web-Reporting 1. How much human resources does it take to conduct hand hygiene observations? How many observations an observer can make over a period of time is largely determined by the activity on that unit during that time period. In general observers should spend around mins on a unit at a time to record observations. As an estimate, a hospital with 25 units will need to spend around 15 hours of hand hygiene observations each month to meet the Collaborative s requirement (a minimum of 30 observations per unit per month meets the requirement of Maryland Hospital Hand Hygiene Collaborative). 2. Who can enter data from each hospital? Only the users with the Observer access level can enter data. A hospital can choose to assign multiple users who work with data with this access level, including hand hygiene observers, data analyst, and administrative staff. 3. What is the benefit of the customizable feature for the observation measures? The customizable feature is designed to support the hospitals in meeting the reporting requirement for the Collaborative (described below) a. report the Maryland Hospital Hand Hygiene Core Data Set described in this protocol; b. report the Maryland Hospital Hand Hygiene Core Data Set described in this protocol, and maintain current organizational measurement strategy, or; c. elect to observe for both Entry and Exit from Patient Environment ( consistent with Hopkins measurement approach ) In particular, for the hospitals who want to report the Core Data set and maintain current organizational measurement strategy, they have the ability to add specific measures onto the observation collection form.