NoCVA SSI/VTE Safe Surgery Collaborative Orientation Webinar #3 Measures and Data Collection July 19, 2012 Presented by: Jan Mangun, MT(ASCP), MSA, CPHRM Executive Director, Quality and Patient Safety Virginia Hospital and Healthcare Association
NoCVA This activity is part of the North Carolina Virginia Hospital Engagement Network(NoCVA) NoCVA is led by the NC Quality Center in partnership with the VA Hospital and Health Association NoCVA exists to support the goals of the CMS national effort - The Partnership for Patients
Partnership for Patients Goals By the end of 2013, preventable hospital acquired conditions would be reduced by 40%, compared to 2010 By the end of 2013, 30-day hospital readmissions would be reduced by 20%, compared to 2010 The NoCVA Safe Surgery Collaborative is designed to impact the SSI and VTE goals
Timeline Recruitment March 2012 May 2012 Pre-work May 2012 June 2012 Surgical Safety Culture Survey (baseline) Learning Session 1 Learning Session 2 May-July 2012 June 11, 2012 January 29-February 1, 2013 Action Periods June 2012 December 2013 Data Collection 2 nd qtr 2012-4 th qtr 2013 6 Weekly Orientation Webinars Late June 2012 Monthly Webinars August 2012 4
Collaborative Actions Customize, test and implement checklist Data assessment and review: clinical Train Observers and complete 5 observations quarterly Teamwork Training Orientation Webinars #1: June 28, 130pm Orientation Webinar #2: July 12, 130pm Completion Date: September 30th Orientation Webinar #3: July 19, 130pm Measurement June 11 Learning Session Modules on CD from June Learning Session Materials on NoCVA QDS website Begin Observations as Checklist is implemented Submit Team Assessment Tool October 1, 2012 Orientation Webinar #4: July 26, 130pm Executive Partnerships Orientation Webinar #5: Aug 2, 130pm Change: Learning from Defects analysis Orientation Webinar #6: Aug 9, 130pm
Polling Question #1 Where are you in completing these Collaborative activities? 1. 1, 2, 3 and 4 2. 1, 2 and 3 3. 1 and 2 only 4. None 1. Project Team in QDS 2. OR Roster to NCQC 3. Safety Culture Survey underway 4. Checklist modification process begun
Objectives Name the process and outcome measures for the SSI/VTE Safe Surgery Collaborative Understand the required vs. optional measures Understand the cultural and teamwork measures for this Collaborative
Measurement Process Measures (to be pulled from CMS warehouse) SSI VTE Outcome Measures All or none bundle of SCIP INF Measures for surgical site infection prevention as defined by CMS by surgery type Percentage of surgical patients receiving VTE prophylaxis as defined by CMS (SCIP VTE 2) SSI VTE Standardized Infection Ratio for selected surgical procedure (as entered into NHSN) or No. of SSI / total No. Surgeries (if entered into QDS for orthopedic procedures) % of Patients with VTE undergoing selected surgical procedure(s) 8
Measurement Culture Process Measures: o Teamwork Observation Tool o o Checklist Observation Tool: Surgical Safety Culture Survey: pre- and postaction period 9
Why these surgeries? Why HYST/COLO? National focus via NHSN reporting Make it easy: no additional data burden Why HPRO/KPRO? Chance to show impact: surgical volume Inclusivity: performed in majority of the hospitals in the state Passionate leadership 10
ABDOMINAL HYSTERECTOMY & COLON PROCEDURES Overview Measure definition Due dates NHSN submission only Understanding feedback: standardized infection ratios
HYST/COLO overview SSI rates for BOTH inpatient abdominal hysterectomy & colon surgeries SSI are required o This aligns with CMS requirement o SSIs for HYST/COLO will be tracked every quarter CMS requires NHSN submission effective January 2012 o NoCVA HEN also requires NHSN submission
HYST/COLO: Measure definition Definition of SSI and HYST/COLO procedures can be found in NHSN documentation: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf? agree=yes&next=accept Numerator: Deep incisional primary and organ/space SSIs that were identified during admission (A) or readmission to your facility (R), as defined in the most recent CDC NHSN Manual. Denominator: patients who have undergone HYST & patients who have undergone COLO Note: exclusion criteria for SSI 1. Do not submit superficial SSI 2. Do not submit outpatient SSI 3. Do not submit secondary SSI
What are COLO and HYST? Source: NHSN manual http://www.cdc.gov/nhsn/pdfs/pscmanual/ 9pscSSIcurrent.pdf
HYST/COLO: How? SSI Rates will be pulled from NHSN o Action item: Give group rights to NCQC Some of you have already done this. Will send email at end of this webinar with instructions for how to assign group rights Requires NO ADDITIONAL data collection or submission by hospital
HYST/COLO: When? Baseline: January-June 2012 discharges Quarterly thereafter through December 2013
Risk-adjustment What is risk-adjustment? Risk-adjustment partially corrects for the fact that patients and hospitals differ o For instance, very long procedures are more likely to result in SSIs Risk adjustment allows hospitals/units to more meaningfully compare their rates against each other
Risk-adjustment For HYST/COLO, NHSN automatically provides sophisticated risk adjustment No extra work on your end, so this is just an overview to provide understanding NHSN determines an expected number of SSIs given your patient population and volume o They use a complicated statistical model which takes into account many factors o For instance, for COLO procedures, they take into account age, anesthesia, ASA, duration, endoscope usage, medical school affiliation, bed size, and wound class How do they choose these factors? These factors have been found to be most influential that NHSN collects, after analyzing over 800,000 procedures.
Risk-adjustment: SIRs Risk adjustment will be used to build a standardized infection ratio (SIR) SIR= observed infections expected infections Example: 2 observed SSIs during COLO 4 expected SSIs during COLO SIR= = 0.5
Polling Question #2 At this time, is the measurement plan for hysterectomy & colon surgery clear? Yes Mostly, but I have a few questions Still very unclear
Total Hip & Total Knee Procedures (Optional) Overview Definitions When to submit How to submit Risk-stratification option
Polling Question #3 Does your facility plan to submit data for hip, knee, or both procedures? 1. Hip 2. Knee 3. Both 4. Not sure, possibly 5. Doesn't apply to me
Hip/Knee: Overview SSI rate for HPRO and/or KPRO o Your choice: Hip, Knee, or both o Your choice: risk-stratify or do not risk-stratify o Pre/Post Analysis o Does the SSI rate decrease during the collaborative? Compare: o Six-month rate before the collaborative starts o Six-month rate after collaborative ends
Hip/Knee SSI definition SSI rates will be collected by hospital o Numerator: # of deep incisional & primary organ/space SSIs during admission or readmission during total hip (HPRO) and/or knee (KPRO) replacement surgery o Denominator: # of patients having procedure HPRO and/or KPRO Definition of SSI and HPRO/KPRO procedures can be found in NHSN documentation: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf? agree=yes&next=accept Note: exclusion criteria for SSI 1. Do not submit superficial SSI 2. Do not submit outpatient SSI 3. Do not submit secondary SSI
Hip/Knee SSI details Source: NHSN manual http://www.cdc.gov/nhsn/pdfs/pscmanual/ 9pscSSIcurrent.pdf
Hip/Knee Due Dates Only two due dates 1. Six-month baseline (Sept 2011-March 2012) due August 3, 2012 via QDS 2. Six-month follow-up (July 2013-December 2013) due March 31, 2014via QDS One numerator and denominator per month o Possibly split by risk level (risk-stratification option)-- Optional
Submitting hip and/or knee data: QDS option Most hospitals will enter into QDS By default, only your data person & team leader have QDS access. You can request an additional person if needed. Email the project manager (Dean) and he will contact our webmaster.
Risk-adjustment for hip & knee Will have option to risk adjust hip and knee SSI data in QDS The method uses risk-stratification via the old NHSN risk index. Each patient is assigned a value between 0-3 based on three things: o ASA score (3, 4, or 5) o Wound classification (contaminated or dirty) o Procedure duration (>75 th percentile, i.e. 120 minutes) o Your IP will need to do this scoring for you and may already do this, but is not current NHSN methodology. o If you are interested in risk-stratification and want additional training, contact me via email.
Live in QDS What I will do: Collaborative resources webpage http://www.ncqualitycenter.org/nocva/index.lasso Log in to QDS What if you have forgotten your password? Landing page is less busy for teams Show data tab o Hip procedures ² Non-stratified ² Stratified Data verification
Your choice No risk adjustment Risk adjustment
NHSN entry option Some facilities are entering HPRO and KPRO SSIs into NHSN already. Ask your IP. o That s great! o If you use NHSN, you do NOT have to enter into QDS as well o If you use NHSN, you DO have to give group rights to the Quality Center for this data ² Note: EVERYONE will need to give group rights for HYST/ COLO, so this information should be useful to all ² An email will be sent after this webinar with instructions on giving group rights.
Polling Question #4 At this time, is the measurement plan for hip and knee clear? 1. Yes 2. Mostly, but I have a few questions 3. Still very unclear
HPRO/KPRO v. HYST/COLO HPRO and/or KPRO Report to QDS or NHSN Numerator/Denominator only You have a choice: hip, knee, or both (NCQC is flexible) Only two deadlines (May 30, 2012 & 2013) Risk adjustment is up to you, but requires some extra work. Risk adjustment is via basic stratification. HYST & COLO Report to NHSN, giving group rights to NCQC Follow NHSN reporting guidelines Both HYST & COLO required Quarterly deadlines (NHSN requires monthly) Risk-adjustment happens automatically with no extra effort Risk adjustment uses a very complex statistical model
Venous Thrombosis Embolism Outcome Measures Quick overview VTE
VTE data collection Good news! NO additional data entry on your end for VTE o We recognized that SSI is already complex/burdensome o VTE rates are so low at many hospitals that we were not confident we can get meaningful data We will ask you to consider doing a defect analysis on VTE o VTE is a QI priority, just very hard to to track clinical data We will track VTE rates using VA state patient data base data. Does factor in POA Feedback will be provided to the collaborative.
VTE PSI #12 AHRQ PSI #12: Postoperative Pulmonary embolism or deep vein thrombosis rate o Numerator: DVT or PE in any secondary diagnosis field o Denominator: Surgical discharges, 18+ yrs of age o Population exclusions: ² principle diagnosis of DVT/PE or secondary diagnosis present on admission (POA) ² procedures for interruption of vena cava ² MDC 14 (pregnancy/childbirth/puerperium)
Other measures Culture Survey Checklist Observation Tool Team Observation Tool
Surgical Safety Culture Survey Why this survey? It asks specifically about culture in the OR Developed by Harvard Safe Surgery 2015 39
Surgical Safety Culture Survey Surgical Safety Culture Survey o Each hospital will take it twice o Once at start of the collaborative o Once at the end of collaborative Submit OR Roster to NCQC (for denominator only) jhayes@ncha.org Complete by July 31 st
How will it be used? Survey questions look at perceptions of OR teamwork and culture Questions address 5 dimensions of culture o Speaking up o Sharing information o Feeling respected o Working well together o OR Leadership Will share de-identified, aggregated data back to each of you o Can be used to identify strengths/weaknesses, build buy-in among personnel, and initiate conversations o Information is only as good as your response rate get us those OR rosters! And encourage participation! 41
Sample graph from survey report 42
Observation Tools Observe 5 surgeries each quarter (at least 1 hr) o Use 2 tools: 1. checklist observation 2. teamwork observation Extensive training at June 11 on-site Learning Session o Materials available on DVD and on NoCVA HEN website.
Checklist Observation Tool Tool 4: Surgical Safety Checklist Coaching Tool Date of procedure: / / Hospital name: Procedure Information Patient age: Time of incision: : AM / PM Urgent/emergent case (requiring same-day completion): Yes No Patient gender: M F Surgical end time: : AM / PM Significant nonclinical disruptions: Yes No Surgeon s specialty: Case delayed >30min: Yes No Procedure performed: Patient disposition: Inpatient Outpatient Observer Information Observer role: Circulating Nurse Other: Observer age: Observer gender: M F Years in current role at this hospital: Processes of Care 1. Was an antibiotic given within 1 hour of incision? Yes, w/o prompting Yes, prompted by checklist No N/A 2. Were compression boots placed (mechanical DVT prophylaxis)? Yes, w/o prompting Yes, prompted by checklist No N/A 3. Was a warmer placed (for case >1 hour)? Yes, w/o prompting Yes, prompted by checklist No N/A Briefing 4. Which of the following individuals participated in confirming the patient s identity, procedure or operative site before incision? (Mark all that apply.) Circulating nurse Anesthesia provider Surgeon Surgical tech Not confirmed 5. Did team members introduce themselves by name and role (e.g., Lynn, the anesthesiologist. )? Yes No 5a. If no, was this team established (i.e., introductions performed earlier the same day)? Yes No 6. Before incision, did the surgeon discuss the operative plan? Yes No 7. Before incision, did the surgeon state the expected duration of the procedure? Yes No 8. Before incision, did the surgeon communicate the expected blood loss (EBL)? Yes No 9. Before incision, did the nurse discuss sterility, equipment, or any other concerns? Yes No 10. Before incision, did the anesthesia provider discuss the anesthesia plan (including airway or other concerns)? Yes No 11. Were all checklist items read aloud, without reliance on memory? Yes No Debriefing 12. Before the patient left the OR, did the team discuss specimen labeling (e.g., labels / patient name read aloud)? Yes No 13. Before the patient left the OR, did the team discuss equipment or other problems that arose? Yes No 14. Before the patient left the OR, did the team discuss key concerns for patient recovery and post-op management? Yes No
Team Assessment Tool This is a 3 rd tool that is designed to provide feedback to the Collaborative on how things are going with your Project Implementation team It is very brief Quarterly Submission Available in QDS
Team Assessment Tool No Yes Comments 1. Our project team has met monthly this quarter 2. 75% or more of our project team has attended each team meeting this quarter. 3. Our surgeon and anesthesia champions have attended at least half our team meetings this quarter 4. Our project team has a patient, family member, or patient advisor who participated in at least half our team meetings this quarter. 5. Our surgeon champion uses the checklist consistently and has spoken 1:1 with other surgeons this quarter, encouraging participation in the project. 6. We have fully implemented the checklist in all hip and knee replacement surgeries 7. We have fully implemented the checklist in all colon and abdominal hysterectomy surgeries 8. We have fully implemented the checklist in these additional surgical specialties. 9. Our team has accessed the NoCVA Safe Surgery toolkit this quarter. The section we reviewed and used was 10. Members of our project team have spoken 1:1 with each staff person and physician who have begun using the checklist, prior to their using the checklist. 11. We are using our process for capturing the information from the OR debriefing section of the checklist, and we have a standardized way of addressing issues identified there 12. Our executive sponsor has completed safety rounds in the OR this quarter. How often? 13. Information from safety rounds is shared with the project team and with other staff at least quarterly. 14. The project team reviewed SSI, VTE, near misses of adverse events, and teamwork observation data at least monthly this quarter. 15. We have conducted a defect analysis on a SSI, VTE, adverse event or near miss this quarter. 16. There has been confusion this quarter on how to proceed with collaborative / project activities with regards to the cultural component to improve safety (safety rounds, teamwork, reporting near misses, etc.) 17. We lack sufficient time and resources to complete this project.
Data Submission Schedule Table 1: Data Schedule for Virginia In-person session on June 11 Overview of All Measurement Due Dates & Submission Method Timeframe of Data Measure Due date* Where to submit 5/24/12-7/31/12 Culture Survey Jul 31, 2012 SurveyMonkey link 1/1/12-3/31/12 and 4/1/12 6/30/12 HYST & COLO SSI (baseline) VTE Sept, 2012 NHSN CMS & VA Data base 9/01/11-3/31/12 HPRO & KPRO SSI Aug 3, 2012 QDS 7/1/12 9/30/12 5 Checklist Observation Tools 5 Teamwork Observation Tools Oct 1, 2012 Fax, mail or secure email forms to Quality Center; keep a copy for yourself 7/1/12 9/30/12 TAT Oct 1, 2012 QDS 7/1/12 9/30/12 HYST & COLO SSI VTE Dec 1, 2012 NHSN CMS & VA Data base 10/1/12 12/31/12 5 Checklist Observation Tools 5 Teamwork Observation Tools February1, 2013 Fax, mail or secure email forms to Quality Center; keep a copy for yourself 10/1/12 12/31/12 TAT February 1, 2013 QDS 10/1/12 12/31/12 HYST & COLO SSI VTE March 1, 2013 1/1/13 3/31/13 5 Checklist Observation Tools May1, 2013 5 Teamwork Observation Tools NHSN CMS & VA Data base Fax, mail or secure email forms to Quality Center; keep a copy for yourself 1/1/13 3/31/13 TAT May 1, 2013 QDS 1/1/13 3/31/13 HYST & COLO SSI VTE May 1, 2013 NHSN CMS & VA Data Base 4/1/13 6/30/13 5 Checklist Observation Tools 5 Teamwork Observation Tools Aug 1, 2013 Fax, mail or secure email forms to Quality Center; keep a copy for yourself 4/1/13 6/31/13 TAT August 1, 2013 QDS 4/1/13 6/30/13 HYST& COLO SSI VTE September 1, 2013 NHSN CMS & VA Data Base 7/1/13 9/30/13 5 Checklist Observation Tools 5 Teamwork Observation Tools November 1, 2013 Fax, mail or secure email forms to Quality Center; keep a copy for yourself 7/1/13 9/31/13 TAT November 1, 2013 QDS 7/1/13 9/30/13 HYST & COLO SSI VTE Dec 2, 2013 10/1/13 12/31/13 5 Checklist Observation Tools February 1, 2014 5 Teamwork Observation Tools 12/01/13-12/31/13 Culture Survey December 31, 2013 Survey Monkey (improvement) 07/01/13-12/31/13 HPRO & KPRO SSI February 1, 2014 QDS 10/1/13 12/31/13 TAT February 1, 2014 QDS NHSN CMS & VA Data Base Fax, mail or secure email forms to Quality Center; keep a copy for yourself 10/01/13-12/31/12 HYST & COLO SSI VTE March 1, 2014 NHSN CMS & VA Data Base Schedule will be sent in follow-up email and also available in Data Manual
Action Items; Next Steps HYST/COLO Assign NHSN group rights to NCQC Make sure IPS knows about NCQC due dates HPRO/KPRO VTE Culture Observation Tools TAT Decide whether to report hip, knee or both Decide whether to risk-stratify Who will do QDS data entry (or NHSN, if applicable)? When? No data action items Submit OR Roster to NCQC Complete Culture of Safety Survey by July 31st 5 surgeries (use 2 tools for each) due October 1 st No current action items http://www.ncqualitycenter.org/nocva/ssvaresources.lasso
Polling Question #5 Amount of useful information and ideas provided: Excellent 1. Excellent 2. Good 3. Fair 4. Poor 5. N/A
Polling Question #6 Usefulness to my hospital of the information and ideas provided: 1. Excellent 2. Good 3. Fair 4. Poor 5. N/A
Polling Question #7 Chance that the information and ideas provided will improve my effectiveness and results:
Questions?
Contact Information Jan Mangun, MT(ASCP), MSA, CPHRM Executive Directive, Quality & Patient Safety jmangun@vhha.org 804-965-1202 Debbie Roddenberry Assistant Director droddenberry@vhha.com 804-965-5714