How to Use the SUSP Online Portal A training call for SUSP facilitators

1. How to Use the SUSP Online PortalA training call for SUSP facilitators Terry Tsai, PhD, MPH & Sallie Weaver, PhD Armstrong Institute for Patient Safety and Quality October 28 & October 30, 2013

2. You enable SUSP teams’ success At the end of this webinar, you should be able to: • Identify the roles and responsibilities of SUSP facilitators • Explain the SUSP Online Portal registration process • Locate the HSOPS ‘app’ and SSI data registry on the SUSP portal • Discuss the HSOPS administration and SSI data transfer processes

3. How we’ve structured this call Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Start high level • Get in the weeds (not too far!) • Point you to step-by-step resources for training on specific skills

4. The Power of Data Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Frontline clinicians often don’t have access to hospitals’ performance data • Through the SUSP Online Portal (website), you can put two types of project data in their hands: • Hospital Survey on Patient Safety (HSOPS), or patient safety culture survey data • Surgical site infection (SSI) data

5. The SUSP Online Portal is your project data resource Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • You can get real-time safety culture and SSI data through the portal • HSOPS ‘app’ will generate a report of your safety culture scores 24 hours after the Cohort 4 survey period closes • Cohort 4 HSOPS survey period = Oct 28-Dec 16, 2013 • SSI Data Registry will generate SSI reports for unadjusted data every month • After data has been entered into system

6. SUSP Facilitators All Work as a Team Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Coordinating Entity • HSOPS Survey Coordinator • SUSP Data Lead (“Hospital Administrator”)

7. SUSP Facilitator Responsibilities • Coordinating Entity • Connects hospitals and the National Project Team (NPT) • Facilitates networking and improvement work • HSOPS Survey Coordinator • Leads HSOPS administration (or data upload) at the hospital level • SUSP Data Lead (“Hospital Administrator”) • Leads the process of connecting frontline staff to hospital SSI data

8. Your first step to accessing SUSP project data SUSP Online Portal registration

9. High Level Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • SUSP Online Portal Registration is a crucial first step to optimizing your participation in this project • We use your registration info to create “networks” in the SUSP Online portal • Networks ensure that your hospital team sees the right SSI and HSOPS data

10. In the Weeds Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • You are awesome! We have all of your SUSP Portal Registration Forms! • We will send all SUSP facilitators an email with a temporary login password when they are registered in the online portal

11. Training Resources Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • SUSP Project Registration Fast Facts • SUSP Project Registration Manual • Registration videos • For all SUSP Facilitators • Distinguishes between three types of project registration

12. Measure your perioperative area’s safety culture HSOPS Administration

13. Safety Culture Matters Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011. • Safety culture is related to outcomes • Patient outcomes • Clinician outcomes • Safety culture influences the effectiveness of other safety and quality interventions • Can enhance or inhibit effects of other interventions • Safety culture can change through intervention • Best evidence so far for culture interventions that use multiple components

14. The SUSP Model to Improve Care http://www.hopkinsmedicine.org/armstrong_institute

15. Do I have to upload or collect HSOPS data to participate in this project? • No • No formal requirement to collect fresh HSOPS data or to upload previously collected data to the SUSP data platform • BUT! Safety culture data is a value-add for your SUSP work… • Helps diagnose areas where culture might be hindering reliable use of evidence-based practices • Can help to understand why clinicians and staff are engaged (or not engaged) in safety efforts

16. Two Safety Culture Data Collection Methods Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

17. The HSOPS App is Located on the SUSP Portal Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) You can only access the HSOPS Data App with a SUSP Portal login and password The HSOPS Data App will be functional within a specific time period of HSOPS “open” and “close” dates Cohort 4 Open Date: October 28, 2013 Cohort 4 Close Date*: December 16, 2013

18. Survey coordinators will use the HSOPS app to… • Collect new HSOPS data or upload previous HSOPS data • Send invitation emails to survey participants • Emails contain a unique link that participants will click on to complete the survey • Check on the response rate for their work areas • Goal = 60% response rate • Stretch goal = 80% response rate or higher • Download a .pdf report that summarizes survey results for their work area(s) • Reports will be available after the survey closes

19. New SUSP Main page

20. Locating the HSOPS App Log in to the portal using your login and password (https://armstrongresearch.hopkinsmedicine.org) Select My Tools

21. Accessing the HSOPS App Click Manage

23. Accessing the HSOPS App • After Cohort 4 Survey “Closes” • Download aggregate report to obtain results of the HSOPS for your work area, including charts and graphs • Use the aggregate report to debrief results with frontline staff and clinicians • The purpose of the debriefing discussion(s) are to identify strengths and areas to improve using CUSP

24. Key Steps: If collecting fresh HSOPS data • Determine whom to survey • Compile email lists (Pre-op, OR, PACU) • Log on to the SUSP Online Portal: https://armstrongresearch.hopkinsmedicine.org • Upload a list of survey participant email addresses for participating work area(s) • The app will send each study participant an email which contains a unique link to the survey. • Check survey response rate weekly • Download .pdf report after survey closes • Based on your survey debriefing plan, share with project team, leadership, and frontline staff members

25. Is your email list up to date? Make sure your list is up to date, check for: Staff on administrative or extended sick leave, Staff who appear in more than one staffing category or hospital area/unit, Staff who have moved to another hospital area/unit, Staff who no longer work at the hospital, and Other changes that may affect the accuracy of your list email addresses Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

26. Key Steps: If uploading previously collected HSOPS data for your surgical work area • Log on to the SUSP Online Portal: https://armstrongresearch.hopkinsmedicine.org • Download HSOPS data formatting manual, data file template, & watch “how to upload HSOPS data” video • Format your HSOPS data excel file according to HSOPS data formatting requirements • Upload your correctly formatted HSOPS excel file to the HSOPS App • Check to make sure file uploaded correctly • Download report after survey closes • Based on your survey debriefing plan, share with project team, leadership, and frontline staff members

27. Thinking about uploading existing HSOPS data? Some important questions Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Has data about the safety culture in our work area been collected in the last 12 months? • If yes: • When was this data collected and how (e.g., online survey, paper survey, in person interviews)? Who has access to this data? • What aspects of culture were measurement/what data were captured? • Is it possible to obtain copies of the raw data (e.g., an excel file of responses) or only reports (e.g., pdf file with charts and graphs).

28. Please aim for a response rate of 60% or higher • Response rate = Number of respondents who completed the online survey divided by the total number of unit members who were invited to complete the survey • Safety culture reflects the shared perceptions among unit members • Response rate of 60% is minimum necessary for a relatively representative sample • Important for validity and reliability of results

29. Effective surveys… Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) Are confidential and anonymous Have a clear reason and motivation to complete them Are publically supported by both formal and informal unit leaders

30. Thinking ahead: Creating a Debriefing Plan for your Survey Results Debriefing is… A semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Purpose… Encourage open communication, transparency, and interactive discussion about the survey results across all levels To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area

31. HSOPS Tools & Resources Available on the SUSP Online Portal • Planning and Preparing • HSOPS Fast Facts • Survey coordinator role description • Debriefing & using your HSOPS results for meaningful change Example .pdf report of HSOPS results Template: HSOPS Debriefing plan Culture check up tool Improving patient safety in hospitals: A resource list

32. HSOPS Tools & Resources Available on the SUSP Online Portal • If collecting fresh HSOPS data: • Video guide: How to Collect New HSOPS Data • HSOPS Manual: Planning and Preparing for your survey • Example survey pre-notification materials • Example email invitation to participants • Template: Email list

33. HSOPS Tools & Resources Available on the SUSP Online Portal • If uploading previously collected HSOPS data: • Video guide: How to Upload Existing HSOPS Data • HSOPS data formatting & definition guide • Template: HSOPS data upload template

34. References Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct-Dec;34(4):300-11. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print]. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004. van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9. Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011. Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.

35. Use the SUSP Online Portal to get performance data in the hands of your frontline staff. SSI data transfer

36. Access timely SSI data reports through the SUSP Portal Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Unlike NHSN or NSQIP, you can generate monthly unadjusted SSI data reports from the SUSP Portal • Teams do not need to wait 6 months for actionable data • SUSP SSI data reports are simple and easy to interpret

37. Find SSI Data in the SSI Data Registry (SSI ‘app’) • You can only access the SSI Data Registry with a SUSP Portal login and password • The NPT will add the SSI Data Registry ‘app’ to each hospital team’s network • Like adding an app to your smart phone • We’ll talk about this more in a few moments

38. Locating the SSI Data Registry Log in to the portal using your login and password (https://armstrongresearch.hopkinsmedicine.org) Select My Tools

39. Accessing your SSI Data Viewing for SSI Network as Demo User Click Reports

40. Sample SSI Data Report

41. SSI Data Transfer Steps (NSQIP) • Hospital returns SUSP Portal Registration Form and DUA to NPT (susp@jhmi.edu) and Coordinating Entity • NSQIP will contact hospital to complete an Addendum DUA

42. SSI Data Transfer Steps (NSQIP) • NPT registers hospital team in the SUSP SSI data registry • NPT downloads hospital SSI data from NSQIP, and uploads it into the SUSP Portal

43. SSI Data Transfer Steps (NHSN) Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Hospital returns SUSP Portal Registration Form and DUA to NPT (susp@jhmi.edu) and Coordinating Entity • We cannot proceed with the data transfer process until we have these documents

44. SSI Data Transfer Steps (NHSN) Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) 2. NPT registers hospital team in the SUSP SSI data registry • We will ask each coordinating entity for demographic info (e.g. bed size) about their participating hospitals • We will send coordinating entities a spreadsheet via email to get this info

45. SSI Data Transfer Steps (NHSN) Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) Coordinating entities download hospital SSI data from NHSN, and upload it into the SUSP Portal We will contact each CE when they reach this step to review NHSN transfer materials and answer your questions

46. Training Resources Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) SSI Data Transfer Fast Facts NHSN SSI Data Transfer Manual NHSN SSI Data Transfer Video

47. Training Resources Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • SSI Data Transfer Fast Facts • For Coordinating Entities and SUSP Data Leads • Provides a high-level overview of “who does what, when?” and points you to additional training resources

48. Training Resources Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • NHSN SSI Data Transfer Manual and Video • For Coordinating Entities • A step-by-step of the following tasks: • Create a ‘group’ in NHSN if you do not already have one • Configure NHSN template to download surgical code-specific SSI data from NHSN • Upload NHSN data file into the SUSP Portal

49. Next Steps Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu) • Complete the SSI Data Fast Facts checklist and download your hospitals’ SSI report for the month of October • We’ll teach you how to download reports on the January 13th call. • Complete the SUSP HSOPS Fast Facts checklist and bring a copy of your HSOPS report to the January 13th call

50. Key Dates