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

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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

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How we’ve structured this call

• Start high level– Get in the weeds (not too far!)

• Point you to step-by-step resources for training on specific skills

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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The Power of Data

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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The SUSP Online Portal is your project data resource

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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SUSP Facilitators All Work as a Team

• Coordinating Entity• HSOPS Survey Coordinator• SUSP Data Lead (“Hospital

Administrator”)

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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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

SUSP ONLINE PORTAL REGISTRATION

Your first step to accessing SUSP project data

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High Level

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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In the Weeds

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Training Resources

• SUSP Project Registration Fast Facts• SUSP Project Registration Manual• Registration videos

– For all SUSP Facilitators– Distinguishes between three types of

project registration

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

HSOPS ADMINISTRATIONMeasure your perioperative area’s safety culture

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Safety Culture Matters

• 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

Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

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The SUSP Model to Improve Care

http://www.hopkinsmedicine.org/armstrong_institute

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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

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Two Safety Culture Data Collection Methods

Yes, we have previously

collected HSOPS data

• Upload perioperative HSOPS data to the HSOPS App in the SUSP Online Portal https://armstrongresearch.hopkinsmedicine.org

No, we have not previously collected

HSOPS data… or would like to collect

new data for the work areas

participating in this project

• Collect new HSOPS data using the HSOPS App in the SUSP Online Portal

• https://armstrongresearch.hopkinsmedicine.org

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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The HSOPS App is Located on the SUSP Portal

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Survey coordinators will use the HSOPS app to…

1. 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

2. Check on the response rate for their work areas– Goal = 60% response rate – Stretch goal = 80% response rate or higher

3. Download a .pdf report that summarizes survey results for their work area(s)– Reports will be available after the survey closes

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New SUSP Main page

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Locating the HSOPS App

• Log in to the portal using your login and password (https://armstrongresearch.hopkinsmedicine.org)

• Select My Tools

Accessing the HSOPS App

Click Manage

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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

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Key Steps: If collecting fresh HSOPS data

1. Determine whom to survey

2. Compile email lists (Pre-op, OR, PACU)

3. Log on to the SUSP Online Portal:

https://armstrongresearch.hopkinsmedicine.org

4. Upload a list of survey participant email addresses for participating work area(s)

5. The app will send each study participant an email which contains a unique link to the survey.

6. Check survey response rate weekly

7. Download .pdf report after survey closes

• Based on your survey debriefing plan, share with project team, leadership, and frontline staff members

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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)

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Key Steps: If uploading previously collected HSOPS data for your surgical work area

1. Log on to the SUSP Online Portal:

https://armstrongresearch.hopkinsmedicine.org

2. Download HSOPS data formatting manual, data file template, & watch “how to upload HSOPS data” video

3. Format your HSOPS data excel file according to HSOPS data formatting requirements

4. Upload your correctly formatted HSOPS excel file to the HSOPS App

5. Check to make sure file uploaded correctly

6. Download report after survey closes

– Based on your survey debriefing plan, share with project team, leadership, and frontline staff members

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Thinking about uploading existing HSOPS data? Some important questions

• 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).

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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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

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Effective surveys…

• Are confidential and anonymous

• Have a clear reason and motivation to complete them

• Are publically supported by both formal and informal unit leaders

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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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

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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

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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

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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

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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.

SSI DATA TRANSFER

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

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Access timely SSI data reports through the SUSP Portal

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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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

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Locating the SSI Data Registry• Log in to the portal using your login and password (

https://armstrongresearch.hopkinsmedicine.org)• Select My Tools

Accessing your SSI Data

Click Reports

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Viewing for SSI Network as Demo User

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Sample SSI Data Report

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SSI Data Transfer Steps (NSQIP)

1. 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

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SSI Data Transfer Steps (NSQIP)

2. NPT registers hospital team in the SUSP SSI data registry

3. NPT downloads hospital SSI data from NSQIP, and uploads it into the SUSP Portal

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SSI Data Transfer Steps (NHSN)

1. 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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SSI Data Transfer Steps (NHSN)

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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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SSI Data Transfer Steps (NHSN)

3. 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Training Resources

• SSI Data Transfer Fast Facts• NHSN SSI Data Transfer Manual• NHSN SSI Data Transfer Video

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Training Resources

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Training Resources

• 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 PortalQuestions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Next Steps

• 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

Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)

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Key Dates

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Next Call

What questions do you have?

• Remember you have a support network– You can ask questions during coaching

calls– You can contact the SUSP helpdesk

52Questions? Contact the SUSP helpdesk! (SUSP@jhmi.edu)