Embed Size (px)
Citation preview
Measurement for SHN! – Submitting DataJanuary 31, 2006
Virginia Flintoft, RN MScProject Manager, SHN! Central Measurement Team
Measurement Strategies – SHN!
• When to send
• Where to Send
• How to send
• What to send
• Privacy
Pilo
t Tes
t – B
asel
ine
& E
arly
Impl
emen
tatio
nF
ull I
mpl
emen
tatio
n
Select SHN intervention(s)
Form your intervention-specific team
Set Aims for Intervention
Identify changes that will likely lead to improvement
PDSA CyclePlan - Do - Study - Act
Implement small-scale tests
of change
Collect Baseline data by
retrospective review
Collect Early Implementation
Data – concurrent or retrospective
Ongoing Collaboration with
Node SIA
Implementation on broad scale
e.g. unit level
Collect Full Implementation
Data – concurrent or retrospective
Submit Baseline Data to CMT on
Measurement Worksheet –
1 dataset
Submit Early Implementation Data to CMT on Measurement Worksheet -
Monthly
Submit Full ImplementationData to CMT on Measurement Worksheet -
Monthly
Intervention Process
Data Collection
Data Submission
Reports
Quarterly Reports to Team, Node & SHN Steering Cte
Safer Healthcare Now – Process and Data Flow
Measurement - When to Send?
• Plan to receive data in all forms by end of February
• Teams to retain data until CEO signed consent for CMT to receive
• Teams will be notified by email when to send and contact information
• Teams report monthly on their work
Measurement – Where to Send?
• Data to be sent directly to SHN! Central Measurement Team (CMT) at University of Toronto
• Data to be received on secure server or by fax in locked office both at UofT
Mechanics for Data CollectionMWG Management Strategy for Data Collection, Monitoring and Reporting
Hospital
Hospital
Hospital
NodeSIA
CMT
SHN! Steering Committee
Mo
nth
ly D
ata
Su
bm
issi
on
Qu
a rt er ly Re p
or ts
Monthly Monitoring
MWG Management Strategy for Data Collection, Monitoring and Reporting
Hospital
Hospital
Hospital
NodeSIA
CMT
SHN! Steering Committee
Mo
nth
ly D
ata
Su
bm
issi
on
Qu
a rt er ly Re p
or ts
Monthly Monitoring
Measurement – How to Send?
• Data to be sent to Central Measurement Team at University of Toronto by:• Facsimile
• Hardcopy of Measurement Worksheet or Spreadsheet
• Use SHN! Fax cover sheet
• Fax number TBA
• Web Transfer• Electronic version of Measurement Worksheet or Spreadsheet
• Link to secure web transfer site from SHN website and CoP
• Email Attachment• Not recommended
• Teams send data by email attachment at your own risk
Measurement – What to Send?
• Data to be sent to Central Measurement Team at University of Toronto includes:• Hardcopy of Measurement Worksheet or Spreadsheet
• Containing only aggregate data
OR
• Electronic version of Measurement Spreadsheet or Worksheet
• Containing only aggregate data
OR
• Do NOT send individual identifiable patient information
Data Collection Tool - Measurement Worksheet - SSI
Data Collection Tool – SSIMeasurement Worksheet - Completed
3.0 Percent of Clean Surgery Patients with Surgical Infection – Measurement Worksheet
Prevention of Surgical Site Infection (SSI)
Intervention: Reducing Surgical Site Infection
Definition: Rate of infection in patients undergoing clean surgery (NNIS Class 3 or 4 wound class: Appendix C)
Goal: Goal may be set by individual organizations/teams however, IHI recommends a reduction of 50%
Data Collection Details
Hospital Name: A - LARGE - MANITOBA - HOSPITALHealth Region: X NA or Specify Region:
Year:Indicate the year for which the data was collected: 2004 2005 X 2006 2007 Other (specify): ____
Collection Method:
X Concurrent Retrospective
Month: Indicate the month for which the data was collected: Jan. X Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.
Implementation Stage:
Baseline stage X Early implementation stage Full implementation stage (Pre-intervention) (Some team members in selected unit(s) (All team members on selected unit(s) are
have begun implementing AMI bundle) consistently implementing AMI bundle)
Patient Sample:1 worksheet/sample
Indicate the “clean” surgical procedure you have selected to monitor by placing a in the corresponding box. We recommend you use separate sheets for monitoring individual procedures, however if you choose to monitor more than one surgical procedure at once please indicate your selection by placing a in the corresponding boxes for all procedures.Surgical Procedure: CABG Cardiac Surgery X Hip arthroplasty Knee arthroplasty Colon surgery Hysterectomy Vascular Surgery
Data Collection Tool – SSIMeasurement Worksheet - CompletedCalculation of Denominator Formula Answer
3.1What is the total number of patients during the previous month who had an inpatient surgicalprocedure of the type indicated above? If more than one surgical procedures are performed during a single index hospitalization include data from the first surgical procedure only (CCI related codes: Appendix B)
25
3.2What is the total number of patients in # 3.1 whose age was less than 18 yrs on admissionto hospital? Exclude from patient list for calculating Percentage of “clean” surgery patients with surgical infection.
3
3.3 Subtract the total of # 3.2 from the total of # 3.1 and enter here. (3.1 - 3.2 = ) 22
3.4What is the total number of patients with an existing infectious process at the same site asthe surgical procedure or surgeries that are classified as wound class 3 or 4?
1
3.5 Subtract the total of # 3.4 from the total of # 3.3 and enter here. (3.3 - 3.4 = ) 21
Calculation of Numerator – Retrospective Formula Answer
3.6What is the total number of patients in # 3.5 (wound classification 1 & 2) who developed apost-operative wound infection / nosocomial infection as defined by NNIS(www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf) - see Appendix C.
15
Final Calculation Formula Answer
3.7 Divide # 3.6 by #3.5. Multiply by 100. (3.6 / 3.5) x 100 71 %
Data Collection Tool –Sample Excel SS & Run Chart3.0 Percentage of Clean Surgery Patients with Surgical Infection
Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
3.1
# of patients who had an IP surgical procedure. If more than 1 surgical procedure is performed during a single index hospitalization, include data from the 1st surgical procedure only (CCI related codes: Appendix B of How-to Guide)
25 32 29 35
3.2
# of patients in 3.1 who were less than 18 years of age on admission to hospital? Exclude from patient list for calculating percentage of "clean" surgery patients with surgical infection.
3 3 4 2
3.3 Subtract 3.2 from 3.1 22 29 25 33 0 0 0 0 0 0 0 0
3.4
Total # of patients with an existing infectious process at the same site as the planned surgical procedure - or - surgeries that are classified under wound class three or four (NNIS) on admission to the hospital?
1 4 3 0
3.5 Subtract 3.4 from 3.3 21 25 22 33 0 0 0 0 0 0 0 0
3.6
Total # of patients in 3.5 (wound classification 1 & 2) who developed a post-operative wound infection/nosocomial infection as defined by NNIS (www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf) - see Appendix C.
15 17 16 20
3.7 Divide 3.6 by 3.5 and multiply by 100 0.71 0.68 0.73 0.61 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A3.8 Goal 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%
DENOMINATOR
FINAL CALCULATION
MONTH
NUMERATOR
% of Clean Surgery Patients with Surgical Infection
0%
20%
40%
60%
80%
100%
Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
Sources for Help with Measurement and Submission• Help for teams in measurement
• Safety & Improvement Advisors (SIAs)
• Conference calls on interventions
• Communities of Practice
• National Learning Series workshops and Local meetings coordinated by Nodes
Measurement – Privacy
• Each participating hospital / health region will give CMT permission to receive, store, analyze and report data
• Secure data transfer and storage assured
• REB (UofT) and Privacy Consultant’s approval of process to act as agents for Ontario Health Information Custodians
• Policies consistent with Ontario PHIPA
Data Privacy
• Data privacy strategies will include:• Anonymized data;
• Technological measures including maintaining data on a secure system accessible only by the measurement team using passwords and data encryption.
• Individual hospitals results will not be identified without consent
• Data collected for QI and may be used for research
Questions or More Information
Virginia Flintoft
416.946.8350
G. Ross Baker Peter Norton
416.978.7804 403.210.9236
