>> Alright Good morning everyone You guys ready? Alright. My name’s Scott Decker I’m a public health analyst with DHQP, and I work on NHSN A lot of you probably know me by my email handle if you send questions to the NHSN box about locations, or annual surveys, they’re more than likely– they’ll come to me But, for this morning’s presentation, I’m going to, you know, veer away from those topics for the most part, and focus mostly on just giving you guys an introduction of an NHSN analysis And, really, this morning, I know there’s a wide breadth in experience, in terms of infection control, and more specifically, NHSN users here, so my whole goal for this morning, I think, is just to provide a really good foundation of all the analytic options and functions that you will see throughout this week, through specific HAI analytic presentations that my colleagues will be presenting throughout the week, so I want to give you guys an opportunity to see all the screens, see all the different choices, and options, and folders, and reports that you can run I’ll show some examples of what they’ll look like, how to manipulate or modify those reports a little bit, but I think, you know, the meat on how to use those reports for your specific analytic purposes for specific HAIs– my colleagues are going to cover that throughout the week, so If you’re a new user, I think this is going to be extremely beneficial for you, so if you’re a more seasoned and veteran NHSN user, I believe I sprinkled some things in there that you may find interesting or useful, that have not used in the past, so We’ll see where it takes us Just a quick message about the data for this presentation, it’s been created in a testing environment, and it’s for training purposes only So, the information you’re going to see today do not represent any actual data that’s been submitted to NHSN by participating facilities Alright. Before we get to those NHSN reports, we want to make sure that we prep our data, and have good quality data to analyze in NHSN That starts, you know, with our data entry sources So, looking at the NHSN screen on the left-hand side, you’ll notice the NHSN home page, and all these different options you have, so The main four areas that I’ve identified that you’re going to input your data are going to be those Events, Procedure-level data, Summary-level data So, this is your MDRO Your Device-associated summary reports for patient days, line days, MDRO days, things of that matter And, finally, those surveys that are completed once a year I’ll go into a little bit today how those surveys can impact, specifically your SIR and how those surveys are used for data analysis, and what potentially you could be entering in those surveys How they could change or impact your SIRs So, if you click on any of those options, your Events, your Summaries, your Surveys, you’re going to be greeted with, you know, more than likely three options Add, Find, or Incomplete Add is pretty obvious, right? You’re going to add new events, you’re going to add procedures, add summary reports, add a survey Find and Incomplete So, those Find options, you know, this is, you know, in lieu of maybe using some NHSN analytics, if you’re just looking for a simple line listing of events, or procedures, or reporting plans, you can just enter very few details in terms of, maybe, event dates, like a range of– excuse me– a range of dates A range of reporting plans, and find the listing of all those events, procedures, reporting plans within that given field range So, that’s one way to use the Find And of course, Incomplete, if you have incomplete summary reporting plans, or incomplete data fields, looking for– just like in that option will provide you a line list, or provide you an output of that Annual surveys and data analysis Like I mentioned, every year a new survey is entered into NHSN to reflect data from the prior calendar year So, currently we’re, you know– the deadline’s past, but just as a public service announcement, if you haven’t completed your surveys, we’re still taking them, so get them in as soon as possible So, those surveys are titled the 2018 Annual Survey And, again, that’s representative of the full calendar year of 2018 And so, what that does, those survey data, those survey years, will be used to risk adjust, or to apply to your SIR calculations for the years 2018 and 2019 Now, there may be some pause when I say, you know, your 2018 survey’s used for 2019 data That’s because we have a business rule in place that, you know, if– you know, if the most recent survey for that specific year of data that you’re using is not entered, it’s going to use the most recent survey that’s been entered into NHSN, so If, for example, you have not completed your 2018 survey, your– not only is your 2000– and the most recent survey you have completed is 2017, your NHSN data’s going to use the 2017 data survey to risk adjust for your 2017, your 2018, and your 2019 data

until you update your 2018 annual survey And, this is just a visual representation of how NHSN, behind the scenery– how the reports and analysis functionality works Falling into this little tunnel here is, you know, your event-level data, the survey data, your summary data, your procedures These are all the things that you control, and you contribute to NHSN, into the system And then, output of course, is your desired reports Whether you’re looking at rate tables, your SIRs, your CMS reports, all those things that, you know, we create behind the scenes to give you that infor– or to use your data to give you something meaningful with, is your output OK. So, monthly reporting plans This is, I think, kind of a– this is– we’re at a good starting point, I guess, in terms of data entry for NHSN, and for, you know, required reporting, should start It’s used by all NHSN facilities to inform CDC, and our partners, which patient safety modules will be used in a given month So, participating facilities must select the modules used, if any And, the events and procedures, and/or locations that are going to be monitored in-plan So, this is really our first indication when we actually ultimately send data maybe to CMS This is what’s being used to reference– this is what’s being used to look at, to see, OK, there’s data from these locations, or from these required locations, or from these required procedures, that need to be sent into CMS This is kind of the reference points, this is what’s being used to identify what’s being sent OK? To add a monthly reporting plan, again, we’re going to go to that left-hand navigation bar, in NHSN You’re going to get the option to Add or Find If you want to add a reporting plan, you’ll just select Add It’s going to take you to this next screen, where you’re going to select a Month and a Year for your plan that you want to create Now, for whatever reason you do not have data for a specific month, there’s no locations, there’s no events, there’s no procedures happening, maybe there’s– a facility closes for renovations for whatever reasons There’s– sometimes this does happen If there’s nothing to report, you can simply select No NHSN Patient Safety Modules Followed this Month So, that’ll gray out all the options you had to report for the reporting plan You’ll save it and move on However, if you, you know, select that you do not have that option, that you do have data to enter, you’re greeted with these options And, they’re broken down into different HAIs So, we have the Device-Associated Modules, Procedure, AUR, and MDRO So, you know, based on the specific module you’re looking at, there’s going to be specific indicators that you want to, you know, select So, for device-associated, obviously there’re location levels that you want to create, or you want to add to your monthly reporting plan for procedures You’re obviously looking for procedures And, additionally for MDRO and AUR, you’re looking at the location level And, from there, you can select, you know, for device-associated, if you want to follow CLABSI, VAE, CAUTI, CLIP or what have you This is just an example of what it looks like for procedural-level module If you want to follow knee procedures, or knee prosthesis procedures, for that particular month, and you want to select in- and out-patient, just know that you have to select both in and out for that procedure for it, you know, to register, for it to look as its in-plan for NHSN If you’re looking to add rows, or add procedures, to add locations, hit the Add Row button You’ll get another opportunity to get another drop-down window to add additional or multiple locations, multiple procedures in NHSN And, finally, the other option you have there is Copy from Previous Month, so whatever you have, you create a ton of monthly reporting plans Nothing’s changed for the last month to this current month, you can simply select Copy Previous Month, and it’s going to transfer and rollover all those locations, all those procedures, and all those options, whether they’re in-patient, out-patient, or your various HAIs you’ve selected for those locations I’ve got a Poll Everywhere question here I think we’re still– I think it’s still up right now We’re at 0 So, umm, looks like you guys are ahead of me So, if you have an opportunity to, you know, participate in the Poll Everywhere, we really encourage it Just text NHSN to 22333 Looks like it’s working We’re getting answers in So, the question is, can you add inactive locations to your monthly reporting plan? I’ll give you guys a minute to work through that It’s OK. The correct answer is true And, [inaudible] The correct answer is true I noticed a lot of you guys selected false

You can always add inactive locations to your monthly reporting plans Or, you can have them included in your monthly reporting plans And, just to know that if you have inactive locations that have data that’s been uploaded, that data that you want to have submitted to, you know, say CMS for example, in that required location type, it will be sent there, so If you have an inactive location, and you remove it from your monthly reporting plan for a given month, that data would not be sent So, it’s imperative that if, you know, there are locations that you make inactive because they’re no longer active, but you have, you know, previous or past location data that you want to send to CMS, it needs to be included in that monthly reporting plan So, if you want to make those edits, you can, you know, go back and add those inactive locations to those monthly reporting plans, or if they’re there, keep them But, you know, however, if, you know, you have an inactive location, there is no data coming from them, or there’s no data that month, you need to remove it by clicking that little trash can icon on the left-hand side Alright, alerts So, alerts, you know, monthly reporting plans and alerts, kind of go hand-in-hand The monthly reporting plans are what help generate alerts So, if you have off-plan data, so there’s data you’re entering in NHSN that’s off-plan, you know, alerts will not be generated And so, as many of you know, this is one of the first things that greets you when you log into NHSN When they, you know, provide you information on, you know, incomplete or missing in-plan data that you may need to correct or add before moving forward with your analysis So, clicking on one of those, like, window panes, or one of those alert boxes is going to bring you to this page And, it’s going to give you, you know, an individual line list of those specific alerts, or those specific missing or incomplete data that you need to correct in order for those alerts to be cleared So. In order for one specific alert to be cleared– so, if you want to, you know, remove one of those boxes– so, for example, if you have 132 incomplete events, you need to complete– or, you need to, you know, complete all 132 of those events for that box to be cleared Resolving alerts If you click on one of those, you know, one of those items from this line list here, it’s going to bring you to a page like this So, there is an incomplete summary data form, you’ll notice here that there’s an open box here for CLABSI, for Report No Events, and so, when you’ve completed your summary reporting plan in the first case, you did not select this box, maybe because you thought there was an event, or there could be an event still for that summary report that wasn’t reported yet But, you’ve gone back, and you’ve verified that there wasn’t a event to report for that particular month for CLABSI or CAUTI You can select it here And, that will clear that alert However, if you do know that you have an event, you’d have to– I’d say have to move backwards, and add that event to HSN, and that’s another way, too, for this incomplete summary record to be resolved, and to be cleared So, you know, once you, you know, added all your monthly reporting plans, you’ve entered all your patient-level data You’ve made all the changes you’d like And, you’re ready to step into the reports section of NHSN, and do your, some analysis, and see what’s going on with your data, the last thing we ask you to do is generate those data sets And so, it’s pretty simple It’s going to generate new data sets, and all that new information that you entered in your last session before you previously generate your data is going to be uploaded So, without doing that, when you run NHSN reports or analysis, no data will be used that you just entered without generating data sets And, don’t forget to check the box to include all years of data So, if you want to include all your data that you’ve added throughout the years, make sure to check that box So, once we generate data sets, we’re now ready to navigate data analysis, and dig into our reports, and see what our data looks like, what it’s telling us, potentially So, you can click on Reports, underneath the Analysis tab on that left-hand side of NHSN And then, I look at here– this is, you know, the first set of folders that greets you in NHSN Analysis And, the ones I’ve highlighted here are ones that are the most commonly used at NHSN, whether for different HAI modules, or your CMS reports I don’t see Rashad here, he might argue that TAP reports are used a lot too They are. So, you might say to include them, but TAP reports are also available, too We’ll learn more about that later today So, if you collapse one of those folders [inaudible] for example, you just look at device-associated, there’s going to be, you know, subfolders, and multiple reports you can run for specific device-associated data You can look at bar charts, line listing of events, frequency tables, rate charts You can look at SIR reports that aren’t specific to those CMS requirements So, if you have locations that are not CMS-required, but you want to look at your SIRs, this is the place to go for that Again, this is just more folders that provide specific analysis for on your reportable HAIs Again, if you want to look at specific SIRs that aren’t submitted to CMS,

underneath all these folders is a good place to start This is just a collapsed folder, what it looks like for LabID reporting So, all the different LabID events that you can look at within MDRO module are available here And, finally, here are those CMS reports This folder provides default reports that mirror CMS reporting requirements When I say default reports, I mean– I’ll demonstrate later that a lot of these reports in these other folders, and the Advanced folders, you can make specific modifications to The CMS reports folder are extremely limited in what you can modify, and that’s, you know, to, you know, have, you know, have complete compliance, or complete compliance to CMS requirements you’re going to be submitting, and to mirror those reports that CMS is running that you’re going to see on hospital compare, so you can look at your data and, you know, make a really quick compare to make– to validate what’s been, what’s been reported So, we do limit, you know, what type of data is– can be viewed or looked at for those reports Also, we have Baseline Set 1 reports, so we did a lot of education over the last few years about the rebaseline that we did in 2015 And, if your facility participated in NHSN prior to 2015 or 2016, and have data that used the old risk adjustment modules within NHSN, you want to look at those reports The Baseline 1 Set Reports is a good place to do that But, again, just be mindful that, you know, anything beyond 2016 will not be found in this report You’ll have to run just the general HAI module reports that I previewed in those previous slides, so That’s always there Finally, the NHSN Analysis Reports, the Advanced folder This is, you know, this is a folder that I think a lot of analysts on our team looked to troubleshoot data that we get from users, or questions we get from users There’s a lot of modifications There’s a lot of really cool things you can do to manipulate your data and view Specific time frames, and really parse out the data that you want to look at So, I think this folder offers a lot of opportunities to look at– you have, you know, summary-level data that you can look at Monthly reporting plans in a line listing format rather than going into individual reporting plans from the NHSN navigation page So, there’s a lot of interesting things you can do with this folder, which I’ll preview later So, when you actually want to run a report, you actually want to look at some of these reports in NHSN, there’s three options typically when you select a report you want to run, or you want to look at One, you can just simply run a report And, that’s going to provide an output of all available data for an HAI or for a CMS report that you select So, you’re not doing any kind of modification Whatever you’ve put into NHSN, you regenerated your data sets, it’s going to get spit out when you run report Alright? Now, if you want to look at a specific time frame, you want to look at specific locations, if you want to change your data just to look at a cross– like a cross-section of it, Modify Report is the place to go, where you can select specific variables, sort your data for different timeframes This is a good way to do that And, finally, Export your data sets So, this allows you to transfer your data from several different file types Excel, just text documents, SAS, SAS files That’s all available So, I’ll go into a demonstration of how you can export– there’s two different, like, export options If you export from this screen, if you export your data from this screen, again, just like Run Report, it’s going to pull all of the data that you’ve entered NHSN for that specific measure into that export When you start modifying your data, you can get a more finite, you can get a more specific exported of what you’ve modified in your report So, I’ll explain how to do that in a– little bit later But, there is two options when you look at NHSN analysis to export your data And, they could give you two very different types of data sets when you’re done with it So, I’ve chosen just to modify analysis reports So, this way if you do select Modify in lieu of Run, this is the first screen you’re going to get There’s a couple things I want to point out here We have a Show descriptive variable name, so all those really kind of confusing or cumbersome variable names that you’ll see in those stock reports that you run at NHSN, if you just simply select Show descriptive variable names, you’ll have a more clear, and more, I think, digestible description of what those variables, what those columns and rows mean And, I’ll show you– I’ll compare and contrast the two different options, so Additionally on this screen it tells you what types of data sets you’re using here It also tells you what date your data set was generated on So, again, this is kind of your final warning just to check that here, so if you know you’ve updated data, or added more data since that data set generation, you’re going to have to move backwards, and regenerate data before you come back to review the reports [inaudible] Modify Analysis Reports This is just if you want to change the title So, there’s just a default title that greets you when you open these reports If you want to change your title, you’re more than welcome to do that

And, I’ll show you how that could be useful in terms of organizing or saving custom reports But, just know that you can always modify and change that title that you first see on this screen And, finally here, there’s a format option too, the basic or default option for format is HTML, but there’s– you know, there’s PDF, xls, and rtf files that you can choose and opt for in terms of outputting your data Time periods So, this allows for a selection of specific time periods for your report You can select a date variable from the date variable drop-down menu And, specify the beginning and ending for your desired time period So, if you leave these– again, if you leave these two fields blank, you’re going to get all the data from that time All the data you’ve entered in NHSN is going to be spit out, so if you’re here to modify, and you’re here to look at a specific interval of time, I suggest, you know, selecting a specific Date Variable, whether it’s a year, month, or quarter, or span of those things This is the place to do that So, for my example, I just want to look at the full year of 2018 So, I’m looking at summaryYr to indicate year From 2018 and ending in 2018 So, this would give me all that data that’s been entered for that calendar year I want to move over the next option I’m going to get is our filters Each addition of a group and a rule will allow you to specify values Again, so after you select a variable to filter, click on the empty box, the drop-down arrow to select the operator So, things like equal to– it all depends what you’re looking– if you’re looking at specific dates, or if you’re looking at a location type, that’s going to kind of dictate what kind of operators you want to use for your filters And, I’ll show you an example in a minute here So, again, this is kind of a good way to remember this So, a group will help you generate a table with a select number of rules and conditions set And so, a rule is a set of conditions that will restrict what type of data’s populated in that group So, that group is– each group you have is, you’re kind of creating your own table And, within that table, those specific rules you get, so for example, I’m using location type In that table, you’re only going to have location types that are equal to CC And, what that means is, for this report, I’m looking at for CLABSI data for SIRs from 2018 I just want to look at data that’s coming from all active critical care locations, mapped to the facility, during 2018 So, I got one group and one rule in my filter And, finally, display options is your final thing to select your modify again This is creating more tables So, you selected a time period of what you want to look at your data at with, and if you want to group your data– so, say you’re looking at data for 2018, for the full calendar year But, you want it broken up into quarters when you look at your output So, you can simply select by group by YH to indicate half a year So, then you’re going to get two tables One for the first six months, and one for the second six months of the year You can select YM That’s going to give you a table for each month For 2018, YQ It’s a quarter So, you’re going to get four tables, one for each quarter And then, if you leave it at summary year or cumulative for this example, you’re going to have just one table for 2018 And, once you’re done modifying, you can now Run And, this is your output And, again, so you’re going to see all those modifications you made in that previous screen, are all going to be displayed here, so you can see that your location type equaled CC, so this just includes those critical care options And, it’s just including that summary year for 2018 You also will notice, too, that these– there’s certain rows here that are highlighted in yellow That’s to indicate that NHSN, those NHSN analytics or risk adjustment module, or models were applied, and that’s NHSN calculations That’s nothing that you inputted or incorporated, specifically You didn’t do anything to generate that calculation, except put your data in And then, like I said, that’s the NHSN analysis on the back end is created those number predicted, your SIRs, your p-values All that data– all those data that [inaudible] infection count, your number of CL days, those are data that you’re responsible, that you are responsible for inputting That’s stuff that you’ve put in Your number of events, your number of CL days, and those summary reporting plans That’s coming from the NHSN user side Alright. Interpreting the output This is what your report looks like when you show descriptive variable– OK I wanted to show you that So, this looks like– so, what I did not slide, a few slides ago I showed you descriptive– the options to select Show descriptive variable names This is not showing those variable names This is kind of, the default names that we created to organize these data sets So, if you want something more– if you want to know what this means, or you want to show someone else that doesn’t want to interpret what, you know, numPred means, that’s not familiar with these types of reports, you can simply, you know, by selecting that descriptive variable names, you’ll see a more cleaner, and more clear breakdown written description of what these variables all mean Alright. Interpreting our output

So, again, like I said, those numbers not in yellow, are ones– are variables or values that we’re responsible for, so we identified one event from 2018 from these locations from critical cares You’ll see that with the events row And, the SIR is calculated with one event over the number of predicted So, the number predicted is something that NHSN calculates using, you know, using your survey, using your number of central line days, number of patient days, you had in your summary record plans All those risk adjustment models are used, and for this specific example, we predicted that 2.61 infections were to have occurred during this month from this facility Or, for this– actually for this calendar year from this facility And so, finally the SIR with one event over the number predicted gave us a SIR of .07– excuse me– .0374 So, this signifies that during this time period, this facility identified less CLABSI events than predicted And then, again, we’ll repeat this throughout the week, but SIRs will only be calculated if the number of predicted infections is greater than or equal to 1 The p-value So, this is also on SIR reports It’s a statistical measure that tells you the observed number of infections as significantly different from what was predicted So, by our definitions, on how we use the p-value, anything less than 0.05 indicates the number of observed CLABSIs is statistically significant different– or different from the number of predicted, so You can see in this example, our p-value is 0.3232, so we’re saying that there is no significant difference in 2018 between the number of infections observed, and the number of infections predicted, even though by just looking at it visually, we know that we have less events than we expected to have And, finally, the confidence intervals This is the 95% confidence interval is kind of the range of values in which the true SIR is thought to lie Again, so this is kind of another way to look to see if your information, if your data is statistically significant So, if you have a confidence interval that has a lower bound that is less than or equal to 1, an upper bound that is greater than or equal to 1, then the SIR is not significant So, again, we’re seeing that here in our analysis for the 2018 data for CLABSI Alright. Another Poll Everywhere question The question is, what interval of time is not available for the Date Variable selection when you modify a CMS report? You guys have two minutes to think about that Alright. I think we’re set on this one The answer is B. Looks like everyone was pretty clear with that Again, you can only select half year, you can look at months, you can look at quarters, looking at years, but we don’t have weeks available Alright, modifying your analysis report Saving your reports So, say you spent all this time modifying your report that you really wanted There may be a lot of different groups, a lot of different filters going on You like your report, it looks good You want to look at it again, and you don’t want to go to the trouble of, you know, setting it up and creating it all over You can simply select Save to save that report in your NHSN folders If you select Save again, you’re going to get an opportunity to name your report so that– that title change, that name change that you may have changed or created at the beginning of the modify report, is going to be here You have another opportunity to edit or change that here So, anything that’s specific that you want to identify this report, that’s be helpful for you to access it in the future would be, you know, recommended, so I just simply said this is my report, SIR ICU for 2018 for my hospital So, then you just simply select Save And, once you do that, that Custom Reports folder is going to be created at the bottom of the folder you first accessed to generate and modify the report, so I found that I first used the SIR acute care hospitals for CLABSI data, to modify and create this report And, I’m going to have to go back to this central line-associated BSI folder to find my saved custom reports And, they’ll be at the bottom there, so You can continue to edit, modify, delete You can export that data in future, if you like It’ll be there for you And, again, like I said, export Another opportunity to Export your data This is really for exporting your modified data that you just had You’re like– I said, if you export your data at the beginning when you get the option of running, modifying, exporting, if you export just then, you’re going to get everything And, maybe you just want the 2018 data exported to some kind of file type, so Again, this just kind of explains the difference here You have the option of exporting the entire analysis data set You can see on that bottom photo there, you can just select Export Entire Analysis Data Set

That’ll give you everything But, if you just want that data that you just modified, select the bottom option And, again, there’s different file types I selected to export it as an Excel file And, you’ll see that I have my 2018 data from this location type that’s been spit out into an Excel file Alright. So, we’ve modified our data, we’ve looked at our data, and maybe we see something wrong, or something that looks kind of off about it That’s another opportunity for us to do, you know, data quality checks, validation And, so that’s kind of the next piece I want to talk about right now So, you know, we just looked at our SIRs We may have seen a number of predicted, or maybe a number of events that were either low or too high than what we were expecting, or what we found to be normal from past analysis And so, you ask, you know, what can impact that? Why is my SIR, why is my unpredicted so high or so low? And, it could be, you know, a laundry list of things, but these are kind of the common things you should be asking, or thinking about Specifically for each of these data selection screens Monthly reporting plans, you can ask, are these monthly reporting plans complete? Are all my active locations available on those monthly plans? Are all the appropriate procedures selected for in-patient, out-patient? For annual surveys, are the number of beds updated from the previous survey year? Has our medical school affiliation changed from one year to the next? That’s sometimes the main culprit of why SIRs could change from year to year And, also too, did we clear all those alerts that we saw at the beginning when we logged into NHSN? Are those still there? So, again, like I mentioned earlier on the presentation, I think the Advanced folder is the place for us as analysts with NHSN like to go in terms of trouble shooting facility data, or facility questions I think it just offers a really large menu of options when looking at summary-level data, or plan data, that, you know, looking at individual level, looking at every single reporting plan, every single summary record on an individual basis is– it takes a lot of time for us, so we opt to, you know, use the Advanced folder to look at those reports So, again here, you’ll see the different options You can look at patient-level data, event-level data You can look at your denominator forms, your plan data It’s going to give you all your monthly reporting plans you’ve entered, and it’ll include all the information you’ve added, and had available on each month’s report Facility-level data and data quality Alright. So, within the facility-level data, that’s where you’re going to find your annual survey data set So, this is a good tool for routine data quality checks Like I said, there’s a lot of information from the annual surveys that are applied to different SIRs And, this is a really good way of looking at a quick snapshot of how your survey’s changed, and what kind of data did you put into your survey over the past years that, you know, could be the change for your new SIR that you’re looking at So, again, this is the Modify screen again I’ve selected variables that are really only germane to the creation of the SIR There’s a ton of variables, as I’m sure, if you fill out the annual survey, you know there’s a lot of questions, so What I have on the right-hand side does not encompass everything on the survey, but if you want to look at responses from the full survey, you’re more than welcome to do that by pulling all those display variables over to your right-hand side, and you’ll have those, the other information But, for the sake of time, I’m just– so we can just quickly read it, I’ve just selected the information that’s used for risk adjustment purposes on the right-hand side So, when I run my report, I can see 2015 – 2017 survey data here And, I can look at how the number of beds have changed from year to year Number of patient days I can also see the medical school affiliation, and if that’s changed and, I see here in 2015 – 2017, there is a change It’s gone from major to undergraduate to no medical school affiliation, so That is a good chance that your SIR could change within those years because of that And so, that’s an opportunity for you to, you know, I guess to investigate the CO– did– are we really in to the definitions, the current definitions for medical school affiliation? Do we have it crafted here correctly? Is that right? And, if not, is that what’s causing the problem? Not the problem, but the discrepancy in my SIR? Again, another option in the Advanced folder is the Data Quality folder This is, you know, a lot of information that may be exclusion criteria for SSI data that would be captured here in a quick line list We have the CDI Test Method histories, so Just looking at your CDI test methods that you’ve reported on the quarterly level for previous years will be found here And so, this is another easy option if you want to get your feet wet with data quality We have some, I think, some common issues that facilities have found in the past, and just try to replicate it, or report that includes that so you can look at it quickly

So, we’re going to do one more scenario, then we’re going to move to questions But, the scenario we want to look at to use the Advanced folder is, you want to confirm that COLO and HYST in-patient and out-patient procedures were selected for 2018 Q1 data on the monthly reporting plans So, there’s two ways you can check and do this Like I said, you can take– well, I think this is the slower route, which is looking at each individual monthly reporting plan, going back and forth to make sure you’ve captured everything you wanted on it That could be time-consuming Or, you could use the Advanced folder You can use some of the tools you’ve been equipped with during this training, to look at your plan-level data report, to see what was included in all your plans, and just in one simple table So, again, here the time period is an option of this report I’m selecting just looking at the beginning and ending of– I just want to look at Quarter 1’s I’m just selecting the month of January 2018 And, I want to end at March, 2018 So, that’s just going to include that first quarter’s worth of data to see what’s on there My procedure codes for my filters I want to add procedure codes for HYST Looks like I forgot COLO, but I want to include HYST and COLO to see what those are on monthly reporting plans for those full three months OK? Then, I want to pull my selected variables I want to look at, you know, I want to look at my Org ID and my Facility ID I want those procedure codes up there I want to look at the Create Date, and the Modify Date And, I’ll explain what those variables can do, and what those can help you understand about your data in a moment I want to look at the output So, this is the output after I made those modifications to the time, and those filters This is what I’m seeing in my monthly reporting plan output for 2018, Quarter 1 So, there’s a couple things I see I should expect, because I’m looking for both in-patient and out-patient data, there should be two COLOs and two HYSTs on this table for each month So, what I’m seeing here for January, I’m looking at– I only see one COLO and two HYSTs So, the two HYSTs looks right Looks like I have an in-patient and an out-patient underneath Setting So, I’ve got it included there, but I only see one in-patient COLO procedure for the monthly reporting plan for January Whereas, I look at February, I see I have two COLOs and two HYSTs So, that’s right So, looks like I’m missing a COLO out-patient in my plan for January So, that’s something I need to change Additionally, there’s a whole month missing I don’t see March here So, I know that I’m missing a monthly reporting plan for March 2018 So, before I, you know, regenerate data sets, and look at my analysis again, I want to make sure I go back and add those procedures to my March 2018 plan Alright, I talked to you about the Create Date and Modify Date So, the Create Data is, you know, what– the Create Date value for the Advanced folder indicates what date that summary reporting– or, excuse me, that monthly reporting plan was created in NHSN So, the first time it was uploaded, the first time everything was saved to it, it’s going to be cached here and timestamped here, and that won’t change, OK? You can also see the User ID next to it for data entry So, this is going to tell you which user created that plan Which user first created that data you’re seeing on this report It requires you to know your data entry ID for all your personnel, all the [inaudible] that use NHSN for facility, but it is unique to whoever includes that data, so Obviously, the Last Modified date is when that data– if that data was ever changed or modified So, if your monthly reporting plan was updated, something was deleted or removed, that’s going to be captured and timestamped there And so, this is a field that can change if your plan, or if the data you’re looking at continuously gets changed And so, the last time it was modified is different from that Create Date So, that maybe the reason why something is missing, or something looks different, or looks off about my data And so, I could then look at who the Modify User ID was I can go to them and ask them, you know, is there a reason why you don’t have March? Going through the reporting [inaudible] NHSN There probably isn’t a good reason, so they’re going to want to go back and add it, so That’s a good indication of– you know, where to investigate, and where to maybe find some answers about your data And, just generally, just data quality within NHSN, I really advocate the use of the guide to the SIR that I think we’re going to see throughout this week, to identify important factors in your facility’s data that can impact your SIRs Work with staff to develop a list of routine checks that you can perform on a monthly, quarterly, and/or annual basis And, I think also, too, just to modify and save NHSN reports in NHSN to help expedite and organize your processes, so if you create data quality checks using NHSN reports, and you save those reports in NHSN, the next time you go back and do it, it’s a much more faster and cleaner process But, those are all things that we suggest doing in terms of data quality Fortunately, my colleague, Jennifer Watkins is going to talk more about data validation next

So, please pay attention to that She knows more– she has more tools and more tips, I think, with cleaning and analyzing and validating your data to make sure it’s of the highest quality, so With that, I have couple additional resources that I used– that I helped use to create some of these reports today that you may find helpful And, with that, I think I’m done I’m all wrapped up So, I have some time for questions Looks like I’ve got about 15– 10, 15 minutes, so If any one has any questions, they’d like to ask me right now, I can feel free to answer them And, if not, I’ll be here throughout the week to field any questions And, if you have location or survey questions, I love talking about both of those topics And, I would love to do that in a one-on-one conversation with you Yes? [ Inaudible Question ] >> — for SSIs, in-patients, so that had, they were classified as dirty or contaminated And, where do I look to run that list of patients? So, I know it must exist You have your denominator data And, you’ve put all this information in >> Right >> How do I run a report for, let’s say, for 2018, the patients who had COLO surgery, and the entire line list of the, you know, with the ASA scores and the wound classifications? I figure it’s got to be there somewhere >> It is there And, Rebecca, are you going to cover all the different variables that are included in SSI reports? I’m not, you know, intimately familiar with the SSI reports– >> OK >> But, all those variables are available in those SSI reports that you can pull in to then look at those ASA scores and procedure durations >> Right >> And, you can pull those into– and, those modify screens, and view them, and look at them >> Right. But, I’m not actually looking at the SSI report, per se Just the people who had an SSI who were dirty or contaminated >> Just procedure? >> I’m just looking for the list of procedures >> OK >> The patient list >> Yes. Let me go back, because I think I have a screenshot of– within the Advanced folder, there’s an opportunity to look at just procedures There’s a Procedure folder that I didn’t collapse that folder Let me go back Here we go So, yes, Procedure-Level Data there >> OK. So, is that– >> So, all your procedures that you’ve entered into NHSN will be– and, you can find them all there They’re not excluded– >> OK. So, that’s where I need to look OK >> That’s where you need to go >> [inaudible] >> Yes >> I have a question about whether you have– so, when you first log on, you see the missing, you know– >> The alerts, right? >> Incomplete >> Yes >> But, you can’t really tell from that if the data is relatively skewed So, for example, one denominator, let’s say line days, for one unit for that month is 3 And, it’s usually 300 >> OK >> So, you have to run one of those Advanced reports to see that discrepancy, or is there some other way to do that? >> Right. Yes, so you’re saying that it– that wouldn’t necessarily be an alert If you’ve entered three– >> It’s not an alert, that’s the problem >> Yes. I mean, that’s where using the NHSN analysis functions and use the Advanced folder to find those discrepancies, and find data entry errors They’re not going to be populated in those alerts for that specific example You’re going to have to run those specific line listings to look at– you know, if you’re looking at monthly reporting plans, you’re going to have to go– if the Advance folder here, if you go under that summary-level data, you can run and look at those months at a month-to-month basis to see, you know, if everything is, you know, mostly normal in terms of what you’re reporting To identify the 3 where it should be 300 That’s the way to do that >> But you get it in a huge line listing, or is there some other way to display it so you can kind of pick it out? So, in the past, I had a analytics person who would be able to actually extract the tables And, visually, from the tables, you could see, you know, if, you know, it had one digit or if it had 12 digits Is that a better way to look at those types of discrepancies? And, if it is, please explain to me how you run those tables [laughs] How do you extract the tables? >> Yes, the tables– are you talking about Excel tables? >> Right >> So, again, I mean, it all really depends how deep, how specific you get with your modifications You know? If you’re looking at summary-level data, and you know there’s a span of months that you want to look at So, I know looking at a giant line list of all the summary-level data– >> Yes >> Yes. It’s a lot So, again, if you use those techniques I was talking

about earlier, about restricting it to those specific months, or that specific calendar year that you’re looking at, you then can export that data to Excel So, it will spit out to you– what you’d see at NHSN on those NHSN reports, but it would be in Excel with just those months, and you could just simply select those variables that you’re interested in looking at So, number of CL days, number of patient days, they would be there >> OK. So, then I can see that a little more easily >> Yes. We can walk through it this week >> Please! [laughs] >> I think we have a question from online that’s been submitted? I think Rebecca’s going to provide it to me >> So, this question is from a critical access hospital user And, she would like to know, on the annual survey, it asks for annual admissions Her question is specifically is it just IP admissions, or all admissions included on their reporting plans? So– especially those from obs and swing beds? So, is it all admissions, or is specifically just IP admissions? >> In-patient? >> Yes >> The question indicates that for that question on the annual survey, the question she’s asking is, for number of admissions, what should I include my total number of in-patient admissions, or all– >> Everything on their [inaudible] >> [inaudible] So, if you– all in-patient locations that are located within your facility should be captured on total admissions for your annual survey >> And, she would like to know the same for patient days >> The same thing applies to all patient days that are captured within all in-patient locations throughout your facility, should be captured and included on your annual survey I don’t see any more questions Like I said, we’re– it’s only Monday, so New ones come to you, please find me I’ve got the blue lanyard I’m more than happy to speak with you one-on-one Thanks again for your time Looks like we’re going to have a short break