The Leapfrog Hospital Survey Reference Book Supporting Documentation for the
The Leapfrog Hospital Survey Reference Book Supporting Documentation for the 2014 Leapfrog Hospital Survey Page 1 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Reference Book Table of Contents SURVEY OVERVIEW AND SECTION 1: BASIC HOSPITAL INFORMATION ................................. 6 WHAT’S NEW IN THE 2014 SURVEY ........................................................................................................... 6 CHANGE SUMMARY SINCE RELEASE .......................................................................................................... 7 FREQUENTLY ASKED QUESTIONS (FAQS) ................................................................................................. 7 Development of Survey ........................................................................................................................ 7 Process for Completing the Survey ..................................................................................................... 7 Intended Use of Hospital Responses ................................................................................................... 9 Regional Roll-Out of Survey .............................................................................................................. 10 Leapfrog Hospital Recognition Program ........................................................................................... 10 SECTION 2: 2014 COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) LEAP ........................ 11 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 11 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 11 CPOE FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................................... 11 CPOE SCORING ALGORITHM FOR ADULT/GENERAL HOSPITALS ............................................................ 12 CPOE SCORING ALGORITHM FOR PEDIATRIC HOSPITALS ....................................................................... 13 SECTION 3: 2014 EVIDENCE-BASED HOSPITAL REFERRAL (EBHR) STANDARDS ................ 14 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 14 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 14 EBHR REPORTING TIME PERIODS .......................................................................................................... 15 EBHR GENERAL INFORMATION .............................................................................................................. 16 EBHR Frequently Asked Questions (FAQs) ..................................................................................... 16 General Questions .......................................................................................................................................... 16 AVR MEASURE REFERENCES .................................................................................................................. 18 AVR Volume Standard: Survey p.15 ................................................................................................. 18 Q.1: Total number of patients undergoing procedure ................................................................................... 18 Q.2: Total number of patients undergoing a Transcatheter aortic repair procedure .................................. 18 AVR Outcomes Specifications: Survey p.15-16 ................................................................................ 19 Q. 4 - 7: Instructions for National Performance Measurement Reporting ................................................... 19 Q. 8-12: Instructions for Regional Registries ............................................................................................... 19 AVR Scoring Algorithm ...................................................................................................................... 19 Quality Score (National Outcome Reported) ................................................................................................. 19 Quality Score (Survival Predictor) ................................................................................................................. 19 Overall Quality Score ..................................................................................................................................... 20 AAA REPAIR MEASURE REFERENCES ..................................................................................................... 21 AAA Volume Standard: Survey p.17 ................................................................................................. 21 Q.1: All patients undergoing procedure ......................................................................................................... 21 Q.2: Patients with an unruptured AAA procedure........................................................................................ 22 AAA Scoring Algorithm ...................................................................................................................... 22 Quality Score................................................................................................................................................... 22 PANCREATECTOMY MEASURE REFERENCES............................................................................................ 23 Pancreatectomy Volume Standard: Survey p.18 .............................................................................. 23 Q.1: All patients undergoing procedure ......................................................................................................... 23 Q.2: Select patients in Qu estion #1 with a diagnosis of duodenal, biliary, or pancreatic cancer............... 24 Pancreatectomy Scoring Algorithm................................................................................................... 24 Quality Score................................................................................................................................................... 24 ESOPHAGECTOMY MEASURE REFERENCES ............................................................................................. 25 Esophagectomy Volume Standard: Survey p.19 ............................................................................. 25 Q.1: All patients undergoing procedure ......................................................................................................... 25 Q.2: Select patients in Question #1 with a diagnosis of esophageal cancer ................................................. 25 Esophagectomy Scoring Algorithm ................................................................................................... 26 Quality Score................................................................................................................................................... 26 Page 2 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Reference Book HIGH-RISK DELIVERIES MEASURE REFERENCES .................................................................................... 27 High-Risk Deliveries Volume Standard: Survey p.20 ...................................................................... 27 Q.4: Instructions for Volume Reporting......................................................................................................... 27 High-Risk Deliveries Outcome Measure: Survey p.21 ..................................................................... 28 Q.5 - 10: Instructions for reporting on Death or Morbidity .......................................................................... 28 High-Risk Deliveries Process Measures Specifications: Survey p.21-22 ........................................ 29 High-Risk Deliveries Frequently Asked Questions (FAQs)............................................................. 30 General Questions .......................................................................................................................................... 30 Process Measure ............................................................................................................................................. 30 High-Risk Deliveries Scoring Algorithm .......................................................................................... 31 SECTION 4: 2014 MATERNITY CARE ............................................................................................. 33 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 33 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 33 MATERNITY CARE MEASURES REFERENCES ........................................................................................... 34 Maternity Care Volume Standard: Survey p.24 ............................................................................... 34 Maternity Outcome Measure Specifications: Survey p.24-27 ......................................................... 34 Early Elective Deliveries ................................................................................................................................ 34 Cesarean Sections ........................................................................................................................................... 38 Episiotomy ...................................................................................................................................................... 40 Maternity Care Process Measures Specifications: Survey p. 28 ..................................................... 41 Maternity Care Frequently Asked Questions (FAQs) ..................................................................... 42 MATERNITY CARE SCORING ALGORITHM ................................................................................................ 44 Outcome Measure Score – Early Elective Deliveries .................................................................................... 44 Outcome Measure Score – Cesarean Section ................................................................................................ 44 Outcome Measure Score – Episiotomy .......................................................................................................... 45 Maternity Care Process Measures Score ....................................................................................................... 45 SECTION 5: 2014 ICU PHYSICIAN STAFFING (IPS) LEAP ........................................................... 46 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 46 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 46 IPS FREQUENTLY ASKED QUESTIONS (FAQS) ........................................................................................ 46 IPS SCORING ALGORITHM ....................................................................................................................... 49 SECTION 6: 2014 LEAPFROG SAFE PRACTICES SCORE (SPS) ................................................... 51 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 51 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 51 SPS FREQUENTLY ASKED QUESTIONS (FAQS) ....................................................................................... 52 SPS SCORING ALGORITHM ...................................................................................................................... 57 SECTION 7: MANAGING SERIOUS ERRORS ................................................................................. 59 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 59 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 59 NEVER EVENTS ........................................................................................................................................ 60 Never Events Frequently Asked Questions (FAQs) ......................................................................... 60 Never Events Scoring Algorithm ....................................................................................................... 62 HOSPITAL-ACQUIRED CONDITIONS (HAC) REPORTING TIME PERIODS .................................................. 63 CENTRAL-LINE ASSOCIATED BLOOD STREAM INFECTIONS (CLABSI) .................................................... 63 CLABSI Specifications: Survey p.53-55 ............................................................................................ 63 CLABSI Scoring Algorithm ............................................................................................................... 66 Summary Score ............................................................................................................................................... 66 Public Reporting ............................................................................................................................................. 68 CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) ............................................................ 69 CAUTI Specifications: Survey p.56-57 .............................................................................................. 69 CAUTI Scoring Algorithm ................................................................................................................. 71 Summary Score ............................................................................................................................................... 71 Page 3 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Reference Book Public Reporting ............................................................................................................................................. 72 HOSPITAL-ACQUIRED PRESSURE ULCERS AND INJURIES ........................................................................ 73 Pressure Ulcers Specifications: Survey p.58 .................................................................................... 73 Injuries Specifications: Survey p.57 .................................................................................................. 73 Pressure Ulcers and Injuries Scoring Algorithm ............................................................................. 74 SECTION 8: SAFETY-FOCUSED SCHEDULING ............................................................................ 75 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 75 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 75 SAFETY-FOCUSED SCHEDULING .............................................................................................................. 76 Utilization Specifications ................................................................................................................... 76 Safety-Focused Scheduling Frequently Asked Questions (FAQs) .................................................. 78 Safety-Focused Scheduling Scoring Algorithm ................................................................................ 79 Patient Access to Operating Rooms Scoring Algorithm ................................................................... 80 SECTION 9: RESOURCE USE FOR COMMON ACUTE CONDITIONS .......................................... 81 WHAT’S NEW IN THE 2014 SURVEY ......................................................................................................... 81 CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 81 Length of Stay Measures Specifications - AMI: Survey p. 68-69 .................................................... 82 AMI Case Count.............................................................................................................................................. 82 Geometric Mean Length of Stay – AMI ......................................................................................................... 83 AMI Case Counts by Risk Factor ................................................................................................................... 85 AMI Risk Factor Definitions .......................................................................................................................... 85 Length of Stay Measures Specifications – Heart Failure: Survey p. 70-71 .................................... 87 Heart Failure Case Count .............................................................................................................................. 87 Heart Failure Geometric Mean Length of Stay ............................................................................................ 88 Heart Failure Case Counts by Risk Factor ................................................................................................... 88 Heart Failure Risk Factor Definitions ........................................................................................................... 88 Length of Stay Measures Specifications – Pneumonia: Survey p. 72-73 ........................................ 90 Pneumonia Case Count .................................................................................................................................. 90 Pneumonia Geometric Mean Length of Stay................................................................................................. 91 Pneumonia Case Counts by Risk Factor ....................................................................................................... 91 Pneumonia Risk Factor Definitions ............................................................................................................... 91 Length of Stay Scoring ................................................................................................................................... 93 Length of Stay Scoring Algorithm ..................................................................................................... 94 Readmissions Measures – AMI, HF, and PN ................................................................................... 96 Readmission Measures Scoring Algorithm ....................................................................................... 97 Note: “Survey P. XX” refers to the page number(s) in the Leapfrog Hospital Survey Page 4 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Basic Hospital Information 2014 Leapfrog Hospital Survey THIS PAGE WAS LEFT INTENTIONALLY LEFT BLANK Page 5 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Basic Hospital Information 2014 Leapfrog Hospital Survey Survey Overview and Section 1: Basic Hospital Information What’s New in the 2014 Survey 1. Only the hospital’s organizational and contact information from the 2013 survey is retained in the online survey. Review answers in the first section of the survey and update as needed. Hospitals are required to review, update, affirm and submit their survey responses by June 30, 2014. After that date, Leapfrog will no longer report results based on 2013 surveys submitted prior to December 31, 2013. 2. The Leapfrog Group will ask hospitals to “opt-out” if they do not want their contact information shared with a third party. The contact information that would be shared includes: CEO name, survey contact name, survey contact title, survey contact email address, survey contact phone number, system contact name, and system contact email address. 3. The Leapfrog Group will continue to conduct desk reviews of hospitals’ survey responses in a similar fashion as has been done in previous survey cycles (For more details on the desk review process, please see: https://leapfroghospitalsurvey.org/web/wp-content/uploads/deskreview.pdf In addition to the desk reviews, Leapfrog has asked randomly selected hospitals to provide documentation related to their submitted responses. Given the recent use of the Leapfrog Hospital Survey data by high-visibility data licensees, we do encourage hospitals to be extra careful in ensuring their survey responses are accurate. As a reminder, all quantitative numbers entered in response fields are considered numerical values; there are no opportunities to enter placeholders (0) or codes for missing data (9999) in the Leapfrog Hospital Survey. 4. Hospitals that submit a Leapfrog Hospital Survey by the initial June 30, 2014 reporting period deadline will receive a free Leapfrog Hospital Recognition Program (LHRP) Summary Report. LHRP Summary Reports illustrate how your hospital compares to others in the state and the nation in quality, resource use, and efficiency. The reports are generated by applying the LHRP Scoring Methodology to 2014 Leapfrog Hospital Survey responses. The LHRP Summary Reports are mailed to the hospital CEO provided by your hospital in the demographics section of the survey. You can obtain more information about LHRP Reports, the LHRP Scoring Methodology, and more detailed performance reports at www.leapfroggroup.org/lhrpreports. In New Jersey, health care payors have licensed the Leapfrog Hospital Recognition Program and offer further recognition and rewards to hospitals that participate in the Leapfrog Survey. To be eligible for recognition or rewards in these hospital markets, hospitals must submit a survey by June 30, 2014 and an updated survey between September 1, 2014 and December 31, 2014. For questions or more information, please contact [email protected]. 5. Any changes made to the measure specifications in the middle of the survey cycle will be reflected in the Leapfrog Hospital Survey Reference Book, under the Change Summary header, for each impacted survey section. In addition, the updates to the specifications will be highlighted in yellow. If the changes are substantial, we will e-mail the survey contact your hospital indicated in the demographic section of the survey. If the notification is sent before your hospital submits a 2014 Leapfrog Hospital Survey, the e-mail will go to the survey contact provided in the last survey submitted in the 2013 survey cycle. 6. The signed affirmation at the end of each section of the survey is used as a check to ensure hospitals are submitting accurate responses to the survey. The affirmation language at the end of each section has been updated to reflect that the affirmation needs to be completed by the hospital CEO, or by an individual that that has been designated as a delegate by the hospital CEO. Page 6 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Basic Hospital Information Change Summary since Release None. If any substantive changes are made to this section of the survey after release on April 1, 2014 they will be documented in this Change Summary section. Frequently Asked Questions (FAQs) Development of Survey 1. How was this hospital survey developed? The Leapfrog Hospital Survey was first published over a decade ago based on a set of safety practices, or Leaps, aimed at improving the safety in U.S. hospitals. The first three Leaps were developed through an extensive literature review, and with input from national subject matter experts and quality researchers, in partnership with National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), National Quality Forum (NQF) and large national purchasers, and included Computerized Physician Order Entry (Section 2), EvidenceBased Hospital Referral (Section 3), and ICU Physician Staffing (Section 5). A fourth leap was later developed based on the National Quality Forum’s Safe Practices for Better Healthcare (Section 6). Since its original development, the survey has evolved to include not only standards that focus on patient safety, but also quality of care and resource utilization. Leapfrog has continued to ensure that these national standards are carefully harmonized across TJC, CMS, AHRQ, and other national organizations. In addition, hospital industry associations and individual hospital representatives provide input to Leapfrog each year through a formal Public Comment Period and a Pilot Test Program. Process for Completing the Survey 2. Who should be involved in the process of completing the survey? This survey requires a variety of information crossing hospital units, and as a result one person may not have all the information readily available. We recommend that you print a hard copy of it, review it, and then assign the survey completion to others in your organization as appropriate. This should include someone from your quality management area who regularly compiles data about your hospital, someone with the ability to query your hospital’s administrative data systems, as well as representatives from your information technology group or medical staff. Before you can complete Section 6: NQF Safe Practices, you should download a copy of the full National Quality Forum’s Safe Practices for Better Healthcare 2010 Update: A Consensus Report using the link on the home page of the online survey. This is an important reference you will definitely need to complete that section. Depending on the number of sections of the survey that are applicable to your hospital, the time required to complete the survey will vary. Hospitals that piloted the survey and completed all sections of the survey suggested it might take anywhere from five to seven days to gather these data depending on the number of people involved in collecting the data and the ease of access to information for calculating the number of procedures. Once the data have been collected, the CEO or his/her designated respondent(s) can complete the survey online, with answers in hand, typically in less than 90 minutes. 3. What types of hospitals should complete the survey? Acute-care, short-term general and pediatric hospitals should complete the survey. The survey was not designed for rehabilitation or psychiatric hospitals, for long-term care facilities, or for hospitals that operate as units of other institutions, e.g., prison hospitals. Some of the NQF Safe Practices do not apply to all hospitals. This can be indicated in the hospital’s survey responses. Page 7 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Basic Hospital Information 2014 Leapfrog Hospital Survey The Evidence-based Hospital Referral (EBHR) Leap is applicable to rural hospitals to the extent those services are offered (electively for EBHR) at the hospital. This can also be indicated in the survey. 4. Do any of the standards on the Leapfrog Hospital Survey apply to pediatric hospitals? Yes. Computer physician order entry (CPOE) and the NQF Safe Practices apply to all pediatric hospitals. The ICU Physician Staffing (IPS) Leap applies to pediatric ICUs. Leapfrog’s Never Events policy, rates of central line associated bloodstream infections (CLABSI), rates of catheter associated urinary tract infections (CAUTI), and safety-focused scheduling also apply to pediatric hospitals. The recently updated NQF Safe Practices for Better Healthcare report cited above provides specific reference to pediatric hospitals for every practice. 5. What should I do if my hospital is part of a multi-hospital system? Can multi-hospital systems fill out just one survey for all of the hospitals in the system? If your hospital is part of a multi-hospital healthcare system, or is a multi-campus hospital that shares a Medicare Provider Number with another hospital, you will need to complete the survey for each individual hospital. The test for whether a hospital is one or multiple units should be from the eyes of the consumer. Public results from The Leapfrog Hospital Survey can help consumers make more informed hospital choices. They should have the information that permits them to participate knowledgeably in the selection of the hospital unit to which they are referred. See the Leapfrog policy at https://leapfroghospitalsurvey.org/web/wp-content/uploads/multicampus.pdf. 6. But all units in our multi-hospital share the same license and Medicare Provider Number. How can we report as separate hospitals? Even though hospitals are identified in the Leapfrog Hospital Survey based on their Medicare Provider Number (MPN), a shared MPN is not a sufficient reason for reporting as one hospital in the Leapfrog Hospital Survey. Hospitals that share a common MPN do so because of joint billing practices which are not relevant to the survey. The Survey Help Desk can issue additional Leapfrog-specific MPNs to distinguish these hospitals where appropriate. 7. How frequently should my hospital respond to this survey? Throughout the year, hospitals should resubmit their responses if and when their status changes with regard to any of the questions. This will ensure that hospitals’ most current status is accurately reported to The Leapfrog Group and in the results it publishes. The Leapfrog Group revises the hospital survey on a yearly schedule designed to coincide with most employers’ health care benefits enrollment periods and pay-for-performance reporting. We are committed to depicting your current patient safety improvement efforts accurately to consumers and purchasers, maintaining current information, and keeping our patient safety recommendations up to date based on continuous input from national experts. Annual survey revisions are planned for release each April. All publicly reported results will be replaced in midJuly with results based on new surveys submitted through June 30. Public results will be updated monthly thereafter, on approximately the fifth business day of each month, based on surveys (re)submitted through the end of the previous month. 8. How do I get a security code to complete the online survey? If your hospital is one of the Regional Roll-Out areas of the U.S., the security code needed to complete the survey online should have been sent to your hospital’s CEO by the Regional RollOut organization. See the listing of regions on the home page of the online survey and use the link to determine if your hospital is in one of those regions. If so, call the contact for your region indicated there; he/she can tell you where the security code was sent or send another copy of the code to your hospital’s CEO. Your hospital CEO may have authorized the Help Desk to email a security code to the CEO or directly to a delegate. Check with the regional contact to determine if so. Use the code request form online to have your CEO make this delegation. Page 8 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Basic Hospital Information 2014 Leapfrog Hospital Survey If you are a free-standing pediatric or general acute-care hospital and you are located outside of one of the Roll-Out Regions, a letter requesting your hospital’s participation in the survey and containing a security code for completing the survey online will come directly from The Leapfrog Group. The Leapfrog Group invites all hospitals nationwide to complete the survey and to share their progress and plans with their communities. If your organization is not located in one of the Regional Roll-Out areas, or did not receive a security code in the mail from Leapfrog, but would like to complete the survey, you can request an ID and security code on the ‘Get a Security Code’ page of the online survey: https://leapfroghospitalsurvey.org/get-a-security-code/. 9. I want to submit written comments with the survey. How do I do that? We do not collect free-form text comments in the online survey. Hospitals are encouraged to provide this additional information on their hospital Web site to inform consumers about their efforts in improving patient safety. Several hospitals have welcomed our suggestion that they consider developing patient safety, or even Leapfrog-specific, content on selected pages at their Web site, then entering the URL pointing directly to that page in the Organizational Information section of the online survey. Consumers viewing the public results of a hospital’s survey responses are linked to that page when they click on the little green “i’ next to the hospital’s name on the public site. Intended Use of Hospital Responses 10. What does The Leapfrog Group intend to do with the hospital responses to this survey? Once hospital responses are scored and publicly reported, Leapfrog purchasers agree to use the survey results to: (1) educate and inform enrollees about patient safety and the importance of comparing provider progress and plans regarding Leapfrog’s safety, quality, and resource utilization standards; and (2) recognize and reward providers for their progress and plans to implement the standards. This means that purchasers will share the survey results with their enrollees. It also means that purchasers will use the survey results in their contracting negotiations with plans and providers and to determine strategies for rewarding and recognizing providers which meet Leapfrog’s safety practices. In addition, The Leapfrog Group will make all hospital survey results available to the public through various channels, including Leapfrog’s public reporting website www.leapfroggroup.org/cp. In 2012, The Leapfrog Group launched the Hospital Safety Score. The Hospital Safety Score is an A, B, C, D, or F letter grade reflecting how safe hospitals are for patients. The score is a composite of 28 national measures of patient safety. Several of the measures come directly from the Leapfrog Hospital Survey. For hospitals that are eligible for a Hospital Safety Score, Leapfrog Hospital Survey Results are used in calculating the composite. For more information, visit www.HosptialSafetyScore.org. 11. How will purchasers educate and inform their enrollees about the survey results? Leapfrog purchasers plan to educate and inform enrollees about medical errors and the importance of considering the Leapfrog standards in choosing a hospital. The Leapfrog Group continues to work on enrollee communications materials that will include these broader messages, as well as hospital-specific information based on the hospital responses to this survey. 12. How will purchasers use the survey results in discussions with plans and providers? Leapfrog purchasers and their health plans will use the survey results to educate and inform their enrollees and members about local hospitals’ status vis à vis the Leapfrog Hospital Survey Results, including designating in their provider directories which hospitals meet the standards. Many Leapfrog purchasers will also ask their health plans to help the hospitals in their networks Page 9 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Basic Hospital Information 2014 Leapfrog Hospital Survey work toward meeting the standards. 13. I submitted my survey. Why doesn’t the public reporting website reflect results of my submission? Results from surveys submitted (or re-submitted) by hospitals as of the last business day of each month are released monthly by Leapfrog on its public reporting website (www.leapfroggroup.org/cp) typically by the fifth business day of the following month, from July through January. (No updates occur from February through June while a new annual update of the survey is tested and first fielded; the initial July update may be after the fifth calendar day of the month and replaces all prior results). Other vendors that license the Leapfrog data update their results shortly after that. Check the public reporting website for the “last submitted survey” date. If you completed a survey prior to the end of month and results do not appear on the public reporting website in the next month, log back in to your survey to make sure that you submitted the survey. Surveys that are completed and saved, but not submitted, will not be scored and publicly reported. Regional Roll-Out of Survey 14. How is Leapfrog’s initiative being rolled out? The Leapfrog Group’s efforts are national. In addition, there are a select set of regions around the country where Regional Roll-Outs directly target hospitals for participation in the survey. The “Regional Roll-Outs” are led by healthcare purchasers in healthcare markets where there is significant Leapfrog purchaser participation, and where market characteristics are favorable for turning Leapfrog from a purchaser-driven movement to a community-wide collaboration, inviting the participation of purchasers, hospitals, health plans, physicians, unions, consumer groups, and others. Hospitals around the country are invited to complete the survey and share their performance with their community, regardless of whether or not they are located in a Leapfrog Regional Roll-Out market. The survey is available to all hospitals free of charge at www.leapfroghospitalsurvey.org. 15. Who is rolling out the survey in which geographic regions? The Leapfrog Group leads a national roll-out of the survey; however, there are several states where Leapfrog has a designated Regional Roll-Out leading a local roll-out of the survey. Hospitals can find a list of the Regional Roll-Outs in the ‘Get a Security Code’ section of the survey website at https://www.leapfroghospitalsurvey.org. Leapfrog Hospital Recognition Program 16. How does a hospital participate in the Leapfrog Hospital Recognition Program? An employer or health plan must license the program from The Leapfrog Group and invite your hospital to participate. The LHRP is currently being implemented in New Jersey by Horizon Blue Cross Blue Shield of New Jersey. If your hospital is interested in participating in this program, we encourage you to talk to employers and health plans in your market. 17. What is the data submission timeline for hospitals participating in the rewards program? LHRP requires submission of a Leapfrog Hospital Survey twice during the annual survey cycle. A th current survey must be submitted by June 30 . An updated survey must be submitted between st st September 1 and December 31 . For full LHRP details, please see:http://www.leapfroggroup.org/56440/CompetitiveBenchmarking/4751817. For more information, please contact your representative at Horizon Blue Cross Blue Shield of New Jersey. Page 10 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Computerized Physician Order Entry 2014 Leapfrog Hospital Survey Section 2: 2014 Computerized Physician Order Entry (CPOE) Leap Note: The Pediatric Inpatient CPOE Evaluation Tool is not available. Pediatric Hospitals should complete Q1 and Q2 only. What’s New in the 2014 Survey No substantive changes were made to this section. Please review the CPOE Evaluation Tool Instructions carefully for updates to time limits: https://leapfroghospitalsurvey.org/cpoe-evaluation-tool/. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014 they will be documented in this Change Summary section. CPOE Frequently Asked Questions (FAQs) 1. What is the definition of “functioning” CPOE? Functioning means only that a CPOE system (real-time intercept of potentially problematic physician orders) is currently operational in any inpatient unit in the hospital. It does not imply that the Leapfrog standards are fully met. 2. Is there a common vision of how CPOE should look (e.g., GUI interface, connectivity to hand-held devices, etc.)? No. The Leapfrog Group is interested in promoting the use of CPOE systems that are effective at preventing serious medication errors, but does not specify a comprehensive set of specifications. In the survey, The Leapfrog Group uses a CPOE evaluation methodology developed by First Consulting Group and the Institute for Safe Medication Practices, with ongoing updates funded by the Agency for Healthcare Research and Quality (AHRQ); it provides hospitals with a tool to test the effectiveness of their CPOE system implementation. 3. How do hospitals access the CPOE Evaluation Tool? Adult and general hospitals completing the survey and indicating in Section 2, question 1, that they have a functioning CPOE system in at least one inpatient unit of the hospital will be eligible to access the CPOE Evaluation Tool. There is a button on the survey dashboard (Open CPOE tool) that will give hospitals access to the tool. When they complete the evaluation, their survey results will be adjusted by Leapfrog to reflect their performance on the tool. Once the evaluation is complete, hospitals will need to come back into the survey and complete any uncompleted sections of the survey, or they will receive a score of “Declined to Respond” for those sections. 4. Does a pharmacy system that catches prescribing errors like potential interactions, dosing errors, etc. qualify as a CPOE? I.e. (a) physician dictates or writes order;(b) nurse or unit clerk may transcribe order but then sends order to pharmacy; (c) order entered into pharmacy system after received in the pharmacy; (d) system alerts someone in pharmacy if potential problem and pharmacy calls prescriber? No. This does not qualify as CPOE. In fact, the very large favorable impact documented at the Brigham and Women’s hospital was achieved when CPOE replaced a prior electronic prescribing system identical to the pharmacy order entry systems which the inquirer is describing. While it is very important to eliminate hand-written prescriptions, it is also important to have in place decision-support. Page 11 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Computerized Physician Order Entry 2014 Leapfrog Hospital Survey 5. What level of feedback will the CPOE Evaluation Tool provide our hospital about our CPOE system? Hospitals that complete the CPOE Evaluation Tool will be provided with feedback on those scenarios that include a potentially fatal order that their CPOE system did not correctly alert the prescriber. Due to the costs associated with developing the patients and orders for the tool, the database of orders and patients is limited. Therefore, revealing all of the incorrect or missed alerts would provide hospitals that have taken the tool before a potential advantage over hospitals with recent CPOE implementations. CPOE Scoring Algorithm for Adult/General Hospitals Score on CPOE Evaluation Tool Fully Implemented Good Progress in Implementing Good Early Stage Effort Completed The Evaluation Incomplete Evaluation (Failed deception analysis) -orDid not complete an evaluation Fully Meets Standards Fully Meets Standards Substantial Progress Substantial Progress Willing to Report 50-74% of all inpatient medication orders entered through CPOE System Substantial Progress Substantial Progress Substantial Progress Some Progress Willing to Report 25-49% of all inpatient medication orders entered through CPOE System Substantial Progress Some Progress Some Progress Some Progress Willing to Report Some Progress Some Progress Willing to Report Willing to Report Willing to Report Implementation Status 75% or greater of all inpatient medication orders entered through CPOE System CPOE implemented at least one inpatient unit but <25% of all inpatient medication orders entered through CPOE System CPOE not implemented in at least one inpatient unit Cannot take CPOE Evaluation Tool; Will receive score of “Willing to Report” Declined to respond: The hospital did not respond to this section of the survey, or did not complete the survey. Page 12 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Computerized Physician Order Entry 2014 Leapfrog Hospital Survey CPOE Scoring Algorithm for Pediatric Hospitals Implementation Status 75% or greater of all inpatient medication orders entered through CPOE System 50-74% of all inpatient medication orders entered through CPOE System 25-49% of all inpatient medication orders entered through CPOE System CPOE implemented at least one inpatient unit but <25% of all inpatient medication orders entered through CPOE System CPOE not implemented in at least one inpatient unit CPOE Score Fully Meets Standards Substantial Progress Some Progress Willing to Report Willing to Report Declined to respond: The hospital did not respond to this section of the survey, or did not complete the survey. Page 13 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Section 3: 2014 Evidence-Based Hospital Referral (EBHR) Standards Note: This section is not applicable to Pediatric hospitals. What’s New in the 2014 Survey Over the past several years, the number of AAA’s repaired via endovascular procedures have significantly increased. These endovascular procedures are typically lower risk than traditional open repair, and the importance of beta blockers has not been well studied within this group of patients. Therefore, Leapfrog removed the perioperative beta blocker for AAA patients on beta blockers prior to arrival (AAA-1) measure from Section 3B. Hospitals will be simply scored on the predicted survival of patients undergoing this procedure at their hospital. The AAA scoring algorithm will mirror how hospitals arebeen scored on the Pancreatectomy and Esophogectomy subsections of the survey. For several years, Leapfrog has given hospitals two options when reporting on the administration of antenatal steroids to women prior to delivery of very low birth-weight babies: (1) hospitals could report data submitted to the Vermont Oxford Network or (2) use Leapfrog’s measure specifications, which closely align with the Vermont Oxford Network. Beginning in 2014, Leapfrog will replace the second option (Leapfrog’s own measure specifications) with the Joint Commission’s PC-03 Antenatal Steroids measure. Hospitals will continue to have the option of reporting data submitted to the Vermont Oxford Network. The scoring algorithm for this section will remain unchanged. The target for all hospitals on the antenatal steroid measure will remain 80% or greater adherence. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014 they will be documented in this Change Summary section. May 5, 2014 High-Risk Deliveries Process Measure Updated first FAQ in High-Risk Deliveries process measure section regarding initiation of antenatal steroids for women transferred from another facility. Page 14 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey EBHR Reporting Time Periods When completing survey Section 3, use this as a guide to the time periods for which data are to be collected and/or reported. Procedure/ Condition Surveys submitted prior to September 1, 2014 Surveys submitted on or after September 1, 2014 12 months, or 24 months (annual average), ending December 31, 2013 12 months, or 24 months (annual average), ending June 30, 2014 AVR Volume National Performance Measurement (STS) Regional Registry (NNECDSG) Most recent 12-month report received from STS (indicate month-year ending of period in Q4) Most recent 12-month report received from NNECDSG (indicate month-year ending of period in Q8) AAA Volume & Mortality 12 months, or 24 months (annual average), ending December 31, 2013 12 months, or 24 months (annual average), ending June 30, 2014 12 months, or 24 months (annual average), ending December 31, 2013 12 months, or 24 months (annual average), ending June 30, 2014 12 months, or 24 months (annual average), ending December 31, 2013 12 months, or 24 months (annual average), ending June 30, 2014 12 months ending December 31, 2013 12 months ending June 30, 2014 Pancreatic Resection Volume & Mortality Esophagectomy Volume & Mortality High-Risk Deliveries Volume Outcome Process Measures of Quality Page 15 Most recent 12-month or 36-month report received from VON (indicate month-year ending of period in Q6) 12 months ending December 31, 2013 12 months ending June 30, 2014 … or most recent 12-month VON report … or most recent 12-month VON report Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey EBHR General Information EBHR Frequently Asked Questions (FAQs) General Questions 1. How are the procedure codes used to define the high-risk procedures; do they refer to primary procedure codes, or primary and secondary codes? When counting patient volume for the procedure, the procedure code may be in either a primary or secondary field. The High Risk Delivery volume measure also utilizes diagnosis codes to determine volume of very low birth weight babies. The diagnosis can be either primary or secondary for determining the elective status of the high risk delivery. For the Leapfrog Expert-Panel/NQF Endorsed Process Measures of Quality, see the specifications for each of those indicators; many require that the procedure code be the primary or principal procedure. Don’t use the Process Measures specifications for counting volume, and vice versa. 2. What criteria were used to identify the codes? Sometimes it appears that an entire code group was selected and at other times just a subset of a code group was selected. Codes were determined by the measure developer; Leapfrog is using endorsed or national performance measures in the survey where possible. Thus, we use the codes identified by the specific measure developer. All exclusions are intentional. They are based on a combination of the actual mortality risk of the condition, clinical judgment, and consistency with data and measure sources in the evidence used to establish volume cut points. Additionally, codes may be retired and new codes added by the coding developers. 3. We are developing a volume report for our hospital. Our counts include all coded procedures that match the ICD-9 codes for each of the four high-risk surgeries of the Leapfrog EBHR standard. The volume numbers in our report are higher than the number of discharges. Should we count procedures or discharges? Count discharges that have one or more of the procedure codes for that respective high-risk surgery. A patient discharge should never be counted more than once for the high-risk procedure. (The same patient discharge may be counted once each for different high-risk surgeries if the patient stay included different high-risk procedures.) 4. Why is Leapfrog asking for the number of deaths in our hospital for specific procedures? How will this information be used? The Leapfrog Group collects this information for use in a composite measure of survival developed by experts in the measurement of quality and safety. This measure utilizes information on hospital volume and mortality. More information about the composite surgical survival measure is available on the Survey homepage. Leapfrog does not publish the specific number of deaths occurring for the procedure; it instead publishes the results of the composite measure. 5. How should we count the following procedures? When a patient has a procedure done multiple times during an admission? Count the patient only once for that high-risk procedure. If the procedure is repeated during a subsequent hospital stay, count that one as well. Page 16 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey 6. Where can I find more information about the STS and NNECDSG measurement systems for AVR? How do I determine whether our hospital has participated in any of those measurement systems and what our performance has been? Follow the links for STS (www.sts.org) and NNECDSG (www.nnecdsg.org) at the beginning of the EBHR survey section for more information about these measurement systems. Your hospital’s participation status or performance results are not publicly reported on any of the sites and Leapfrog does not have access to that information. Your hospital’s chief of cardiology or general surgery may know more about these measurement systems, and they should know whether your hospital has recently participated in them and, if applicable, the results for your hospital. 7. How will The Leapfrog Group account for hospitals that do not perform all of the high-risk surgeries? A hospital’s responses are evaluated separately by high-risk procedure or condition. For a hospital not performing a high-risk procedure on an elective basis, or that does not admit high-risk deliveries, the standard for that procedure or condition does not apply and this will be indicated in Leapfrog public results. 8. Should I use the admission or discharge date when determining whether or not a case falls within the Reporting Period? The discharge date should be used to determine whether or not a case falls within the Reporting Period. Page 17 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey AVR Measure References AVR Volume Standard: Survey p.15 For AVR, there is only one set of codes for counting all patients who have had the procedure. While it is expected that most procedures would be indicated as a principal procedure given their severity, if the procedure code is found in a secondary position, the patient can be counted if the code qualifies according to the definition. Use only ICD-9-CM codes as indicated in each specification. When calculating hospital volume: count the number of patients with any one or more of the specified procedure codes for that EBHR procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether the patient qualifies to be counted. Q.1: Total number of patients undergoing procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM PROCEDURE CODES: 35.21 or 35.22 in any procedure field. Age 18 years and older ICD-9-CM AVR procedure codes: 35.21 Replacement of aortic valve with tissue graft 35.22 Other replacement of aortic valve Q.2: Total number of patients undergoing a Transcatheter aortic repair procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM PROCEDURE CODES: 35.05 or 35.06 in any procedure field. Age 18 years and older ICD-9-CM TAVR procedure codes: Endovascular replacement of aortic valve 35.05 Transapical replacement of aortic valve 35.06 Page 18 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Evidence-Based Hospital Referral AVR Outcomes Specifications: Survey p.15-16 Q. 4 - 7: Instructions for National Performance Measurement Reporting Entity: STS (Isolated AVR Report) Operative mortality, Riskadjusted Rate for Your Hospital (Observed): For the latest year reported, enter your hospital’s “Risk-adjusted Operative Mortality rate” for AVR (report p. AV Replace-62 or a page nearby) in AVR Q5, respectively. These are your hospital’s actual operative mortality rates, standardized (riskadjusted) to the STS all-hospital risk. Operative mortality includes in-hospital and 30day post-operative mortality out-of-hospital. Operative mortality, Riskadjusted Rate for All STS Cohort (Expected): Enter the all-hospital STS “Risk-adjusted Operative Mortality rate” for AVR operative mortality (report p. AV Replace-62 or a page nearby) in AVR Q6, respectively. These are the national expected operative mortality rates to which you hospital’s actual standardized rate in AVR Q5 will be compared. Operative mortality includes inhospital and 30-day post-operative mortality out-of-hospital. Q. 8-12: Instructions for Regional Registries Entity: NNECDSG (ME, NH, VT only) Observed mortality rate: In-hospital mortality rate includes any post-operative death during their admission for the procedure. Report this as a percentage, with two decimal-place precision. If the mortality rate in the NNECDSG report has fewer than two decimal-place precision, add 0's to extend it when reporting, e.g., from a report indicating 2.6%, enter 2.60 in the online survey. If the precision is more than two decimal-place precision, round it to two, e.g., 2.605% rounds to 2.61%; report 2.61. Risk-Adjusted expected mortality rate: In-hospital mortality rate includes any post-operative death during their admission for the procedure. This is the expected mortality rate based on all-hospital average mortality, but risk-adjusted for the severity of the hospital's patient severity for the hospital's reported cases. Report this as a percentage, with two decimal-place precision. In no event should statistical confidence intervals be used or reported. AVR Scoring Algorithm Quality Score (National Outcome Reported) For hospitals that report a risk-adjusted outcome from a national measurement system (STS), or from a regional registry (NNECDSG-AVR), their quality score is based on a combination of overall hospital volume and risk-adjusted mortality rates. For hospitals that do not report a risk-adjusted outcome for a surgical procedure from a national performance measurement system (STS), or from a regional registry (NNECDSG-AVR), their quality score for that surgical procedure is based on their Survival Predictor performance. See below for details on the Survival Predictor calculation and scoring. Quality Score (Survival Predictor) The Survival Predictor is only calculated for hospitals that do not report a risk-adjusted outcome. The Survival Predictor is a composite measure that predicts future mortality rates and can be calculated for four of the EBHR high-risk surgeries (AVR, AAA, Pancreatectomy, and Esophagectomy). The measures are designed to optimally forecast hospital performance, based on prior hospital volumes and prior Page 19 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey mortality rates. More details on the Survival Predictor composite measure can be found in a white paper on the Survey homepage: http://www.leapfroggroup.org/media/file/SurvivalPredictorWhitepaper.pdf. Also see more details about calculating and scoring the Survival Predictor at https://leapfroghospitalsurvey.org/web/wp-content/uploads/survivalscoring.pdf. The composite measure is a weighted combination of a hospital’s observed raw mortality rate and the mortality rate expected given the hospital’s volume. The observed mortality rate is weighted according to reliability (a function of the case volume at that hospital). The composite measure is found to be a good predictor of subsequent hospital performance. Hospitals can calculate their predicted survival for any of the four high-risk surgeries using the Survival Predictor Calculator located in the ‘Download Survey Materials’ section of the survey website: https://leapfroghospitalsurvey.org/download-survey-materials/. Overall Quality Score Volume Credit (if the hospital reports a risk-adjusted outcome) ½ credit if overall hospital volume >= 120 (Q1 and Q2 combined) otherwise, ¼ credit Mortality Outcomes (if the hospital reports a risk-adjusted outcome) ½ additional credit if the hospital’s actual mortality rate, as indicated in the latest annual report from STS/NNECDSG, is Better than National Average on a risk-adjusted basis. OR Survival Predictor (if the hospital does not report a risk-adjusted outcome) Full credit, if “Best Odds of Survival” meaning the hospital is in the best quartile for the composite measure for this procedure. ¾ credit, if “Better Odds of Survival” meaning the hospital is above the midpoint (median), but not in the best quartile for the composite measure for this procedure. ½ credit, if “Improved Odds of Survival” meaning the hospital is below the midpoint (median), but not in the worst quartile for the composite measure for that procedure. ¼ credit, if “Lower Odds of Survival” meaning means the hospital is in the worst quartile for the composite measure for that procedure. Declined to respond means the hospital did not respond to this section of the survey, or did not submit a survey. Does Not Apply means the hospital does not perform the procedure electively. AVR Section Complete Save your Responses! Page 20 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey AAA Repair Measure References AAA Volume Standard: Survey p.17 For AAA, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The first set of codes is for counting all patients who have had the procedure (Question #1). The second set of codes for AAA is for counting patients who have had a non-emergent or non-ruptured repair (AAA Question #2). While it is expected that most procedures would be indicated as a principal procedure given their severity, if the procedure code is found in a secondary position, the patient can be counted if the code qualifies according to the definition. Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volume: count the number of patients with any one or more of the specified procedure codes for that EBHR procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether the patient qualifies to be counted. Q.1: All patients undergoing procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM codes of 38.34, 38.44, 38.64, 39.25 or 39.71 in any procedure field. Age 18 years and older ICD-9-CM 38.34 38.44 38.64 39.25 39.71 AAA procedure codes: Resection of aorta with anastomosis Resection of abdominal aorta with replacement Other excision of abdominal aorta Aorta-iliac-femoral bypass Endovascular implementation of graft in abdominal aorta Exclude cases: MDC 14 (pregnancy, childbirth, and puerperium) MDC 15 (newborns and other neonates) Page 21 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Q.2: Patients with an unruptured AAA procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM procedure codes of 38.34, 38.44, 38.64, 39.25 or 39.71 in any procedure field with an ICD-9-CM diagnosis code of 441.4 or 441.9 in any field. Age 18 years and older ICD-9-CM 38.34 38.44 38.64 39.25 39.71 AAA procedure codes: Resection of aorta with anastomosis Resection of abdominal aorta with replacement Other excision of abdominal aorta Aorta-iliac-femoral bypass Endovascular implementation of graft in abdominal aorta AND ICD-9-CM Diagnosis Codes 441.4 Abdominal aneurysm without mention of rupture 441.9 Aortic aneurysm of unspecified site without rupture Exclude cases: MDC 14 (pregnancy, childbirth, and puerperium) MDC 15 (newborns and other neonates) AAA Scoring Algorithm Quality Score Survival Predictor: Details on p. 23 Full credit, if “Best Odds of Survival” ¾ credit, if “Better Odds of Survival” ½ credit, if “Improved Odds of Survival” ¼ credit, if “Lower Odds of Survival” AAA Section Complete Save your Responses! Page 22 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Pancreatectomy Measure References Pancreatectomy Volume Standard: Survey p.18 For Pancreatectomy, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The first set of codes is for counting all patients who have had the procedure (Question #1). The second set of codes for Pancreatectomy is for counting patients who have had the procedure and also had a diagnosis of cancer (Question #2). While it is expected that most procedures would be indicated as a principal procedure given their severity, if the procedure code is found in a secondary position, the patient can be counted if the code qualifies according to the definition. Use only ICD-9-CM codes as indicated in each specification. When calculating hospital volume: count the number of patients with any one or more of the specified procedure codes for that EBHR procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether the patient qualifies to be counted. The count for the volume measures can include emergent cases as well as “elective” scheduled cases. Q.1: All patients undergoing procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM codes of 52.51, 52.53, 52.6 or 52.7 in any procedure field. Age 18 years and older. ICD-9-CM 52.51 52.53 52.6 52.7 Page 23 pancreatic resection procedure codes: Proximal pancreatectomy Radical subtotal pancreatectomy Total Pancreatectomy Radical Pancreaticoduodenectomy Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Q.2: Select patients in Qu estion #1 with a diagnosis of duodenal, biliary, or pancreatic cancer Source: The Leapfrog Group Number of patients identified in Question #1 that also had an ICD-9-CM diagnosis code of 152.0-152.9 or 156.0-157.9. ICD-9-CM 152.0 152.1 152.2 152.3 152.8 152.9 156.0 156.1 156.2 156.8 156.9 157.0 157.1 157.2 157.3 157.4 157.8 157.9 duodenal, biliary, and pancreatic cancer diagnosis codes: Malignant neoplasm of duodenum Malignant neoplasm of jejunum Malignant neoplasm of ileum Malignant neoplasm of meckel's diverticulum Malignant neoplasm of other specified sites of small intestine Malignant neoplasm of small intestine unspecified site Malignant neoplasm of gallbladder Malignant neoplasm of extrahepatic bile ducts Malignant neoplasm of ampulla of vater Malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts Malignant neoplasm of biliary tract part unspecified site Malignant neoplasm of head of pancreas Malignant neoplasm of body of pancreas Malignant neoplasm of tail of pancreas Malignant neoplasm of pancreatic duct Malignant neoplasm of islets of langerhans Malignant neoplasm of other specified sites of pancreas Malignant neoplasm of pancreas part unspecified Pancreatectomy Scoring Algorithm Quality Score Survival Predictor: Details on p.19 Full credit, if “Best Odds of Survival” ¾ credit, if “Better Odds of Survival” ½ credit, if “Improved Odds of Survival” ¼ credit, if “Lower Odds of Survival” Pancreatectomy Section Complete Save your Responses! Page 24 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Esophagectomy Measure References Esophagectomy Volume Standard: Survey p.19 For Esophagectomy, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The first set of codes is for counting all patients who have had the procedure (Question #1). The second set of codes for Esophagectomy are for counting patients who have had the procedure and also had a diagnosis of cancer (Question #2). While it is expected that most procedures would be indicated as a principal procedure given their severity, if the procedure code is found in a secondary position, the patient can be counted if the code qualifies according to the definition. Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes, count the number of patients with any one or more of the specified procedure codes for that EBHR procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether the patient qualifies to be counted. The count for the volume measures can include emergent cases as well as “elective” scheduled cases. Q.1: All patients undergoing procedure Source: The Leapfrog Group Number of patients discharged with ICD-9-CM codes of 42.4, 42.40, 42.41, 42.42, or 43.99 in any procedure field. Age 18 years and older ICD-9-CM esophageal resection procedure codes: 42.4 Excision of esophagus 42.40 Esophagectomy, not otherwise specified 42.41 Partial esophagectomy 42.42 Total esophagectomy 43.99 Other total gastrectomy Q.2: Select patients in Question #1 with a diagnosis of esophageal cancer Source: The Leapfrog Group Number of patients identified in Question #1 that also had an ICD-9-CM diagnosis code of 150.0-151.0. ICD-9-CM esophageal cancer diagnosis codes: 150.0 Malignant neoplasm of cervical esophagus 150.1 Malignant neoplasm of thoracic esophagus 150.2 Malignant neoplasm of abdominal esophagus 150.3 Malignant neoplasm of upper third of esophagus 150.4 Malignant neoplasm of middle third of esophagus 150.5 Malignant neoplasm of lower third of esophagus 150.8 Malignant neoplasm of other specified part of esophagus 150.9 Malignant neoplasm of esophagus unspecified site 151.0 Malignant neoplasm of cardio-esophageal junction Page 25 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Esophagectomy Scoring Algorithm Quality Score Survival Predictor: Details on p.19 Full credit, if “Best Odds of Survival” ¾ credit, if “Better Odds of Survival” ½ credit, if “Improved Odds of Survival” ¼ credit, if “Lower Odds of Survival” Esophagectomy Section Complete Save your Responses! Page 26 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey High-Risk Deliveries Measure References Note: Hospitals should respond to either Q4 (Volume) OR Q5-10 (National Performance Measure). High-Risk Deliveries Volume Standard: Survey p.20 Q.4: Instructions for Volume Reporting Important Note: Do not use these codes for measuring and reporting the Antenatal Steroids Process Measure; use the separate specifications for that indicator. Patient populations used for the process measure typically DIFFER from patient populations included here in the volume counts. Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volume: count the number of patients with any one or more of the specified procedure codes for that EBHR procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether the patient qualifies to be counted. The count for the volume measures can include emergent cases as well as “elective” scheduled cases. The count can include inborn as well as transfer cases. Source: The Leapfrog Group (Expert Panel Members including R. Adams Dudley, MD, MBA, Ciaran S. Phibbs, PhD, John Birkmeyer, MD, and other topic experts) Please use the ICD-9 codes below for purposes of identifying the number of very-low birth weight babies (VLBWB) your hospital treated. The ICD-9 codes below should be used only to identify the number of VLBWBs for Q4. Number of newborns admitted to the NICU with the following ICD-9-CM codes: 764.02-764.05 Light for dates without mention of malnutrition—500 gms.-1499 gms. 764.12-764.15 Light for dates with signs of fetal malnutrition -- 500 gms. - 1499 gms. 764.22-764.25 Fetal malnutrition without mention of “light for dates” -- 500 gms. -1499 gms. 764.92-764.95 Fetal growth retardation, unspecified -- 500gms. - 1499 gms. 765.02-765.05 Extreme immaturity -- 500 gms – 1499 gms 765.12-765.15 Other preterm infants -- 500 gms-1499 gms Page 27 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey High-Risk Deliveries Outcome Measure: Survey p.21 Q.5 - 10: Instructions for reporting on Death or Morbidity Entity: Vermont Oxford Network (SMR Report from Nightingale online tool) Volume For the latest 12-month or 36-month SMR report for Death or Morbidity, enter your hospital’s “N” for the volume of cases for the reporting period. SMR 95% (lower bound) From the same report, enter your hospital’s “SMR 95% (lower)” for Death or Morbidity. This represents the lower value of your hospital’s 95% confidence interval. SMR (shrunken) From the same report, enter your hospital’s “SMR (shrunken)” for Death or Morbidity. This is the weighted average of the hospital value and the population (Vermont Oxford Network) mean value. SMR 95% (upper bound) From the same report, enter your hospital’s “SMR 95% (upper)” for Death or Morbidity. This represents the upper value of your hospital’s 95% confidence interval. Page 28 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey High-Risk Deliveries Process Measures Specifications: Survey p.21-22 NICU-1: Antenatal steroids 1 Source: Vermont Oxford Network (see Manual of Operations ) or The Joint Commission (see PC-03 version 2013B) If you participate in the Vermont Oxford Network, measured adherence to this process-of-care quality indicator, reported the results to VON, and continue to submit these data to VON, then use those data when responding to this subsection of survey, and ignore The Joint Commission (TJC) specifications listed below for the measure. If you participate with The Joint Commission, measured adherence to this process-of-care quality indicator, reported the results to The Joint Commission, and continue to submit these data to The Joint Commission, use those data when responding to this subsection of the survey. Otherwise, use The Joint Commission’s PC-03 Antenatal Steroids measure specifications (version 2013B) detailed below to retrospectively collect and report data for this measure. To access the measure specifications directly on The Joint Commission’s website, visit http://manual.jointcommission.org/releases/TJC2013B/PerinatalCare.html). Sampling Cases Hospitals that report the Perinatal Care Measure Set to TJC may use the sampling methodology used by the TJC to report on these questions. Otherwise, hospitals delivering a large number of very-low birth weight newborns may use Leapfrog’s sampling methodology to report on this measure. 1. Review your hospital’s first delivery as of April 15, 2013 (or July 15, 2013 if (re)submitting a survey after September 1, 2014). 2. Evaluate this case against the inclusion criteria; retain the case for the sample if the delivery was >=24 weeks and <32 weeks gestation completed. 3. Evaluate this case against the exclusion criteria; retain the case for the sample if it does not meet any of the listed exclusions. 4. Move to the next delivery and evaluate for inclusion/exclusion applicability. 5. Continue through cases in sequential order until a sample of at least 60 cases is reached, or all cases in the reporting period are reviewed, whichever comes first. Q.12 Denominator: Patients delivering live preterm newborns with >=24 and <32 weeks gestation completed Exclusions: Less than 8 years of age Greater than or equal to 65 years of age Length of Stay >120 days Enrolled in clinical trials Documented Reason for Not Initiating Antenatal Steroid Therapy (http://manual.jointcommission.org/releases/TJC2013B/DataElem0269.html) ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for fetal demise as defined in Appendix A, Table 11.09.1 (http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11 _09_1_Fetal_Demis) 1 VON Manual of Operations 2013, Release 17.1 Page 29 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey Gestational Age < 24 or >= 32 weeks Source: The Joint Commission (see PC-03 version 2013B) Q.13 Numerator: The number of mothers with antenatal steroid therapy initiated prior to delivering preterm newborns (>=24 and <32 weeks gestation completed). Definition of “antenatal steroid therapy initiated” should be reviewed and is available at: http://manual.jointcommission.org/releases/TJC2013B/DataElem0268.html. Source: The Joint Commission (see PC-03 version 2013B) High-Risk Deliveries Frequently Asked Questions (FAQs) General Questions 1. Do the codes related to Leapfrog’s High-Risk Deliveries apply only to neonates? Yes. Older patients should not be included. These codes are used to determine whether your hospital admits or accepts transfers to your NICU of newborns whose weight or gestation period creates higher risk. The codes are also used to count patient volume to compute the number of very low birth weight babies treated in the NICU. This recent change is based on new evidence in the literature. Note: Case selection for the process measures includes both weight and gestation period. Process Measure 1. How do we count a patient transferred here from another facility where they received the steroids at the other facility? Is this patient excluded from our data since we did not administer the steroids? Refer to The Joint Commission’s definition of “antenatal steroid therapy initiated at http://manual.jointcommission.org/releases/TJC2013B/DataElem0268.html. 2. We pulled records based on the gestational age at the time of delivery not the age at the time the steroids were given. Yes, that is correct. 3. We cannot count moms using the Vermont Oxford Network (VON) data; they only count infants. How do we report the process measure for use of antenatal steroids? If using the VON data, use the number of infants, but ONLY for those who are inborn, i.e., where the status of the mothers is known and the mothers were delivered at your hospital. The denominator is the number of low birth weight infants. The numerator includes those infants in the denominator whose moms received ante-natal steroids for that delivery. 4. When using VON reports, what time period should we use? If using VON data to report your hospital’s adherence to this process measure, use the most recent 12 months available. If relying on a report from VON, use the most recently available report, so long as it is based on a 12-month period that ends not more than 24 months prior to your submitting a survey AND your hospital continues to participate in and submit these data to VON. Page 30 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey High-Risk Deliveries Scoring Algorithm Scoring is based on a combination of either (a) a hospital’s annual patient count of very-low birth weight infants or (b) a hospital’s performance on the VON outcome measure, and, where applicable, adherence to the antenatal steroids process-of-care measure. The total credits are reflected in an overall result, which Leapfrog displays in its public release of survey results as filled bars equal to the total credit: EBHR Credit – High-Risk Deliveries/Newborns – (for hospitals that reported on Volume Standard) Substantial progress Some progress Willing to report (3 filled bars) (2 filled bars) (1 filled bar) >=50 VLBW infants < 50 VLBW infants or no NICU <50 VLBW infants or no NICU Not adhere* or Did not measure** Or No cases met criteria** Fully meets standards (4 filled bars) NICU annual patient count >=50 VLBW infants Ante-natal steroid process measure Adhere* Not adhere* or Did not measure** Or No cases met criteria** Adhere* EBHR Credit – High-Risk Deliveries/Newborns – (for hospitals that reported on VON outcome measure) Fully meets standards (4 filled bars) Hospital’s outcomes are Death or Morbidity (from VON)* Substantial progress (3 filled bars) Hospital’s outcomes are Substantial progress (3 filled bars) Hospital’s outcomes are better than expected, after better than expected, after equal to what is expected, adjusting for risk factors in adjusting for risk factors in after adjusting for risk the NICU population the NICU population factors in the NICU population Ante-natal steroid process measure Adhere* Not adhere* or Did not measure** or No cases met criteria** Adhere* EBHR Credit – High-Risk Deliveries/Newborns – (for hospitals that reported on VON outcome measure) Some progress (2 filled bars) Death or Morbidity (from VON)* Ante-natal steroid process measure Willing to report (1 filled bar) Hospital’s outcomes are equal to Hospital’s outcomes are worse than what is expected, after adjusting for expected, after adjusting for risk risk factors in the NICU population Not adhere* or Did not measure** Or No cases met criteria** factors in the NICU population Whether a hospital adheres or does not adhere * Measured and reported adherence to guideline for 80%+ of eligible patients. Page 31 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Evidence-Based Hospital Referral 2014 Leapfrog Hospital Survey ** If the hospital did not measure the process measure, they will be reflected as “Did not measure”. If the hospital did measure the process measure, but reported zero (0) cases meeting the denominator criteria for the measure, they will be scored as “No cases met criteria”. Declined to respond means the hospital did not respond to this section of the survey, or the hospital has not submitted one. Does Not Apply means the hospital does not electively admit high-risk deliveries (answered No to #1). *Note: For hospitals reporting on VON’s Death or Morbidity Outcome Measure: If the upper bound of the shrunken SMR is less than 1, the center is performing better than expected. --e.g. SMR: 0.7; lower bound: 0.3; upper bound: 0.9 If the lower bound of the shrunken SMR is greater than 1, the center is performing worse than expected. --e.g. SMR: 1.6; lower bound: 1.2; upper bound: 2.1 If the lower and upper bounds include 1, then the center is performing as expected. --e.g. SMR: 1.0; lower bound: 0.8; upper bound: 1.2 High-risk Deliveries Section Complete Save your Responses! Page 32 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Section 4: 2014 Maternity Care What’s New in the 2014 Survey The NTSV cesarean section delivery rate measure was added to Section 4: Maternity Care. With this addition, Section 4 will include five measures: three outcome measures (rate of early elective deliveries, rate of episiotomies and rate of NTSV cesarean deliveries) and two process-of-care measures (percentage of newborns screened for Hyperbilirubinemia and percentage of women undergoing cesarean section receiving appropriate DVT prophylaxis). All hospitals reporting at least 50 births annually will be asked to provide their NTSV cesarean section delivery data on the Maternity Care section. Leapfrog will collect hospital responses to the new NTSV cesarean section delivery measure and calculate both an adjusted and unadjusted rate. However, individual hospital rates will not be publicly reported on the Leapfrog’s Hospital Survey Results website (www.leapfroggroup.org/cp) until 2015. In 2014, hospitals will only be able to view their results for this measure on their password-protected “Details” page. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014, they will be documented in this Change Summary section. April 17, 2014 Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery Removed denominator exclusion of “not receiving medical anticoagulation.” There are no exclusions to the denominator. Page 33 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Maternity Care Measures References Maternity Care Volume Standard: Survey p.24 Total Live Births Q.2 The number of live births at this hospital location, reported to your state during the reporting time period. Alternatively, the below list of V codes can be used to identify live births, with the caution that these codes are coded for the newborn, not the mother; likely to be found in your hospital’s birth CIS/medical record system; but often not in claims data since normal newborn care may be included in the mother’s claim without baby’s diagnosis coding. V30 - Single liveborn V31 - Twin, mate liveborn V32 - Twin, mate stillborn V33 - Twin, unspecified V34 - Other multiple, mates all liveborn V36 - Other multiple, mates live- and stillborn V37 - Other multiple, unspecified V39 - Unspecified Note: This data point is simply used to qualify a hospital for further reporting of the normal delivery measures. Maternity Outcome Measure Specifications: Survey p.24-27 Early Elective Deliveries Important Notes: Note 1: Early Elective Deliveries can be reported based on all eligible cases OR a sufficient sample of cases as outlined in the denominator specifications. Page 34 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Wherever possible, administrative codes have been provided to assist hospitals in abstracting the required data for this measure. Hospitals may find their birth certificate registry data to be the most efficient source of obtaining the needed information for this measure. Hospitals that lack data system integration and birth certificate registry reporting capabilities may have to rely on chart review to obtain some of the needed information. Note 2: Leapfrog uses the specifications created by The Joint Commission for the Elective Delivery Prior to 39 weeks measure. As such, Leapfrog will update its’ instructions annually, and more frequently if appropriate, to maintain alignment with the Joint Commission. Hospitals can access the Joint Commission’s measure specifications directly at: http://manual.jointcommission.org/releases/TJC2013B/MIF0166.html. Elective Delivery At or After 37 Completed Weeks or Prior to 39 Completed Weeks of Gestation Source: The Joint Commission (PC-01) v.2013B If you measured this quality indicator, reported the results to The Joint Commission, and continue to submit these data to The Joint Commission, use those data when responding to this subsection of the survey. Otherwise, use The Joint Commissions PC-01 Elective Delivery measure specifications (version 2013B) to retrospectively collect and report data for this measure. The PC-01 measure specifications are outlined below. To access the measure specifications directly on The Joint Commission’s website, visit http://manual.jointcommission.org/releases/TJC2013B/MIF0166.html. Sampling Cases Hospitals that report the Perinatal Care Measure Set to TJC may use the sampling methodology used by the TJC to report on these questions. Hospitals opting to identify a sufficient sample of mothers for this measure, in lieu of full case reporting, should follow these instructions: 1. Review your hospital’s first delivery as of April 15, 2013 (or July 15, 2013 if (re)submitting a survey after September 1, 2014). 2. Evaluate this case against the inclusion criteria; retain the case for the sample if the delivery was at or after 259 days gestation (37 completed weeks gestation) and before 273 days gestation (39 completed weeks gestation). 3. Evaluate this case against the exclusion criteria; retain the case for the sample if it does not meet any of the listed exclusions. 4. Move to the next delivery and evaluate for inclusion/exclusion applicability. 5. Continue through cases in sequential order until a sample of at least 100 cases is reached, or all cases in the reporting period are reviewed, whichever comes first. Q.1 Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed with Excluded Populations removed. Included Populations: ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for planned cesarean section in Page 35 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Maternity Care labor as defined in Appendix A, Table 11.06.1. (http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11_06_1_Pl anned_Ces) Gestational Age at delivery - Use birth certificate registry data; or use the list of exclusions to eliminate cases with early onset of delivery and post-dates, followed by chart review to identify eligible cases. The Joint Commission specifications also provide guidance on methods for determining the newborn’s gestational age: http://manual.jointcommission.org/releases/TJC2013B/DataElem0265.html. If fewer than 10 cases during the reporting period, skip the next question. Excluded Populations: Please retain counts of each excluded populations marked with an asterisk (*) below. These counts will be reported in 1a-1c of the survey. Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days Enrolled in clinical trials* Prior uterine surgery* (http://manual.jointcommission.org/releases/TJC2013B/DataElem0520.html) Exclude any cases with one or more of the following ICD-9-CM principal diagnosis or other diagnosis codes for conditions possibly justifying elective delivery prior to 39 weeks gestation, as defined in Appendix A, Table 11.07 (Note: ICD-9-CM code must be coded, not just a notation in the patient chart)* http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11_07 _Conditions_Po 042 641.01 641.11 641.21 641.31 Human immunodeficiency virus [HIV] disease Placenta previa w/o hemorrhage, delivered w/ or w/out mention of antepartum condition Hemorrhage from placenta previa, delivered w/ or w/out mention of antepartum condition Premature separation of placenta, delivered, w/ or w/out mention of antepartum condition Antepartum hemorrhage associated w/coagulation defects, delivered w/ or w/out mention of antepartum condition 641.81 Other antepartum hemorrhage, delivered w/ or w/out mention of antepartum condition 641.91 Unspecified antepartum hemorrhage, delivered w/ or w/out mention of antepartum condition 642.01 Benign essential hypertension complicating pregnancy, childbirth, & puerperium, delivered w/or w/out mention of antepartum condition 642.02 Benign essential hypertension complicating pregnancy, childbirth, & puerperium, delivered w/mention of postpartum complication 642.11 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, delivered w/ or w/out mention of antepartum condition 642.12 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, delivered w/mention of postpartum complication 642.21 Other pre-existing hypertension complicating pregnancy, childbirth & puerperium, delivered w/ or w/out mention of antepartum condition 642.22 Other pre-existing hypertension complicating pregnancy, childbirth & puerperium, delivered w/mention of postpartum complication 642.31 Transient hypertension of pregnancy, delivered w/ or w/out mention of antepartum condition 642.32 Transient hypertension of pregnancy, delivered w/mention of postpartum complication 642.41 Mild or unspecified pre-eclampsia, delivered w/ or w/out mention of antepartum condition 642.42 Mild or unspecified pre-eclampsia, delivered w/mention of postpartum complication 642.51 Severe pre-eclampsia, delivered w/ or w/out mention of antepartum condition 642.52 Severe pre-eclampsia, delivered w/mention of postpartum complication 642.61 Eclampsia, delivered w/ or w/out mention of antepartum condition 642.62 Eclampsia, delivered w/mention of postpartum complication Page 36 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Maternity Care 642.71 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered w/ or w/out mention of antepartum condition 642.72 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered w/mention of postpartum complication 642.91 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered w/ or w/out mention of antepartum condition 642.92 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered w/mention of postpartum complication 645.11 Post term pregnancy, delivered, w/ or w/out mention of antepartum condition 646.21 Unspecified renal disease in pregnancy, w/out mention of hypertension, delivered w/ or w/out mention of antepartum condition 646.22 Unspecified renal disease in pregnancy, w/out mention of hypertension, delivered w/mention of postpartum complication 646.71 Liver disorders in pregnancy, delivered w/ or w/out mention of antepartum condition 648.01 Diabetes mellitus, delivered, with or without mention of antepartum condition 648.51 Congenital cardiovascular disorders, delivered w/ or w/out mention of antepartum condition 648.52 Congenital cardiovascular disorders, delivered w/mention of postpartum complication 648.61 Other cardiovascular diseases, delivered w/ or w/o mention of antepartum condition 648.62 Other cardiovascular diseases, delivered w/mention of postpartum complication 648.81 Abnormal glucose tolerance, delivered w/ or w/o mention of antepartum condition 648.82 Abnormal glucose tolerance, delivered w/mention of postpartum complication 649.31 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 649.32 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 651.01 Multiple gestation, twin pregnancy, delivered with or without mention of antepartum condition 651.11 Multiple gestation, triplet pregnancy, delivered with or without mention of antepartum condition 651.21 Multiple gestation, quadruplet pregnancy, delivered with or without mention of antepartum condition 651.31 Multiple gestation, twin pregnancy w/fetal loss and retention of 1 fetus, delivered with or without mention of antepartum condition 651.41 Multiple gestation, triplet pregnancy, w/fetal loss and retention of one or more fetus (es), delivered with or without mention of antepartum condition 651.51 Multiple gestation, quadruplet pregnancy, w/fetal loss and retention of 1 or more fetus(es), delivered with or without mention of antepartum condition 651.61 Multiple gestation, other multiple pregnancy, w/fetal loss and retention of 1 or more fetus(es), delivered with or without mention of antepartum condition 651.71 Multiple gestation following (elective) fetal reduction, delivered without mention of antepartum condition 651.81 Multiple gestation, other specified multiple gestation, delivered with or without mention of antepartum condition 651.91 Multiple gestation, unspecified multiple gestation, delivered with or without mention of antepartum condition 652.01 Unstable lie, delivered, w/ or w/out mention of antepartum condition 652.61 Multiple gestation w/malpresentation of 1 fetus or more, delivered, w/ or w/out mention of antepartum condition 655.01 Central nervous system malformation in fetus, delivered, w/ or w/o mention of antepartum condition 655.11 Chromosomal abnormality in fetus, delivered w/ or w/o mention of antepartum condition 655.31 Suspected damage to fetus from viral disease in the mother, delivered w/ or w/o mention of antepartum condition 655.41 Suspected damage to fetus from other disease in the mother, delivered w/ or w/o mention of antepartum condition 655.51 Suspected damage to fetus from drugs, delivered w/ or w/o mention of antepartum condition 655.61 Suspected damage to fetus from radiation, delivered w/ or w/o mention of antepartum condition 655.81 Other known or suspected fetal abnormality not elsewhere classified affecting management of mother with delivered Page 37 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Maternity Care 656.01 Fetal-maternal hemorrhage, delivered, w/ or w/o mention of antepartum condition 656.11 Rhesus isoimmunization, delivered, w/ or w/o mention of antepartum condition 656.21 Isoimmunization from other and unspecified blood-group incompatibility, delivered, w/ or w/o mention of antepartum condition 656.31 Fetal distress, delivered, w/ or w/o mention of antepartum condition 656.41 Intrauterine death, delivered, w/ or w/o mention of antepartum condition 656.51 Poor fetal growth, delivered, w/ or w/o mention of antepartum condition 657.01 Polyhydramnios, delivered w/ or w/o mention of antepartum condition 658.01 Oligohydramnios, delivered w/ or w/o mention of antepartum condition 658.11 Premature rupture of membranes, delivered w/ or w/o mention of antepartum condition 658.21 Delayed delivery after spontaneous or unspecified rupture of membranes, delivered w/ or w/o mention of antepartum condition 658.41 Infection of amniotic cavity delivered 659.71 Abnormality in fetal heart rate or rhythm, delivered, w/ or w/o mention of antepartum condition 663.51 Vasa previa complicating labor and delivery, delivered, with or without mention of antepartum condition V08 Asymptomatic human immunodeficiency virus [HIV] infection virus V23.5 Pregnancy with other poor reproductive history; Pregnancy with history of stillbirth or neonatal death V27.1 Single stillborn Q.2 Numerator: Number of cases included in the denominator (either from full case reporting or a sufficient sample) that delivered their newborns electively. Elective delivery, for purposes of this measure, include the following: Medical induction of labor as defined by the following ICD-9-CM procedure codes: 73.01 (Induction by labor by artificial rupture of membranes) 73.1 (Other surgical induction of labor) 73.4 (Medical induction of labor) Cesarean section as defined by the following ICD-9-CM procedure codes, while not in Active Labor or experiencing Spontaneous Rupture of Membranes: 74.0 (Classical cesarean section) 74.1 (Low cervical cesarean section) 74.2 (Extraperitoneal cesarean section) 74.4 (Cesarean section of other specified type) 74.99 (Other cesarean section of unspecified type) Active Labor: Documentation that the patient was in active labor with regular uterine contractions with cervical change before medical induction and/or cesarean section. Spontaneous Rupture of Membranes: Documentation that the patient had spontaneous rupture of membranes (SROM) before medical induction and/or cesarean section. Cesarean Sections Important Notes: Note 1: NTSV Cesarean Sections can be reported based on all eligible cases OR a sufficient sample of cases as outlined in the denominator specifications. Page 38 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Where ever possible, administrative codes have been provided to assist hospitals in abstracting the required data for this measure. Hospitals may find their birth certificate registry data to be the most efficient source of obtaining the needed information for this measure. Hospitals that lack data system integration and birth certificate registry reporting capabilities may have to rely on chart review to obtain some of the needed information. Note 2: Leapfrog uses the specifications created by The Joint Commission for NTSV Cesarean Sections measure. As such, Leapfrog will update its’ instructions annually to maintain alignment with the Joint Commission. Hospitals can access the Joint Commission’s measure specifications directly at http://manual.jointcommission.org/releases/TJC2013B/MIF0167.html. Note 3: To calculate an adjusted overall rate for this measure, Leapfrog and the Joint Commission use a method of direct standardization to account for differences in cesarean rates that occur within various maternal age stratums. Hospitals will need to identify cases for each maternal age stratum (i.e. patient age 8-14, patient age 15-24, etc). If you do not have any cases that meet the criteria for a particular maternal age stratum, please report “0” for the numerator and the denominator. Do not leave any blanks. Cesarean Sections Source: Joint Commission PC-02 (version 2013B) If you measured this quality indicator, reported the results to The Joint Commission, and continue to submit these data to The Joint Commission, use those data when responding to this subsection of the survey. Otherwise, use The Joint Commissions PC-02 Cesarean Section measure specifications (version 2013B) to retrospectively collect and report data for this measure. The PC-02 measure specifications are outlined below. To access the measure specifications directly on The Joint Commission’s website, visit http://manual.jointcommission.org/releases/TJC2013B/MIF0167.html. Sampling Hospitals that report the Perinatal Care Measure Set to TJC may use the sampling methodology used by the TJC to report on these questions. Hospitals opting to identify a sufficient sample of mothers for this measure, in lieu of full case reporting, should follow these instructions: 1. Review your hospital’s first delivery as of April 15, 2013 (or July 15, 2013 if (re)submitting a survey after September 1, 2014). 2. Evaluate this case against the inclusion criteria; retain the case for the sample if the delivery was >=37 weeks gestation. 3. Evaluate this case against the exclusion criteria; retain the case for the sample if it does not meet any of the listed exclusions. 4. Move to the next delivery and evaluate for inclusion/exclusion applicability. 5. Continue through cases in sequential order until a sample of at least 100 cases is reached, or all cases in the reporting period are reviewed, whichever comes first. 6. Organize cases by Maternal Age (see age stratums in on page 31 of the hard copy of the 2014 Leapfrog Hospital Survey). Q.1a-8a Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex presentation (Please refer to Note 3 above for important information regarding Maternal Age). Included Populations: Page 39 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Nulliparous patients with ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table 11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed. (http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11_08_Outc ome_of_De) Excluded Populations: ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes, for contraindications to vaginal delivery as defined in Appendix A, Table 11.09 (http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11_ 09_Contraindicat) Less than 8 years of age Greater than or equal to 65 years of age Length of Stay >120 days Enrolled in clinical trials Gestational Age < 37 weeks If fewer than 50 cases across all age stratums during the reporting period, skip the next question. Q.1b-8b Numerator: Patients in the denominator with cesarean sections (Please refer to Note 3 above for important information regarding Maternal Age). Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for cesarean section as defined in Appendix A, Table 11.06 (http://manual.jointcommission.org/releases/TJC2013B/AppendixATJC.html#Table_Number_11_06_Ces arean_Sect) Excluded Populations: None Episiotomy Incidence of Episiotomy in Vaginal Deliveries Source: National Quality Forum #0470 Q.1 Denominator: Total number of vaginal deliveries during the reporting period with Excluded Populations removed. For purposes of this measure, use the following MS-DRGs to identify a vaginal delivery: 767 VAGINAL DELIVERY W STERILIZATION &/OR D&C) 768 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C) 774 (VAGINAL DELIVERY W COMPLICATING DIAGNOSES) 775 (VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES) Excluded Populations: Exclude any cases with the following ICD-9-CM diagnostic code in a primary or secondary field: 660.41 (Shoulder (girdle) dystocia, delivered, with or without mention of antepartum condition) Page 40 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Q.2 Numerator: Number of cases included in the denominator that had an episiotomy procedure performed. For purposes of this measure, the following ICD-9-CM procedure codes should be used for identifying an episiotomy: 72.1 (Low forceps operation with episiotomy) 72.21 (Mid forceps operation with episiotomy) 72.31 (High forceps operation with episiotomy) 72.71 (Vacuum extraction with episiotomy) 73.6 (Episiotomy) Maternity Care Process Measures Specifications: Survey p. 28 Important Note: For Maternity Care Process Measures 1 and 2, hospitals with a sufficient sample size (as defined in endnote 21 in the survey document itself), can randomly sample for the denominator of each indicator, and measure and report adherence based on that sample. Most likely the numerator criteria for these two measures will require medical chart review, if these specific data are not already extracted or coded consistently for other purposes. Sampling Instructions for Maternity Care Process Measures 1 and 2: 1. Review your hospital’s first delivery as of April 15, 2013 (or July 15, 2013 if (re)submitting a survey after September 1, 2014). 2. Evaluate this case against the inclusion criteria; retain the case for the sample if it meets the inclusion criteria 3. Evaluate this case against the exclusion criteria; retain the case for the sample if it does not meet any of the listed exclusions. 4. Move to the next delivery and evaluate for inclusion/exclusion applicability. 5. Continue through cases in sequential order until a sample of at least 60 cases is reached, or all cases in the reporting period are reviewed, whichever comes first. Newborn Bilirubin Screening Prior to Discharge Source: Providence Health Q.1b Denominator: Eligible cases include all normal newborns born at or beyond 35 completed weeks gestation that were delivered in the facility during the reporting period (all inborns) with Excluded Populations removed. Excluded Populations: admitted to a NICU, either at your hospital or another hospital; or with parental refusal to test; or prenatal documentation of severe congenital anomalies in the newborn and documentation that the newborn will receive comfort care measures only; or newborn died prior to discharge Q.1c Page 41 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Numerator: Number of eligible cases included in the denominator who have a serum or transcutaneous bilirubin screen prior to discharge to identify risk of hyperbilirubinemia according to the Bhutani Nomogram. For an example of the Bhutani Nomogram, please see: American Academy of Pediatrics Clinical Practice Guidelines: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. http://pediatrics.aappublications.org/content/114/1/297.full Tip: To view any Figure in the reference, click on it to open, then again to enlarge. Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery Source: National Quality Forum #0473 Q.2b Denominator: Eligible cases include all women undergoing cesarean delivery during the reporting period. Include cases with one of the following ICD-9-CM codes (MS-DRG*): 765: Cesarean section w CC/MCC 766: Cesarean section w/o CC/MCC *For hospitals that do not use MS-DRGs, please see the FAQ section at the end of this document for a list of alternative administrative codes that should be used for identifying cases. Excluded Populations: Not receiving medical anticoagulation. Q.2c Numerator: Number of eligible cases included in denominator who received either fractionated or unfractionated heparin or heparinoid, or pneumatic compression devices prior to surgery. Maternity Care Frequently Asked Questions (FAQs) 1. Our hospital is designated as a critical access hospital (CAH) and we do not use MS-DRGs for reimbursement purposes. What alternative coding specifications are available to identify appropriate cases for Maternity Care Process 2 (DVT prophylaxis)? For the denominator, count all cases with one of the delivery diagnosis codes listed below AND one of the c-section procedure codes listed below. Delivery Diagnosis ICD-9 Codes: 640.x1 647.x1 654.x1 658.30 641.x1 647.x2 654.x2 658.40 642.x1 648.x1 655.x1 659.x0 (except 659.40) 642.x2 648.x2 656.x1 659.x1 643.x1 649.x1 656.30 660.x0 644.21 649.x2 656.40 660.x1 Page 42 Version 6.1 663.x0 663.x1 664.x0 664.x1 665.x0 665.x1 668.x1 668.x2 669.x0 669.x1 669.x2 670.02 673.x2 674.x1 674.x2 675.x1 675.x2 676.x1 679.01 679.02 679.11 679.12 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey 645.x1 646.00 646.x1 646.x2 650 651.x1 652.x1 653.x1 657.01 658.x1 658.10 658.20 661.x0 661.x1 662.x0 662.x1 665.x2 666.x2 667.x2 668.x0 671.x1 671.x2 672.02 673.x1 676.x2 678.01 678.11 679.00 Caesarean Section ICD-9 Procedure Codes: 74.0 Classical cesarean section 74.1 Low cervical cesarean section 74.2 Extraperitoneal cesarean section 74.4 Cesarean section of other specified type 74.99 Other cesarean section of unspecified type Page 43 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey 2. Our hospital does not have data for a full reporting period (i.e. 12-months). Can we report on partial reporting period? Hospitals that are not able to provide data for a full reporting period, will need to skip the questions and/or section, and will be scored as “Declined to Respond.” As a reminder, hospitals may (a) retrospectively collect the data using the measure specifications above or (b) update their survey any time before December 31st if the data become available. Maternity Care Scoring Algorithm Outcome Measure Score – Early Elective Deliveries A hospital’s early elective deliveries rate prior to 39 weeks completed gestation is used to determine which performance category a hospital is placed: Fully meets the standard (4 filled bars) means the hospital has an early elective deliveries rate less than or equal to 5% Substantial progress (3 filled bars) means the hospital has an early elective deliveries rate greater than 5% and less than or equal to 10% Some progress (2 filled bars) means the hospital has an early elective deliveries rate greater than 10% and less than or equal to 15% Willing to report (1 filled bar) means the hospital had a rate greater than 15% Unable to calculate score: hospitals that do not meet the minimum reporting size (n < 10) Declined to respond: The hospital did not respond to the questions in this section of the survey, or did not submit a survey. Does Not Apply: The hospital does not deliver newborns (‘No’ to Q1 p.24). Outcome Measure Score – Cesarean Section This measure will not be publicly reported during the 2014 survey cycle. A hospital’s unadjusted rate and adjusted rate will be calculated, and available on the Hospital Detail page on or after July 25, 2014. To access the Hospital Detail page, log in to the survey with your 16-digit security code and select the “Details” button. Calculating an unadjusted NTSV Cesarean Section Rate Sum the numerators and denominators from Q1-Q8 in Section 4B. Divide the summed numerator by the summed denominator, and then multiply by 100 to calculate the unadjusted rate. Calculating an adjusted NTSV Cesarean Section Rate using Direct Standardization Use the NTSV Cesarean Section Rate calculator available in the ‘Download Survey Materials’ section of www.leapfroghospitalsurvey.org. The calculator asks you to enter your hospital’s responses to questions 1b-8c (numerators and denominators for each age stratum) in the marked cells. Using your numerator and denominator for each age stratum, a rate is calculated and then weighted based on the percentage of mothers who delivered live first births at each age stratum (see U.S. weight table located in the calculator). The weighted rates are summed and then multiplied by 100 to equal an adjusted NTSV Cesarean Section rate. Both the adjusted and unadjusted rates are shown in the calculator. Hospitals that report that fewer than 50 cases met the criteria for the denominator across all age stratums will be scored as “Unable to Calculate Score.” Page 44 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Maternity Care 2014 Leapfrog Hospital Survey Outcome Measure Score – Episiotomy A hospital’s incidence of episiotomy is used to determine which category a hospital is placed: Fully meets the standard (4 filled bars) means the hospital has an episiotomy rate less than or equal to 12% Substantial progress (3 filled bars) means the hospital has an episiotomy rate greater than 12% and less than or equal to 20% Some progress (2 filled bars) means the hospital has an episiotomy rate greater than 20% and less than or equal to 30% Willing to report (1 filled bar) means the hospital had an episiotomy rate greater than 30% Unable to calculate score: hospitals that do not meet the minimum reporting size (n < 10) Declined to respond: The hospital did not respond to the questions in this section of the survey, or did not submit a survey. Does Not Apply: The hospital does not deliver newborns (‘No’ to Q1 p.28). Maternity Care Process Measures Score A hospital’s adherence to the two maternity care process measures is used to determine which performance category the hospital is placed. Leapfrog’s target for each process measure is ≥ 80%. Fully meets the Meets the min. sample Meets the min. sample size for 2 measures size for 1 measures Meets the target on both standards Some progress Meets the target for 1 Meets the target for 1 Willing to report Does not meet the Does not meet the target for either target Unable to Calculate Score: The hospital did not meet the minimum reporting requirements for any of the maternity care process measures. Declined to respond: The hospital did not measure either process measure, or did not submit a survey. Does Not Apply: The hospital does not deliver newborns (‘No’ to Q1 p.28). Maternity Care Section Complete Save your Responses! Page 45 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 ICU Physician Staffing 2014 Leapfrog Hospital Survey Section 5: 2014 ICU Physician Staffing (IPS) Leap What’s New in the 2014 Survey Leapfrog will expand hospital’s opportunity to earn partial credit on the IPS standard if the hospital has physicians certified in critical care medicine managing or co-managing ICU patients for at least 4 hours per day, 7 days per week. The physicians providing this care must be ordinarily present on-site in these units and provide clinical care exclusively in one ICU during these hours. The 4 hours per day, 7 days per week coverage will be an alternative to the historical 8 hours a day, 4 days per week coverage that has offered hospitals the opportunity for partial credit. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014, they will be documented in this Change Summary section. IPS Frequently Asked Questions (FAQs) 1. Are the standards applicable only to tertiary-care hospitals? No. The standards apply to all urban hospitals operating adult or pediatric general medical and/or surgical ICUs and neuro ICUs. 2. Is there any empirical basis for specifying a minimum annual number of days of ICU experience for each Board-eligible physician providing ICU care? No. Accordingly, if it is added to the Leapfrog standard in the future, it will be based on newly published research and expert advice. 3. Can hospitalists be counted as intensivists? No. 4. If our hospital requires that ICU calls/pages are answered within five minutes and therefore does not track responses to calls/pages, how should we report our compliance on this part of the standard? To meet the Leapfrog standard, hospitals must affirm to the public that they meet it. If your hospital requires that calls/pages be answered within five minutes and has documentation that they are, then you should indicate that your hospital meets the standard. If your hospital requires that calls/pages are answered within five minutes and you don’t know whether they are or are not, then you should not indicate that your hospital meets the standard. 5. Does The Leapfrog Group specify standards for second tier calls (e.g., the initial call to a physician is not answered within 5 minutes. What is the next step)? No. We do not intend to reach this level of detail in our specifications, absent a compelling case that the gain would offset its added complexity. 6. What training is required in order to be eligible for Critical Care Medicine (CCM) certification? A physician must complete residency in Medicine, Surgery, or Anesthesia and then a one- or twoyear fellowship in critical care medicine. During that year, s/he must spend at least nine months in the ICU. The two-year fellowships generally include research time. Some Medicine residents are certified in critical care through pulmonary subspecialty training where they meet the above requirements during their three-year pulmonary training. New in 2008: Neurologists and neurosurgeons who have been certified as neuro-intensivists are also considered to meet the standard when working in a neuro-ICU. Page 46 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey ICU Physician Staffing 7. If it were a national priority, could enough intensivists be provided (or mobilized from ambulatory care) for urban hospitals within the next 4 years? If it were a national priority, it is possible. Critical care fellowship training extends for either one or two years. History suggests that physicians’ choice of specialty is sensitive to the job market. Further, it is currently estimated that less than 50% of the work time of the existing pool of intensivists is devoted to ICU care. In addition, recently published findings in the peer-reviewed literature (B. Rosenfeld, et al, Critical Care Medicine, Fall 2000) indicate that advanced telemedicine could be used to offset local constraints in available intensivists and telemedicine for intensivists has been incorporated into the standard. 8. How will The Leapfrog Group address the shortage of intensivists? We will (1) create demand via our standard; (2) encourage specialty boards and the Association of Academic Medical Colleges to convey the anticipated new demand; (3) sensitize federal officials who set physician training and loan forgiveness priorities; (4) support ICU consolidation when it makes sense; and (5) encourage hospitals that are successfully using advanced telemedicine to leverage intensivists across multiple ICUs to share their results and learnings with other hospitals. In 2003, The Leapfrog Group broadened the definition of ‘intensivist’ to include doctors who clearly have intensivist qualifications: Because sub-specialty certification is not offered in emergency medicine, emergency medicine physicians are considered certified in critical care if they are board-certified in emergency medicine and have completed a critical care fellowship at an ACEP-accredited program. Physicians who have finished their fellowship in Critical Care Medicine, but have not yet obtained board certification are considered “Certified in Critical Care Medicine” for up to three years after completion of the fellowship. This provides the physician an adequate window to take her/his boards and re-take if necessary. On an interim basis, two other categories of physicians are considered by Leapfrog to be “certified in Critical Care Medicine”: Physicians who completed training prior to availability of subspecialty certification in critical care in their specialty (1987 for Medicine, Anesthesiology, Pediatrics and Surgery), who are board-certified in one of these four specialties, and who have provided at least six weeks of full-time ICU care annually since 1987. (The weeks need not be consecutive weeks). Other physicians who have completed training programs required for certification in critical care medicine. Note: Physicians who have let their board certification lapse are not considered to be “Certified in Critical Care Medicine”. 9. Won't it degrade the meaning of meeting the Leapfrog ICU leap to expand the definition of an intensivist to include physicians certified in emergency medicine who have completed a critical care fellowship and to physicians who trained prior to 1987 and regularly practice full time critical care for a significant period? Though this change also reflects our sensitivity to the intensivist shortage, our decision to provide interim credit for these physicians is based on justice and patient benefit. Board certified emergency medicine physicians cannot become certified in critical care medicine (though their board is working on this) despite completing a fellowship in critical care. Inclusion of physicians who completed their training in surgery, medicine or anesthesiology prior to 1987 when critical care certification first become available only applies to physicians who are board certified and have provided at least 6 weeks annually of full time ICU care since 1987. It includes a significant number of critical care fellowship directors who trained prior to 1987 and who continue to train other critical care physicians. Our expert advisory panel (comprised primarily of physicians who publish research on ICU performance) elected to provide interim Page 47 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 ICU Physician Staffing 2014 Leapfrog Hospital Survey credit to physicians meeting this specification. The 6 week threshold was selected based on a consensus perception of a reasonable minimum of ongoing full time ICU experience. To protect patients from under-qualified physicians, the advisory panel worded the interim standard conservatively. It likely applies to very few physicians. As the supply of intensivists builds, credit will eventually be limited to board certified critical care specialists. The Leapfrog Group strives to make its recommendations based on empirical evidence. When we lack such evidence, we take a common sense approach that builds on the judgment of clinicians most familiar with available scientific evidence and aims at serving patients best. 10. Are we expected to conduct an audit to verify that high-urgency calls/pages are returned within 5 minutes, and are there definitions for what constitutes high and low urgency calls/pages? You should have some quantitative basis for saying that calls/pages are returned within 5 minutes at least 95% of the time. You could study a sample, or could use the tracking mechanism built in to the notification device system, if one exists. The basis for responding affirmatively should be more than just peoples’ perceptions of response time. You don’t have to focus only on high urgency calls/pages – but some notification device systems can make this differentiation and, in these instances, low urgency calls/pages can be carved out of the analysis of response times. Providers can monitor notification device response times in multiple ways, as long as the data collection process is non-biased and scientific. As an example: Providers could maintain an exception log in the ICU(s) on six randomly sampled days per year. On those days, ICU nurses could record: the number of urgent calls/pages made to intensivists when they are not present in the unit (whether on-site or via telemedicine); the number of urgent calls/pages made to other physicians or FCCS-certified effectors when no physician or FCCS-certified effector is physically present in the unit; and the number of times that responses exceed 5 minutes for those respective calls/pages. Hospitals can then cost-effectively estimate whether they meet the 95% timely response standards by dividing the average number of log exceptions per day by the average number of calls/pages per day. 11. Can you clarify how to handle situations where the ICU standard is met some but not all of the time? If the ICU standard is not met at least 8 hours a day, 7 days a week (if you responded no to Question 3), hospitals have the opportunity to get partial credit for having intensivists on-site at least some time during the week, or having telemedicine in place that meets the specified criteria for telemedicine. If the number of hours varies from week to week, hospitals should respond with the number of hours per week that the ICU standard is usually met. 12. What are the standards for staffing a neuro ICU? Who qualifies as a “neurointensivist”? To fully meet the IPS Leap, neuro ICUs must now meet the staffing standards that have been previously set for adult or pediatric general medical and/or surgical ICUs. Patients in a neuro ICU must be managed or co-managed by “neurointensivists” or critical care intensivists who are ordinarily present in the ICU (on-site, or via telemedicine that meets Leapfrog specifications) during daytime hours a minimum of 8 hours per day, 7 days per week, and during this time provide clinical care exclusively in the ICU. When not present, “neurointensivists” or critical care intensivists must return more than 95% of ICU calls/pages within 5 minutes and can rely on a physician or FCCS-certified non-physician “effector” who is in the hospital and able to reach ICU patients within 5 minutes in more than 95% of cases. Page 48 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 ICU Physician Staffing 2014 Leapfrog Hospital Survey “Neurointensivists” are classified as physicians who are board-certified in their primary specialty and who have completed a UCNS-certified fellowship training program in neurocritical care, or a physician certified by the UCNS in neurocritical care*. Existing physicians must obtain certification using the grandfathering process established by UCNS to be considered a neurointensivist. This new category of intensivists applies only to neuro ICUs. Neurointensivists qualify as “intensivists” only for coverage in neuro ICUs, not in other ICUs. 13. How should intensivisits trained in critical medicine in a foreign country be treated for purposes of meeting the ICU Physician Staffing (IPS) Leap? While they offer excellent training, many foreign countries do not offer specific critical care board certifications. Foreign trained physicians who were certified as intensivists in the country in which they trained, also count as intensivists for the purposes of the ICU Physician staffing (IPS) Leap. IPS Scoring Algorithm Fully meets standards: 1. All patients in adult and pediatric general medical and surgical ICU(s) and neuro ICUs are managed or co-managed by one or more physicians who are certified in critical care medicine (intensivists) (answered “Yes” to # 2); and 2. One or more intensivist(s) is/are present in each ICU during daytime hours on-site for at least 8 hours per day, 7 days per week OR via telemedicine 24 hours per day, 7 days per week, with some on-site intensivist time AND provide(s) clinical care exclusively in this ICU during these hours (answered “Yes” to #3); and 3. When intensivists are not present (on-site or via telemedicine) in these ICUs, one of them returns more than 95% of pages from these units within five minutes. (answered “Yes” to #4); and 4. When an intensivist is not present (on-site or via telemedicine) in the ICU, another physician, physician assistant, nurse practitioner or FCCS-certified nurse “effector” is on-site at the hospital and able to reach ICU patients within five minutes in more than 95% of the cases (answered “Yes” to #5). Note: When telemedicine is employed as a substitute for on-site time, it must meet the ten requirements (see endnote #29) including some on-site intensivist time to manage the ICU patients’ admission, discharge, and care planning. Substantial progress: 1. All patients in adult/pediatric medical ICU(s) and neuro ICUs are managed or co-managed by one or more physicians who are certified in critical care medicine (intensivists) when those physicians are present, whether on-site or via telemedicine (answered “Yes” to #2); and 2. The hospital has a board-approved budget that is adequate to meet the IPS commitment (answered “Yes” to #10); and 3. The hospital has implemented any one or more of the following practices: a. Intensivists are present and manage or co-manage all patients in all ICUs on-site at least 8 hours per day, 4 days per week or 4 hours per day, 7 days per week (answered “Yes” to #6 ); b. Intensivists are present and manage or co-manage all patients in all ICUs via telemedicine 24 hours per day, 7 days per week (answered “Yes” to #7) with on-site daily care planning at least 4 days per week (answered “Yes” to #8); use of telemedicine requires that additional Leapfrog telemedicine specifications are met; or c. Clinical pharmacists make daily rounds on adult medical/surgical and neuro ICU patients (answered “Yes” to #11). and 4. An intensivist: a. leads daily, multi-disciplinary team rounds on-site (answered “Yes” to #12), or b. makes admission and discharge decisions when on-site (answered “Yes” to #13). Page 49 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 ICU Physician Staffing 2014 Leapfrog Hospital Survey Substantial progress alternative for Hospitals: 1. All patients in adult/pediatric medical ICU(s) and neuro ICUs are managed or co-managed by one or more physicians who are certified in critical care medicine (intensivists) when those physicians are present, whether on-site or via telemedicine (answered “Yes” to #2); and 2. Intensivists are present and manage or co-manage all patients in all ICUs via telemedicine that is functional 24 hours per day, 7 days per week with onsite care planning done by an intensivist, hospitalist, anesthesiologist, or a physician trained in emergency medicine (answered “Yes” to #7); use of telemedicine requires that additional Leapfrog telemedicine specifications are met. Some progress: 1. The hospital has a board-approved budget that is adequate to meet the IPS commitment (answered “Yes” to #10); and 2. Some patients in the ICU(s) are managed or co-managed by an intensivist when present on-site or via telemedicine (answered “Yes” to # 6 or “yes” to #7 or #8 or #9). Use of telemedicine requires that additional Leapfrog telemedicine specifications are met. Willing to report: The hospital responded to all the Leapfrog survey questions, but it does not yet meet the criteria for Some progress. Declined to respond: The hospital did not respond to this section of the survey, or has not submitted a survey. Does Not Apply: The hospital does not operate an adult or pediatric general medical or surgical intensive care unit or a neuro intensive care unit. ICU Physician Staffing Section Complete Save your Responses! Page 50 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey Section 6: 2014 Leapfrog Safe Practices Score (SPS) What’s New in the 2014 Survey Since introducing the NQF Safe Practices to the Leapfrog survey in 2004, Leapfrog has asked hospitals if they conduct a safety and quality survey of units using a nationally recognized tool. Given research that shows a link between performance on specific domains on culture of safety surveys and better patient outcomes, Leapfrog is interested in better understanding which tool hospitals are using to measure their culture of safety. At the end of the Safe Practices section, Leapfrog had added some detailed questions about the culture of safety instrument each hospital is using; information will not be used in scoring, but will be used to inform future survey questions. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014, they will be documented in this Change Summary section. May 21, 2014 SP 23 Prevention of Ventilator Associated Complications Updated page numbers that reference NQF Safe Practices for Better Healthcare – 2010 Update report. Page 51 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey SPS Frequently Asked Questions (FAQs) Also see the more detailed, practice-specific FAQs for these eight Safe Practices at https://leapfroghospitalsurvey.org/web/wp-content/uploads/safepracticesFAQ.pdf 1. Why was the NQF Safe Practices report used for development and revisions of the survey? The initial NQF Report and the first accompanying set of Safe Practices provided a comprehensive and accessible document addressing specific practices to improve patient safety and healthcare quality. Since that initial report, a Maintenance Committee was established by the NQF and a revised set of Safe Practices were endorsed in 2006, 2009, and 2010. The 2010 report details 34 Safe Practices that should be universally implemented in clinical care to reduce the risk of harm to patents. The practices address the first three “leaps” of the Leapfrog Group and continue to be assessed in separate survey sections. A subset of the remaining 31 practices is now addressed in the SPS survey section. The initial and subsequent NQF reports were developed using a consensus process by a committee representing some of the foremost thought leaders and stakeholders in patient safety. The initial committee and the maintenance committee included members of patient and consumer groups, healthcare purchasers, health plans, healthcare providers, and research and quality improvement organizations. In accordance with the National Technology Transfer Advancement Act of 1995 (P.L. 104-113), the federal government may use the information in the NQF report for standardization purposes. As such, the initial survey was designed to be based on and limited to the content, scope, and evidence provided by the NQF Safe Practices for Better Healthcare: A Consensus Report of May 2003; likewise, the current survey of safe practices is consistent with the content of the 2010 Update released by NQF in April in 2010. 2. How was the NQF Safe Practices survey section developed? This updated survey section was developed based on advice from a 10 member Senior Advisory Board of patient safety and performance improvement national thought leaders. The Senior Advisory Board worked with input from more than 260 subject matter experts (SMEs) who have strong command of the medical literature and deep understanding of the best practices targeting the problem areas addressed in the NQF report. The SME frontline expertise includes the domains of medication management, ICU, surgery, healthcare law, administration, human factors, reliability science, culture and systems psychology. The SMEs contributed to the NQF practice and evidence assessment. They also participated in the development of revised relative weights for each practice for 2007. In addition, several hospital industry associations and numerous individual hospital representatives provided input on the survey content. A number of our Leapfrog experts were former clinicians and administrative contributors to the original NQF report and also served on the maintenance committee. For 2008, Leapfrog reduced the number and length of the survey, allowing hospitals to focus on the most heavily weighted practices for the survey. The number and length of the survey were reduced once again in 2012 to focus on those practices for which the outcome of the safe practice was being measured by Leapfrog or in other public reporting initiatives, and whether the practice, if fully implemented, was considered by experts to have a robust effect on safety in the hospital. 3. After submission of this portion of the survey, how will a hospital be scored? See the detailed scoring algorithm for details on how the Safe Practices section will be scored. The scoring algorithm can be found in the Survey Reference Book. Page 52 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey 4. How much time and effort is required to complete this part of the survey? The time and effort it will take a hospital to complete this section of the survey will vary based on a number of factors, including the number of persons in the organization involved in answering this section of the survey and accessibility to needed information. Leapfrog anticipates the level of burden to complete this section of the survey has been reduced by focusing on just eight of the 31 Safe Practices. 5. What is the most efficient approach to complete the survey? Through the experience of hospitals that participate in Leapfrog’s Pilot Test program, Leapfrog recommends the following steps: Prepare: Obtain copies of the NQF report of 2010 (see link on the ‘Download Survey Materials’ page of the online survey for ordering information). Hardcopy versions of the report, the survey, the Safe Practices Score fact sheet, and the FAQs should be reviewed by the person responsible for submission. That person should decide who should participate on their team to assist in collection of the documentation for assessment. Plan: We suggest that a team be formed that might just be a couple of individuals in some hospitals or a much larger group for larger organizations. That team should be briefed and assigned duties to help capture the key information necessary for submission. Collect: Key documentation should be collected to support answering the survey. It will be helpful to archive it for future reference as Leapfrog does a random review of safe practices documentation every year. In addition, the documentation can be helpful when the survey is updated or re-submitted by the hospital. Assess: When all of the supporting documents are assembled, it is recommended that hospitals review their final responses to section 6 with the CEO and/or responsible leadership. Hospitals should update their answers online as they adopt additional practices. Submit: Section 6 must be completed and affirmed before it can be submitted with the survey. 6. The NQF Safe Practices for Better Healthcare 2010 Update: A Consensus Report was released in April of 2010. How does the survey deal with a report that is lacking detailed measures? The NQF report is an excellent publication; however it is a set of standards and implementation suggestions; it is not an endorsed measure set. The measurement of adoption of the endorsed set of standards is done through this survey; however the design of the survey is closely aligned with the implementation guidance in the report. In order to create an effective survey instrument and relative weighting system, the following principles were followed. Page 53 4 A Framework: The 4 A Adoption Framework (see below) was designed to measure progress on the problem being targeted by the practices; over time the questions in the survey have evolved based on experience and research and now on the new set of Safe Practices. The 4 A Adoption Framework is still in place, but this set of survey questions is more specific than the survey designed for the first report, where more latitude was given to hospitals in terms of implementation strategies and the ability to make commitments for implementation. Focus on Practices: The evidence, practices, and implementation details have gone through a complete and comprehensive review by the NQF Maintenance Committee, and as a result the new report is more actionable than the initial report. The survey is still designed for a mid-level manager of a frontline community hospital to complete. Systematic Application of 4 A Adoption Framework: A framework defining dimensions of progress in patient safety of Awareness, Accountability, Ability, and Action was used in formulation of survey questions. As a result of the changes to the practices, measures are more clearly aimed at specific processes and outcomes. Partial credit is still available for having completed some, but not all of the key strategies for implementing the Safe Practices. Define practices as readily available to mid level manager at frontline community hospital: The Medical Advisory Board and Subject Matter Experts were asked to focus on Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Safe Practices Score the problem cited in the NQF report and emphasize the impact of best practices “currently and readily available to a mid level manager at a frontline urban community hospital” on the problem including, but not limited to, the specifications and implementation approaches cited. This allowed the weighting, survey, and ranking system to be normalized to the most representative case of hospitals across the country. It also limited confusion around currently published studies and opened the field of review to the medical literature, Internet resources, and readily available expert opinion from quality improvement groups. This did not violate the principle of operating within the scope of the NQF report. 7. Given this section of the survey is now shorter—will we still get partial credit? Can we still get credit for commitments? This section of the survey has been reduced, it now reflects on only eight of the remaining 31 safe practices. We have maintained the same structure of Awareness, Accountability, Ability and Action in this new version. It is also still possible to get partial credit, but we no longer give credit for commitments. We have heard hospitals concerns about the veracity of their colleagues in completing the survey. In this year’s SPS section you will note that most of the questions are written to include documentation of efforts made, which will allow for audits by individual plans, other purchasers, or pay-for-performance programs. 8. Why is each practice area is broken down into the 4 A’ Framework: Awareness, Accountability, Ability, and Action? Organizations must have awareness of performance gaps and through direct measurement they must be aware of their own performance gaps. Accountability of leadership to improve performance is critical to accelerate innovation adoption. An organization may be aware, and the leadership accountable, however if the staff do not have the ability to employ new practices meaning the capacity and resources to do so success is at risk. Finally, action must be taken with discipline over time that is measurable both by process measures and outcome measures that clearly tie to closing performance gaps. Awareness: Most of the NQF Safe Practices are defined with a safety objective addressing the nature of a preventable adverse event. The cause of these adverse events are fairly well understood and well known. Each NQF Practice was treated individually depending on how well understood THE performance opportunities are and how well a hospital can address their – OUR performance opportunities. Although all questions were developed custom designed to the safety objective/practice, a standardized guide was developed to assist in the process. Accountability: Accountability addresses direct accountability of the appropriate leaders to the adverse event area. Ability: A graduated set of investment levels were used ranging from investment in education, skill development, allocated human resources, and line item budget allocations. These were adjusted in a safety objective/practice specific way. Actions: Action levels were tied to NQF language well as they could be. Performance Improvement programs and projects were tied to actions as they are recognized as critical to sustained performance. Where possible, the actions were tied to those promulgated by The Joint Commission. 9. This part of the survey places significant emphasis on Performance Improvement Projects/ Programs. Why? The greatest sustained improvement and cost savings have been achieved by hospitals that have undertaken formal Performance Improvement Programs with measurement and process improvement features that then tie to explicit procedures and protocols (as cited in some but not all of the NQF Safe Practices). 10. There are many types of Performance Improvement Programs and project methodologies. What elements are required to satisfy the requirements for credit for such programs or projects? Generally, five elements must be present (and are typically present in most such programs or projects): Page 54 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey Education: Staff and caregivers should be educated regarding the nature of the adverse events being targeted and the impact of better or best practices. Skill Development: Staff and caregivers should be briefed and equipped to have the skills necessary to undertake a performance improvement project. Measurement: Process measures or outcome measures should be assessed and tracked. Process Improvement: A feedback process improvement component should be employed to improve processes, test the change, and then provide feedback through measurement to improve outcomes. Reporting: Results of performance improvement projects or programs should be reported to the administrative leadership and caregivers. However, it is very important to review the NQF Report for more detailed specifics on implementation strategies that are mentioned for each Safe Practice. 11. What Guiding Principles were followed to design the relative Weighting System? Are the weights the same as previous surveys? Below we describe how the weights (which are still applied) were developed. Enterprise-wide Systems & Process Areas Prioritized: In preparation for the formal voting process all Advisory Board members were presented with the concept of allocating weighting to enterprise-wide systems focus areas and enterprise-wide process focus areas as a first step, followed by allocating weight to care setting-specific areas. All were in agreement and this process was followed. Weighting was made to an agreed set of enterprise-wide problems/practices and the balance of the points allocated by a relative weighting vote. Neutralize NQF Report Limitations: As with the survey question design process, the limitations of the NQF report were neutralized by emphasis on the problem cited by the NQF rather than the practices and by employment of the 4 A framework of patient safety progress. Focus on Safety Objectives (cited by NQF) and Practices: The Safety Objectives and cited adverse events addressed in the NQF report were entirely satisfactory and the “right list” as evaluated by the Medical Advisory Board. Emphasize Impact (Frequency x Severity x Practice Impact): The Advisory Board was provided with resources of prior incidence studies (Utah-Colorado and others) and weighting systems used by organizations such as the Veterans Healthcare Administration. The common approach patient safety researchers use is the factor frequency (prevalence), severity of the problem, and impact of readily available practices. A global relative weighting approach was determined to be the most appropriate for this survey. Use Transparent Multi-round Multi-voting: A rapid cycle transparent multi-round voting method was used to allow the Advisory Board to vote, discuss their votes, review individual practices and problems, evaluate point spread across voters and across voting rounds. All practices were individually reviewed and discussed before and after each voting round. Only two voting rounds were required for consensus. Yes, the weights used for each Safe Practice in this year’s Safe Practices section match the weights established by the Advisory Board in 2007. The only change being the number of practices that Leapfrog asks hospitals to report on. 12. How frequently should my hospital respond to this survey? Throughout the year, hospitals should resubmit their responses if and when their status changes with regard to any of the questions. This will ensure that hospitals’ most current status is accurately reported to The Leapfrog Group and in the results they publish. The Leapfrog Group plans to revise its recommended patient safety practices and the hospital survey on a yearly schedule designed to coincide with most employers’ health care benefits enrollment periods. We are committed to depicting your current patient safety improvement efforts accurately to consumer and purchasers, maintaining current information, and keeping our patient safety recommendations up to date based on continuous input from national experts. Page 55 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey Annual survey revisions are planned for release each April. All publicly reported results from the prior survey cycle will be replaced in early July with results based on new surveys submitted through June 30. Public results will be updated monthly thereafter, on approximately the second business day of each month, based on surveys (re)submitted through the end of the previous month. 13. What is required of a hospital to attain the “four bar” top level recognition for the NQF Safe Practices section of the survey? To attain top level recognition, a hospital must rank in the top performance category, based on the distribution of results from surveys submitted as of June 30, 2012. More detailed measure-specific FAQs available at https://leapfroghospitalsurvey.org/web/wpcontent/uploads/safepracticesFAQ.pdf. Page 56 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey SPS Scoring Algorithm The Leapfrog Safe Practices Score (SPS) measures hospitals’ progress on eight of the National Quality Forum Safe Practice areas. Each practice area is assigned an individual weight, which is factored into the overall score. Hospitals are then put into performance categories based on their relative progress out of the total number of possible points. A hospital’s results are publicly released and displayed on the Leapfrog Group Web site in one of five categories: Fully meets standards (4 filled bars) means the hospital is in the top performance category for Overall Points across all Safe Practices that apply to the hospital. Substantial progress (3 filled bars) means the hospital is above the midpoint (median), but not in the top performance category, for Overall Points across all Safe Practices that apply to the hospital. Some progress (2 filled bars) means the hospital is below midpoint (median), but not in the lowest performance category, for Overall Points across all Safe Practices that apply to the hospital. Willing to report (1 filled bar) means the hospital is in the bottom performance category for Overall Points. Declined to respond means the hospital did not respond to this section of the survey, or the hospital was asked to complete the survey but has not submitted one. Within each Safe Practice/Element, each checkbox has the same value, equal to the total points assigned to that Practice/Element divided by the number of checkboxes in that Practice/Element. Where a hospital’s responses indicate that a Safe Practice does not apply, the total available points will be less than the maximum 485 points. In these cases, total points earned for checked items is rebalanced (upward) by the ratio of maximum points to total available points to put the hospital on equal footing with other hospitals to which those NA-items do apply. Scoring and ranking details are described below. 1. Maximum Points: Each of the eight Safe Practices has a number of points, or Maximum Points, based on the relative impact of the safe practice. Maximum Points for all Practices total 485. See below for a list of Safe Practices/Elements and their respective Maximum Point values. Weighting (pts) Safe Practice 1 2 3 4 9 17 19 23 Culture of Safety Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Risks and Hazards a Nursing Workforce Medication Reconciliation Hand Hygiene b Prevention of Aspiration and Ventilator Associated Pneumonia GRAND TOTAL 120 20 40 120 100 35 30 20 485 a Hospitals indicating in Safe Practice #9 that they have current Magnet status designation, as determined by the American Nurses Credentialing Center (ANCC), will receive full points for this Safe Practice. b If this Safe Practice does not apply at your hospital, you can indicate so at the beginning of this Safe-Practice section. To submit this section of the survey, this Safe Practice needs to be completed, even if only to indicate not applicable to your hospital. Page 57 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safe Practices Score 2014 Leapfrog Hospital Survey 2. Point Values per Checkbox: Within a Practice or Element, each question has an equal point value, computed as the Maximum Points for that Practice/Element divided by the number of checkboxes within that Practice/Element. 3. Available Points: Some Practices might not apply to a hospital, in which case total Available Points will be 0 for that Practice (e.g., Safe Practice #23 might not apply to a hospital) If so, the total Available Points across all Practices will not include the Maximum Points for those Practices. The online survey will not allow any checkboxes to be marked in those Practices and scoring for those Practices will be marked NA in Leapfrog public results. Example 1: A hospital respondent indicates Safe Practice #23 does not apply. Total Available Points for all Safe Practices is 465 = 485 less 20 points for Safe Practice #23. 4. Points Earned: Total points earned for each Safe Practice/Element is the sum of the points for each checkbox marked in that respective Safe Practice/Element (the exception being Safe Practice #9, whereby hospitals indicating that they have current Magnet status designation, as determined by the American Nurses Credentialing Center (ANCC), will automatically receive full credit). 5. Overall Points: The overall score of each survey is the sum of all Points Earned for each Safe Practice/Element, re-balanced for Safe Practices that are NA. The sum of Points Earned across all Safe Practices/Elements is multiplied by the ratio of 485 Maximum Points to the sum of Available Points for each Practice/Element. Example 2: Continuing from Example 1, Points Earned across the seven Safe Practices that do apply total 420.30. Overall Points are 438.38 = 420.30 x (485/465). 6. Final Scoring: All responding hospitals are stratified into performance categories based on Overall Points. 7. Performance category cut-points are based on the distribution of surveys submitted as of June 30, 2012. The distribution of scores including new or updated survey results will be reviewed periodically to determine if there are compelling reasons to revise these performance category cut-points further, but there are no current plans or commitments to change the cut-points again during the 2014 survey cycle. 8. Updated Submissions: Hospitals may update and resubmit their surveys as often as needed to reflect actual progress achieved or additional commitments undertaken in these patient safety areas. Hospitals submitting new information will have new results replace the posted results from the prior submission to reflect this progress, consistent with Leapfrog’s monthly update of survey results. Page 58 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Section 7: Managing Serious Errors What’s New in the 2014 Survey For the past several years, Leapfrog has asked hospitals to report on their rates of hospital-acquired infections. Currently, most hospitals are collecting and reporting data on central-line associated blood stream infections and catheter-associated urinary tract infections in ICUs through CDC/NHSN for CMS’ Inpatient Quality Reporting Program. As these data cannot accurately be collected retrospectively, Leapfrog will remove the measures specifications for both HAIs from the Leapfrog Hospital Survey Reference Book. Hospitals should continue to report their data to the Leapfrog Hospital Survey as collected for and submitted to CDC/NHSN. Change Summary since Release Since initial 2014 edition dated 4/1/2014 Page 59 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Managing Serious Errors Never Events Never Events Frequently Asked Questions (FAQs) 1. What are never events? The National Quality Forum, a nonprofit national coalition of physicians, hospitals, businesses and policy-makers, has identified 29 events as occurrences that should never happen in a hospital and can be prevented. They termed them “serious reportable events”, or never events. They include surgical events such as performing the wrong surgical procedure, product or device events such as contaminated drugs or devices and criminal events such as abduction of a patient. To see a complete list of never events go to: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573 To earn credit for this question, hospitals must have a policy in place that addresses the National Quality Forum’s list of Serious Report Events. All references to “never event” or “serious reportable event” are specific to the National Quality Forum list available at http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573. Hospitals may not earn credit for this question if they have only implemented a policy that includes the Center for Medicare and Medicaid (CMS) Never Events. 2. How often do never events occur? By definition, never events are incredibly rare. They are also rarely disclosed, except in confidentiality to reporting programs like The Joint Commission, so precise numbers on their frequency are not available. Some states, such as Minnesota, now have mandatory reporting laws that track never events. In the past few years, Minnesota has averaged around 100 reported never events per year. 3. If never events are so rare, why is Leapfrog choosing to focus on them? While never events are rare, they do sometimes happen – causing serious harm to the patient. Leapfrog wants to promote patient safety and quality in a manner consistent with the recommendations of the National Quality Forum’s report. We also want to recognize those hospitals that are leading the effort in patient safety by being willing to apologize to the patient affected by the never event, investigate its cause and improve processes in response to their analysis, and be willing to share their policy with patients, families, and others. 4. How does the issue of never events relate to other Leapfrog initiatives? Leapfrog’s “leaps”, which in four categories address the Safe Practices for Better Healthcare, also created by the National Quality Forum, are intended to work together with NQF’s 29 Serious Reportable Events in addressing both the processes and outcomes related to adverse events. The implementation of the Safe Practices is intended to prevent adverse events from happening in the first place. The list of never events identifies the rare events that sometimes do happen and makes recommendations for what hospitals can and should do if a never event occurs in their facility. 5. Are there other voices in the health care arena giving attention to the issue of never events? Yes. In May 2006 the Centers for Medicare and Medicaid Services came out with a public statement on never events, (http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863) in which it announced its intention to work with Congress, hospitals, and other health care organizations to reduce payments for never events and to provide more information to the public about when they occur. 6. When reporting Never Events, what “state reporting program for medical errors” applies in my state? Congress has passed legislation requiring all states to develop a reporting program for medical errors. At this time, many states have already enacted or adopted some requirement that Page 60 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey hospitals report serious medical errors or similar adverse events to a state agency(ies). Others are still implementing legislation or regulations that define that requirement. States that have developed programs may also define reportable events differently. 7. What if there is no “state reporting program for medical errors” in my state? Do we still have to report Never Events to meet Leapfrog principles for this policy? To whom? Hospitals in states that do not have a state reporting program or requirement in effect can meet the reporting requirement of Leapfrog’s principles for implementation of a Never Events policy by reporting all Never Events voluntarily to either The Joint Commission or a Patient Safety Organization. If there is no state-required reporting program in effect, no available Patient Safety Organization to which your hospital can report, and your hospital is not Joint Commission accredited, the Leapfrog requirement for reporting to an external agency is amended. Hospitals must report the Never-Event to their governance board. And, hospitals must still perform a root-cause analysis internally of each Never Event to meet Leapfrog’s principle for full implementation of its Never Events policy. 8. The reportable adverse events defined by our state’s reporting program don’t include all 29 Never Events endorsed by the National Quality Forum (NQF) and adopted in the Leapfrog policy. Will reporting only the state-required reportable events to the state agency suffice for meeting Leapfrog’s requirement for reporting Never Events to an external agency? Does our hospital have to report other Never Events, as defined by NQF/Leapfrog, to that state agency even though not required by our state’s reporting program? Hospitals should report all state-required reportable events to the state agency. All other Never Events, as defined by NQF/Leapfrog, that cannot be reported to the state agency, should be reported to the hospital’s governance board. 9. Won’t Leapfrog’s request to have hospitals apologize to the patient put the hospital at risk for liability? Not necessarily. Research indicates that malpractice suits are often the result of a failure on the hospital’s part to communicate openly with the patient and apologize for its error. Patients feel the most anger when they perceive that no one is willing to take responsibility for the adverse event that has occurred. A sincere apology from the responsible hospital staff can help to heal the breach of trust between doctor/hospital and patient. (When Things Go Wrong: Responding to Adverse Events. Boston, 2006. Mass Coalition for the Prevention of Medical Errors) 10. Is Leapfrog’s belief that hospitals should not bill for “never events” just a cost savings measure for employers or health plans? No. These events are rare and most likely do not represent a significant savings for employers or health plans. However, for a patient, it could relieve a significant financial burden. We believe that any patient who suffers from a "never event" should never have to pay for it. 11. How does Leapfrog define “waive cost”? At its core, Leapfrog’s approach to never events is about improving patient care. While the policy asks hospitals to refrain from billing either the patient or a third party payer, such as a health plan or employer company, for any costs directly related to a serious reportable adverse event, Leapfrog understands that, due to the wide array of circumstances surrounding never events, specific details of what constitutes “waiving cost” should be handled on a case-by-case basis by the parties involved. Page 61 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Never Events Scoring Algorithm A hospital’s results are publicly released and displayed on the Leapfrog Group Web site in one of three categories: Fully meets standards (4 filled bars) means the hospital has implemented a policy that adheres to all of the principles of the Leapfrog Group Policy Statement on Serious Reportable Events/ “Never Events” (Answered “Yes” to Q1). Willing to report (1 filled bar) means the hospital responded to the Leapfrog survey question pertaining to adoption of this policy, but does not yet meet the criteria for Fully meets standards (Answered “No” to Q1). Declined to respond means the hospital did not respond to this section of the survey, or the hospital was asked to complete the survey but has not submitted one. Page 62 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Hospital-Acquired Conditions (HAC) Reporting Time Periods Condition Surveys submitted prior to September 1, 2014 Surveys submitted on or after September 1, 2014 Central Line Associated Bloodstream Infections 12 months ending December 31, 2013 12 months ending June 30, 2014 Catheter- Associated Urinary Tract Infections 12 months ending December 31, 2013 12 months ending June 30, 2014 12 months ending December 31, 2013 12 months ending June 30, 2014 12 months ending December 31, 2013 12 months ending June 30, 2014 Pressure Ulcers Injuries Central-line Associated Blood Stream Infections (CLABSI) CLABSI Specifications: Survey p.53-55 Incidence Rate of Central Line Associated Bloodstream Infections Source: National Quality Forum (NQF) Nursing-Sensitive Care Measure 7 Rates will be stratified by ICU type – medical, surgical, medical/surgical, pediatric medical, pediatric surgical, pediatric medical/surgical, coronary care, surgical cardiothoracic, neurology, neurosurgical, burn, trauma, Level II/III NICU, and Level III NICU, (see below for definitions of ICU types) Reporting Time Period: Answer question #1-19 for the 12 months ending : December 31, 2013, for surveys submitted prior to September 1, 2014; June 30, 2014, for surveys (re)submitted after September 1, 2014. Definition of ICU Types Below is a list and brief description of those ICU types for which hospitals should report their centralline associated bloodstream infection (CLABSI) data to the survey: Source: http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html Survey ICU Name / CDC ICU Name Description Medical / Medical Critical Care Critical care area for patients who are being treated for nonsurgical conditions. Surgical / Surgical Critical Care Critical care area for the evaluation and management of patients with serious illness before and/or after surgery. Medical/Surgical / Medical/Surgical Critical Care An area where critically ill patients with medical and/or surgical conditions are managed. Page 63 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Pediatric Medical /Pediatric Medical Critical Care Critical care area for patients ≤18 years old who are being treated for nonsurgical conditions. Pediatric Surgical / Pediatric Surgical Critical Care Critical care area for the evaluation and management of patients ≤18 years old with serious illness before and/or after surgery. Pediatric Medical/Surgical / Pediatric Medical/Surgical Critical Care An area where critically ill patients <=18 years old with medical and/or surgical conditions are managed. Coronary Care / Medical Cardiac Critical Care Critical care area specializing in the care of patients with serious heart problems that do not require heart surgery. (Note: definition intended for adult patients, not pediatric). Surgical Cardiothoracic / Surgical Cardiothoracic Critical Care Critical care area specializing in the care of patients following cardiac and thoracic surgery Neurology / Neurologic Critical Care Critical care area specializing in treating life-threatening neurological diseases. Neurosurgical / Neurosurgical Critical Care Critical care area specializing in the surgical management of patients with severe neurological diseases or those at risk for neurological injury as a result of surgery. Burn / Burn Critical Care Critical care area specializing in the care of patients with significant/major burns. Trauma / Trauma Critical Care Critical care area specializing in the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma. Level II/III NICU / Neonatal Critical Care Special care nursery for care of preterm infants with birth weight >1500g. Includes resuscitation and stabilization of preterm and/or ill infants before transfer to a facility at which newborn intensive care is provided. Level III NICU / Neonatal Critical Care A hospital neonatal intensive care unit (NICU) organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. Level III is subdivided into 4 levels differentiated by the capability to provide advanced medical and surgical care. NOTE: The categories of Level III below are classifications from the American Academy of Pediatrics, Definitions of hospital-based newborn services.1 These classifications are all considered Level III nurseries in NHSN. Level IIIA - Hospital or state-mandated restriction on type and/or duration of mechanical ventilation. Level IIIB - No restrictions on type or duration of mechanical ventilation. No major surgery. Level IIIC - Major surgery performed on site (eg, omphalocele repair, tracheoesophageal fistula or esophageal atresia repair, bowel resection, myelomeningocele repair, ventriculoperitoneal shunt). No surgical repair of serious Page 64 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey congenital heart anomalies that require cardiopulmonary bypass and /or ECMO for medical conditions. Level IIID - Major surgery, surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass, and/or ECMO for medical conditions. Hospitals should not report rates for respiratory or prenatal ICUs to the survey. Not every hospital will have all of the intensive care units listed in the table above. Hospitals decide which type of ICU they have by measuring the type of patients that are cared for in that area and applying the 80% Rule. For instance, if 80% of patients are of a certain type (e.g. critical care patients, with medical, non-surgical problems) then that area is designated as that type of location (in this case, a Medical ICU). If a hospital operates an ICU that is does not consistently have 80% of a specific type of patient (e.g. an ICU averages 50% medical patients, 50% surgical patients), that ICU should be considered a medical-surgical ICU. Hospitals should report on all patients cared for in that particular ICU, regardless of their actual status (e.g. if 10% of a medical ICU are surgical patients, include those surgical patients cared for when reporting that ICU). For additional information, see CDC Locations and Descriptions and Instructions for Mapping Patient Care Locations Instructions for Mapping Patient Care Locations in NHSN”: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf Directions for using central line associated bloodstream infection (CLABSI) data reported to the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) for completing questions Q5-19: Hospitals should use the central line associated bloodstream infection (CLABSI) data they report to the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) in completing columns (b) and (c) for questions Q5-19. Hospitals using CDC/NHSN data should report their denominators in column (b) and numerators in column (c). Actual rates will be calculated by Leapfrog. Hospitals that do not report CLABSI data to CDC/NHSN should report ‘No’ to Q2 and skip the remainder of the subsection. Page 65 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey CLABSI Scoring Algorithm A hospital’s rate of central line-associated bloodstream (CLABSI) infections is calculated for each type of ICU in which they care for patients with central lines or umbilical catheters (e.g. medical, surgical, medical/surgical, pediatric medical, pediatric surgical, pediatric medical/surgical, coronary care, surgical cardiothoracic, neurology, neurosurgical, burn, trauma, Level II/III NICU, and/or Level III NICU). The rate of central line-associated bloodstream infections in an ICU is calculated by dividing the number of central line-associated bloodstream infections acquired in the ICU by the number of central line days in that same ICU. CLABSI rates are reported as a rate of occurrence per 1,000 central line days by ICU type. Note: Major teaching hospitals will have their medical and medical-surgical central line-associated bloodstream infection rates reported independently from other hospitals. Summary Score A standardized infection ratio (SIR) will be calculated for each hospital, which will serve as the hospital’s summary CLABSI score. The SIR calculation divides the total number of observed CLABSI events at a hospital by an “expected” number of events. The “expected” number of events is calculated by multiplying the national CLABSI rate from the standard population by the observed number of central line days for each type of ICU type in which the hospital reported. This "expected" value can also be understood as a prediction or projection. Below are the standard population CLABSI rates that will be used in calculating a hospital’s SIR. They are based on the national NHSN data. Leapfrog makes every effort to align with other national measurement and public reporting entities when possible and appropriate. Therefore, Leapfrog will continue to use the 2006-2008 NHSN benchmarks to maintain alignment with the NHSN and the Centers for Medicare and Medicaid. ICU Type Medical – Major Teaching Medical –Others Surgical Medical/Surgical – Major Teaching Medical/Surgical – Others Pediatric (Pooled for all types) Medical Cardiac (Coronary Care) Surgical cardiothoracic Neurologic Neurosurgical Burn Trauma Mean NHSN CLABSI Rates 2 for 2006-2008 (Standard Population) 2.5679 1.8958 2.3055 2.1078 1.4801 2.9391 2.0073 1.3891 1.3510 2.4615 5.4982 3.6200 2 Rates taken from the National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued December 2009 (Table 3). http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF Page 66 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey ICU Type Mean NHSN CLABSI Rates 2 for 2006-2008 (Standard Population) Level II/III NICU <= 750 g 751 – 1, 000 g 1,001 – 1,500 g 1,501 – 2,500 g > 2,500 g Level III NICU <= 750 g 751 – 1, 000 g 1,001 – 1,500 g 1,501 – 2,500 g > 2,500 g 4.1529 3.2009 2.0376 1.4927 1.2352 3.9339 3.3515 2.4441 2.3898 1.8990 A hospital’s standardized infection ratio is used to determine in which performance category a hospital is placed: Fully meets standards (4 filled bars) means the hospital has a standardized infection ratio of 0.00. Substantial progress (3 filled bars) means the hospital has a standardized infection ratio greater than 0.00 and less than or equal to 0.50. Some progress (2 filled bars) means: o the hospital has a standardized infection ratio greater than 0.50 and less than or equal to 1.10; or o the hospital has a standardized infection ratio greater than 1.10 and utilizes personnel trained in human factors engineering in conducting root-cause analyses or adverse events Willing to report (1 filled bar) means: o the hospital has a standardized infection ratio greater than 1.10 and does not utilize personnel trained in human factors engineering in conducting root-cause analyses or adverse events. Declined to respond means the hospital did not respond to this section of the survey, or has not submitted a survey. Unable to Calculate Score means the hospital reported too small of a sample size to calculate their results reliably (i.e. the number of expected infections across all ICU types is <1). Does Not Apply means that the hospital does not care for patients with central lines in ICUs. Page 67 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Below is an example of the standardized infection ratio calculation: Hospital Reported CLABSI Data ICU Type Mean NHSN CLABSI Rates for 2006-2008 (Standard Population) CLABSI Rate (per1,000 central line- days # CLABSI # Central line-days CLABSI Rate (per1,000 central linedays Neurologic 2 1,200 1.67 1.3510 Surgical 5 4,000 1.25 2.3055 SIR = Observed # events / Expected # events Observed # events = Neurologic # CLABSI + Surgical # CLABSI =2+5 =7 Expected # events = (Neurologic Observed Central line-days * Neurologic Std Pop CLABSI rate) + (Surgical Observed Central line-days * Surgical Std Pop CLABSI rate) = (1,200 * 1.3510/1,000) + (4,000 * 2.3055/1,000) = 1.621+ 9.222 = 10.843 SIR = Observed/Expected = 7 / 10.843 = 0.6456 A standardized infection ratio (SIR) of 0.6456 would place this hospital in the “Some Progress” performance category. Public Reporting In addition to reporting the hospital’s performance category, the hospital’s standardized infection ratio (SIR), the number of central line associated bloodstream infections, and central line days for each ICU type reported will be reported on a secondary webpage accessed via drill-down from the main results page. Page 68 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Catheter-associated Urinary Tract Infections (CAUTI) CAUTI Specifications: Survey p.56-57 Incidence Rate of Catheter-associated Urinary Tract Infections Source: National Quality Forum (NQF) #0138 Rates will be stratified by ICU type – medical, surgical, medical/surgical, pediatric medical, pediatric surgical, pediatric medical/surgical, coronary care, surgical cardiothoracic, neurology, neurosurgical, burn, trauma, pediatric cardiothoracic, and surgical cardiothoracic (see below for definitions of ICU types) Reporting Time Period: Answer question #1-15 for the 12 months ending : December 31, 2013, for surveys submitted prior to September 1, 2014; June 30, 2014 for surveys (re)submitted after September 1, 2014. Definition of ICU Types Below is a list and brief description of those ICU types for which hospitals should report their catheterassociated urinary tract infection data to the survey: Source: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf Survey ICU Name / CDC ICU Name Description Medical / Medical Critical Care Critical care area for patients who are being treated for nonsurgical conditions. Surgical / Surgical Critical Care Critical care area for the evaluation and management of patients with serious illness before and/or after surgery. Medical/Surgical / Medical/Surgical Critical Care An area where critically ill patients with medical and/or surgical conditions are managed. Pediatric Medical /Pediatric Medical Critical Care Critical care area for patients ≤18 years old who are being treated for nonsurgical conditions. Pediatric Surgical / Pediatric Surgical Critical Care Critical care area for the evaluation and management of patients ≤18 years old with serious illness before and/or after surgery. Pediatric Medical/Surgical / Pediatric Medical/Surgical Critical Care An area where critically ill patients <=18 years old with medical and/or surgical conditions are managed. Pediatric Cardiothoracic / Pediatric Cardiothoracic Critical Care Critical care area specializing in the care of patients ≤18 years old following cardiac and thoracic surgery. Coronary Care / Medical Cardiac Critical Care Critical care area specializing in the care of patients with serious heart problems that do not require heart surgery. (Note: definition intended for adult patients, not pediatric). Surgical Cardiothoracic / Surgical Cardiothoracic Critical Care Critical care area specializing in the care of patients following cardiac and thoracic surgery. Page 69 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Critical care area specializing in treating lifethreatening neurological diseases. Neurology / Neurologic Critical Care Neurosurgical / Neurosurgical Critical Care Burn / Burn Critical Care Trauma / Trauma Critical Care Critical care area specializing in the surgical management of patients with severe neurological diseases or those at risk for neurological injury as a result of surgery. Critical care area specializing in the care of patients with significant/major burns. Critical care area specializing in the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma. Not every hospital will have all of the intensive care units listed in the table above. Hospitals decide which type of ICU they have by measuring the type of patients that are cared for in that area and applying the 80% Rule. For instance, if 80% of patients are of a certain type (e.g. critical care patients, with medical, non-surgical problems) then that area is designated as that type of location (in this case, a Medical ICU). If a hospital operates an ICU that is does not consistently have 80% of a specific type of patient (e.g. an ICU averages 50% medical patients, 50% surgical patients), that ICU should be considered a medical-surgical ICU. Hospitals should report on all patients cared for in that particular ICU, regardless of their actual status (e.g. if 10% of a medical ICU are surgical patients, include those surgical patients cared for when reporting that ICU). For additional information, see CDC’s “Instructions for Mapping Patient Care Locations in NHSN”: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf Directions for using catheter-associated urinary tract infection (CAUTI) data reported to the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) for completing questions #4-15. Hospitals are able to use the CAUTI data they report to the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) in completing columns (b) and (c) for questions #4-15. Hospitals using CDC/NHSN data should report their denominators in column (b) and numerators in column (c). Actual rates will be calculated by Leapfrog. Hospitals that do not report CLABSI data to CDC/NHSN should report ‘No’ to Q2 and skip the remainder of the subsection. Page 70 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey CAUTI Scoring Algorithm A hospital’s rate of CAUTI is calculated for each type of ICU in which they care for patients with urinary catheters. The rate of CAUTI in an ICU is calculated by dividing the number of catheter-associated urinary tract infections acquired in the ICU by the number of urinary catheter days in that same ICU. CAUTI rates are reported as a rate of occurrence per 1,000 urinary catheter days by ICU type. Note: Major teaching hospitals will have their medical and medical-surgical CAUTI rates reported independently from other hospitals. Summary Score A standardized infection ratio (SIR) will be calculated for each hospital, which will serve as the hospital’s summary CAUTI score. The SIR calculation divides the total number of observed CAUTI events at a hospital by an “expected” number of events. The “expected” number of events is calculated by multiplying the national CAUTI rate from the standard population by the observed number of urinary catheter days for each type of ICU type in which the hospital reported. This "expected" value can also be understood as a prediction or projection. Page 71 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Managing Serious Errors Below are the standard population CAUTI rates that will be used in calculating a hospital’s SIR. They are based on the national NHSN data. ICU Type Burn Medical - All Other Medical - Major Teaching Medical Cardiac Medical/Surgical - All Other Medical/surgical - Major Teaching Neurologic Neurosurgical Pediatric Surgical - All Other Surgical Cardiothoracic Trauma Mean NHSN CAUTI Rates 3 for 2006-2008 (Standard Population) 7.3764 3.9187 4.7241 4.8183 3.2816 3.3887 7.4274 6.9478 4.2138 4.2845 3.5521 5.4051 A hospital’s standardized infection ratio is used to determine in which performance category a hospital is placed: Fully meets the standard (4 filled bars) means the hospital has a standardized infection ratio of ≤0.293 Substantial progress (3 filled bars) means the hospital has a standardized infection ratio of >0.293 and ≤0.734 Some progress (2 filled bars) means the hospital has a standardized infection ratio of >0.734 and ≤1.243 Willing to report (1 filled bar) means the hospital has a standardized infection ratio of >1.243 Declined to respond means the hospital did not respond to this section of the survey, or has not submitted a survey. Unable to Calculate Score means the hospital reported too small of a sample size to calculate their results reliably (i.e. the number of expected infections across all ICU types is <1). Does Not Apply means that the hospital does not care for patients with urinary catheters in ICUs. Public Reporting In addition to reporting the hospital’s performance category, the hospital’s standardized infection ratio (SIR), the number of central line associated bloodstream infections, and central line days for each ICU type reported will be reported on a secondary webpage accessed via drill-down from the main results page. 3 National Healthcare Safety Network (NHSN) Report, Data Summary for 2006-2008, Device-Associated and Procedure-Associated Module. http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.pdf Page 72 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Hospital-Acquired Pressure Ulcers and Injuries Note: This section does not apply to pediatric hospitals. Pressure Ulcers Specifications: Survey p.58 HAC - Rate of Stage III/IV Pressure Ulcers Source: The Leapfrog Group Reporting Time Period: 12 months ending: December 31, 2013, for surveys submitted prior to September 1, 2014; June 30, 2014 for surveys (re)submitted on or after September 1, 2014. Q.2 Denominator: Total adult (ages 18 and older) inpatient discharges (including deaths) during the reporting time period. [Note: Hospitals should include in the denominator any patient for which they code present-on-admission (POA). This would include most short-stay psych and rehab patients.] Q.3 Numerator: Number of eligible cases included in denominator with any ICD-9 diagnosis code in a secondary diagnosis field of 707.23 or 707.24 AND the diagnosis has a Present-on-Admission (POA) indicator of “N” or “U”. Injuries Specifications: Survey p.58 HAC - Rate of Hospital-Acquired Injuries Source: The Leapfrog Group Reporting Time Period: 12 months ending: December 31, 2013, for surveys submitted prior to September 1, 2014; June 30, 2014 for surveys (re)submitted on or after September 1, 2014. Q.2 Denominator: Total adult (ages 18 and older) inpatient discharges (including deaths) during the reporting time period. [Note: Hospitals should include in the denominator any patient for which they code present-on-admission (POA). This would include most short-stay psych and rehab patients.] Q.4 Numerator: Number of eligible cases included in the denominator with any of the following diagnosis codes as a secondary diagnosis (diagnoses 2-9 on a claim), with a POA code of ‘N’ or ‘U’, and designated as a 2013 Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC): Fracture ............................. 800–829 (CC/MCC) Dislocation ......................... 830–839 (CC/MCC) Intracranial injury ............... 850–854 (CC/MCC) Crushing injury .................. 925–929 (CC/MCC) Burn ....................................940–949 (CC/MCC) Other injuries ......................991–994 (CC/MCC) Download a list of CC/MCC codes in the “Download Survey Materials” section of www.leapfroghospitalsurvey.org Page 73 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Managing Serious Errors 2014 Leapfrog Hospital Survey Pressure Ulcers and Injuries Scoring Algorithm A hospital’s rate of hospital-acquired pressure ulcers and rate of hospital-acquired injuries is calculated and compared to the rates of other hospitals. The rate of the hospital-acquired condition is calculated by dividing the number of discharges with the condition, which was not present on admission (question #3 or #4) by the total number of adult inpatient discharges (including deaths) in question #2. Rates of the hospital-acquired pressure ulcers and hospital-acquired injuries will be reported as a rate of occurrence per 1,000 inpatient discharges. All responding hospitals are stratified into performance categories based on their reported rates. A hospital’s results for each condition are publicly released and displayed on the Leapfrog Group Web site in one of five categories: Fully meets standards (full credit -- 4 filled bars) means the hospital is in the lowest (best) performance category. Substantial progress (¾-credit -- 3 filled bars) means the hospital is above midpoint (median), but not in the highest performance category. Some progress (½-credit -- 2 filled bars) means the hospital is below the midpoint (median), but not in the lowest performance category. Willing to report (¼-credit -- 1 filled bar) means the hospital is in the highest (worst) performance category. Declined to respond means the hospital did not respond to this section of the survey, has not submitted one. Unable to Calculate Score means the hospital reported fewer than 30 cases. Does Not Apply: Standard does not apply to pediatric hospitals. Note: HAC cut-points for 2014 are based on the distribution of results from surveys submitted as of June 30, 2013. These cut-points will remain in place for the entire survey reporting cycle, unless it is determined that there are compelling reasons to make revisions. However, at this time, there are no plans or commitments to change the cut-points. Measure Fully meets Substantial Some Willing to standard progress progress report (4 bars) (3 bars) (2 bars) (1 bar) Incidence rate per 1000 inpatient discharges Top Second Third Bottom Performance Performance Performance Performance Category Category Category Category Hospital-Acquired Pressure Ulcers 0.00 0.00 > 0.00 and ≤0.16 >0.16 Hospital-Acquired Injuries ≤0.16 >0.16 and ≤0.35 >0.35 and ≤0.64 >0.64 Page 74 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey Section 8: Safety-Focused Scheduling What’s New in the 2014 Survey For the past several years, Leapfrog has asked hospitals to report on the utilization of operating rooms that service inpatients, with a target of 85% utilization. This year, Leapfrog is adding a set of questions that focuses on a patient’s access to the operating room by urgency level (i.e., urgent, emergent, scheduled) by surgical service. The goal of these new questions is to ensure that hospitals are achieving appropriate utilization rates without sacrificing patient access. Responses to questions regarding patient access to operating rooms will be scored against access targets. However, results will not be publicly reported on the Leapfrog’s Hospital Survey Results website (www.leapfroggroup.org/cp) until 2015. In 2014, hospitals that respond to the questions will only be able to view their results for this measure on their password-protected “Details” page. Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014, they will be documented in this Change Summary section. Page 75 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey Safety-Focused Scheduling Utilization Specifications Calculating Available and Utilized ‘Prime Time’ Hours of Operating Rooms that Service Inpatients All hospitals should use these specifications and definitions for calculating available and utilized ‘prime time’ hours of its operating rooms that service inpatients (e.g. exclude those operating rooms that exclusively service outpatients and those operating rooms that are not located in the main hospital location). ‘Prime Time’ Each hospital will have its own definition of what constitutes ‘prime time’ for its operating rooms. For a typical hospital, ‘prime time’ will start around 7 am and go until 3-5 pm. Available ‘Prime Time’ Hours These are the hours that the operating rooms were opened and staffed. Across the 6 or 12 month period, calculate the total ‘prime time’ hours these units were available. For a typical hospital, the calculation for available ‘prime time’ hours would be: Available ‘prime time’ hours = number of operating rooms that service inpatients x ‘prime time’ hours x 5 days/week x number of weeks Example: A hospital has applied operations management methods to smooth patient flow in their 10 surgical suites. ‘Prime time’ for this hospital is 7 am – 4 pm daily (Monday- Friday). Available prime time hours = 10 units x 9 hours/day x 5 days/week x 24 weeks = 10,800 hours Note: If a unit is scheduled to close early in the day (i.e. before the end of ‘prime time’), those closed hours can be deducted from the total. Utilized ‘Prime Time’ Hours These are the hours that the inpatient operating rooms were utilized. Across the 6 or 12 month period, calculate the total ‘prime time’ hours these units were utilized. Utilized ‘prime time’ hours = cumulative duration of case lengths in ‘prime time’ + cumulative duration of turnover time in ‘prime time’, across the 6 or 12-month period. Please see section on Calculating Turnover Time on the next page. For calculating utilized hours, hospitals should only include those hours of a case that were done within ‘prime time’. If a case extends past ‘prime time’, only include the subset of hours that were in ‘prime time’. Example: A hospital has applied operations management methods to smooth patient flow in their 10 surgical suites. ‘Prime time’ for this hospital is 7 am – 4 pm daily (Monday- Friday). On one day within the four week period, a surgical suite had a case that went from 7 am – 11 am (a 4 hour case), required 30 minutes of turnover, sat empty for 90 minutes, then had another case from 1:00 – 4:30 (3.5 hour case). The utilized prime time hours for this surgical suite is 7.5 hours = [4.0 hour case + 30 minutes turnover + 3.0 hours of the 3.5 hour case within ‘prime time’]. The 90 minutes that the surgical suite was unoccupied Page 76 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey would not be included in the utilized hours. Any hours of a case that extend past ‘prime time’ would also not be included in the utilized hours. Note: For calculating utilized hours, hospitals should only include those hours of a case that were done within ‘prime time’. If a case extends past ‘prime time’, only include the subset of hours that were in ‘prime time’ Calculating ‘Turnover’ Time The Leapfrog Group defines ‘turn over time’ as the difference in time between ‘wheels out’ of the last patient to the room being ready for the next surgery (not necessarily when the next patient was wheeled in). Hospitals may need to commit manual resources to accurately collect these data. Sampling Due to the manual resources necessary to accurately collect turnover time, hospitals have the option to sample. STEP 1 STEP 2 STEP 3 STEP 4 Page 77 Hospitals that collected turnover time during CY 2013 on all inpatient surgical cases Hospitals that did not collect turnover time during CY 2013 on all inpatient surgical cases Select 2 consecutive weeks within the 6 or 12-month reporting period you will be reporting on for Section 8. For 2 consecutive weeks prior to your hospital’s survey submission, measure the turnover time of every case done in ‘prime time’ in those operating rooms that service inpatients. Using those 2 consecutive weeks of information, calculate the average turnover time for all surgical cases in operating rooms that service inpatients within the available ‘prime time’. Take the average turnover time from Step 2 and multiply this value by the number of cases performed in those operating rooms during ‘prime time’ during the 6 or 12-month reporting period. (In this way, hospitals are applying the average current turnover time to cases done in the prior year.) Using those 2 consecutive weeks of information, calculate the average turnover time for all surgical cases in operating rooms that service inpatients within the available ‘prime time’. Take the average turnover time from Step 2, and multiply this value by the number of cases performed in those operating rooms during ‘prime time’ during the 6 or 12-month reporting period. For example, if your average turnover time in operating rooms that service inpatients was 17 minutes, and 125 cases were performed in those rooms for the 6-month reporting period your hospital has selected to report on, your turnover time for the reporting period would be: 17 mins x 125 cases = 2,125 cumulative duration of turnover time. Add the cumulative duration of turnover time in ‘prime time’ from Step 3 to the cumulative duration of case lengths in ‘prime time’ across the 6 or 12-month reporting period to calculate the total utilized prime time hours. Version 6.1 Add the cumulative duration of turnover time in ‘prime time’ from Step 3 to the cumulative duration of case lengths in ‘prime time’ across the 6 or 12-month reporting period to calculate the total utilized prime time hours. First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey Safety-Focused Scheduling Frequently Asked Questions (FAQs) 1. Which specific "operations management" methods does Leapfrog expect hospitals to implement? While Leapfrog is not prescribing specific “operations management” methods for hospitals to implement, hospitals are STRONGLY URGED to review both the extensive bibliography and technical implementation guidelines provided for a list of the types of methods that successful hospitals have used for smoothing patient flow. 2. If these methods are not already used within our organization, it seems as if will take us a great deal of resources to implement. What are Leapfrog’s thoughts on using an outside organization for implementation? There are a variety of sources hospitals can use to help them in their implementation of these methods. A web search and/or consulting with other hospitals would be a good place to start for recommendations. 3. A lot of the measures Leapfrog uses on its survey are endorsed by the National Quality Forum (NQF). This measure set is currently not endorsed. Is using non-endorsed measures in its survey a change in philosophy for Leapfrog? While The Leapfrog Group does use NQF-endorsed measures when and where possible in its hospital survey, if an endorsed measure does not exist for an important patient safety or efficiency metric, for which there is peer-reviewed evidence, then Leapfrog has, and will continue to use, its discretion in including non-endorsed measures on the survey. 4. With this measure set, is Leapfrog asking hospitals to become a 7-day hospital? Leapfrog does not require hospitals to move to a 7-day concept, as we recognize the significant cultural shift that would require. That said, Leapfrog does see a 7-day hospital concept as a good opportunity for hospitals to use existing resources more efficiently. 5. Over 40% of my hospital’s surgical cases are non-scheduled. While some hospitals know weeks in advance what their surgery schedule looks like, our surgical schedule is completed one business day in advance. Our hospital must be flexible enough to adjust for the acuity of our patient population and a very high proportion of unscheduled admissions. Does this measure set apply to my hospital? With a high percentage of your hospital’s admissions being unscheduled, separating your scheduled and unscheduled patient flows would benefit your hospital even more than hospitals that have a greater percentage of scheduled admissions. 6. Why is Leapfrog asking hospitals to just smooth admissions in operating rooms that service inpatients? Leapfrog is asking hospital to ‘start small’ with smoothing patient flow, by asking them to just focus on inpatient operating rooms. If your hospital believes it can apply these methods to additional areas of the hospital, than please feel free to do so. 7. What specific quantitative benchmarks should hospitals be able to achieve with implementation of these methods? The standards for which hospitals will be measured against is an average utilization of 85%. 8. Would urgent cases that bypass the ED and go directly to an operating room be considered to be part of the unscheduled category? Yes, urgent cases that bypass the ED and go directly into surgery would be considered unscheduled cases. Page 78 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey 9. Should we exclude mothers of newborns from the smoothing admissions? There is no reason to exclude mothers of expectant newborns from the flow smoothing exercise. They should be treated like any other ‘scheduled’ or ‘unscheduled’ admission. Some of the early work on admission smoothing was done in OB units. 10. Do a hospital’s elective inpatient surgeries need to make up 10% or more of their total inpatient admissions to be successful on this part of the survey? Hospitals do not need for their elective inpatient surgeries during the reporting period to be at 10% or greater to be successful on this part of the survey. The question in the survey about elective inpatient surgeries making up 10% or more of total inpatient admissions is simply a filter question. 11. Our hospital has dedicated operating rooms for certain service lines (e.g., cardiac or maternity care), for which our management wants to keep dedicated for patient access reasons. Should these ORs be included in the calculations for utilized and available ‘prime time’ hours? Yes, these units need to be included. While separating elective and emergent flows may not be applicable in these ORs (given the small number of dedicated ORs), smoothing elective cases within these dedicated units across the week is still very much applicable. If your hospital has dedicated operating rooms for certain service lines where you have not separated elective and emergent flows, please respond “No” to Q3 and then report only to Q6 and Q7 for all operating rooms that service inpatients. This would include ORs that are dedicated for cesarean sections only. 12. Our hospital has dedicated operating rooms for scheduled cases, but we may use a scheduled room to treat an emergent case. Does this case count towards our utilized ‘prime time’ hours? Yes, these cases need to be included. This measure seeks to capture total utilization in specified operating rooms. Cases should be included regardless of case type. Safety-Focused Scheduling Scoring Algorithm (Utilization Only) Fully meets the standard (4 bars): The hospital can document an average utilization of 85% or greater across inpatient surgical units. Substantial Progress (3 bars): The hospital can document an average utilization greater than or equal to 75% and less than 85% across inpatient surgical units. Some Progress (2 bars): The hospital can document an average utilization greater than or equal to 60% and less than 75% across inpatient surgical units. Willing to Report (1 bar): The hospital can document an average utilization less than 60% across inpatient surgical units. Does Not Apply: Hospitals that do not operate more than one operating room that services inpatients (Answered “No” to question #1). Response Not Required: Hospital reported that elective surgeries made up less than 10% of their total admissions (Answered “No” to question #2) and choose not to provide responses for the remaining questions. Declined to Respond: The hospital did not provide responses to this section Page 79 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Safety-Focused Scheduling 2014 Leapfrog Hospital Survey Patient Access to Operating Rooms Scoring Algorithm (Access Only) This section will not be publicly reported during the 2014 survey cycle. Leapfrog will calculate the percentage of surgical subspecialties that achieve their own internal access targets for unscheduled cases, stratified by urgency level. These data will available on the Hospital Detail page on or after July 25, 2014. To access the Hospital Detail page, log in to the survey with your 16-digit security code and select the “Details” button. Fully meets the standard (4 filled bars): The hospital can document at least 75% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Substantial Progress (3 filled bars): The hospital can document at least 50% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Some Progress (2 filled bars): The hospital can document at least 25% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Willing to Report (1 filled bar): The hospital can document less than 25% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Does Not Apply: Hospitals that do not operate more than one operating room that services inpatients (Answered “No” to Smooth Patient Scheduling question #1). Response Not Required: Hospital reported that elective surgeries made up less than 10% of their total admissions (Answered “No” to Smooth Patient Scheduling question #2) and choose not to provide responses for the remaining questions. Declined to Respond: The hospital did not provide responses to this section OR answered ‘no’ to question #1 in this subsection OR answered ‘Choose Not to Report’ or ‘Can Not Measure’ to question #2 in this subsection. Page 80 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Section 9: Resource Use for Common Acute Conditions Note: This section does not apply to pediatric hospitals. Critical Access Hospitals can opt to report on this section. What’s New in the 2014 Survey In 2013, Leapfrog added a series of questions based on volume and readmission rates reported by CMS for three common acute conditions: AMI, Heart Failure, and Pneumonia. At that time, critical access hospitals were not able to access these questions in the online survey. This year, critical access hospitals that voluntarily reported 30-day risk standardized readmission rates for AMI, Heart Failure, and/or Pneumonia to CMS will be able to complete these questions on the online Leapfrog Hospital Survey. Critical access hospitals that do not voluntarily report this information to CMS will continue to be scored as “Does Not Apply.” Change Summary since Release None. If substantive changes are made to this section of the survey after release on April 1, 2014, they will be documented in this Change Summary section. Page 81 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Length of Stay Measures Specifications - AMI: Survey p. 68-69 AMI Case Count Q2 = Total number of inpatient discharges (including deaths) at this hospital location with principal diagnosis of Acute Myocardial Infarction for the Reporting Time Period. Inclusion criteria: Discharge date within Reporting Time Period Inpatient discharges (including deaths) during the hospital stay A principal diagnosis code in the following table: ICD-9-CM Diagnosis Codes 410.00 Anterolateral wall, acute myocardial infarction-episode of care unspecified 410.01 410.10 410.11 410.20 410.21 410.30 Anterolateral wall, acute myocardial infarction-initial episode Other anterior wall, acute myocardial infarction-episode of care unspecified Other anterior wall, acute myocardial infarction-initial episode Inferolateral wall, acute myocardial infarction-episode of care unspecified Inferolateral wall, acute myocardial infarction-initial episode Inferoposterior wall, acute myocardial infarction-episode of care unspecified 410.31 410.40 410.41 410.50 410.51 410.60 Inferoposterior wall, acute myocardial infarction-initial episode Other inferior wall, acute myocardial infarction-episode of care unspecified Other inferior wall, acute myocardial infarction-initial episode Other lateral wall, acute myocardial infarction-episode of care unspecified Other lateral wall, acute myocardial infarction-initial episode True posterior wall, acute myocardial infarction-episode of care unspecified 410.61 410.70 410.71 410.80 410.81 410.90 410.91 True posterior wall, acute myocardial infarction-initial episode Subendocardial, acute myocardial infarction – episode of care unspecified Subendocardial, acute myocardial infarction – initial episode Other specified sites, acute myocardial infarction-episode of care unspecified Other specified sites, acute myocardial infarction-initial episode Unspecified site, acute myocardial infarction-episode of care unspecified Unspecified site, acute myocardial infarction-initial episode Exclusions: Patient age < 18 Deaths in ER without inpatient admission Page 82 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Geometric Mean Length of Stay – AMI (applies to Heart Failure, and Pneumonia) For each applicable condition, report the geometric mean length of stay for the cases counted and reported in Q3 per the “Case Count” specifications, above. Length of stay for each case counts the number of inpatient days for the case from admission to discharge, including day of admission but excluding day of discharge, except if discharged (including died) on the same day as admission date, count one(1) day length of stay. Date of death is considered date discharged. The length of stay for each case is a whole number of days, with a minimum one(1) day stayed. Do not count fractional or partial days for late discharge or temporary transfer to another facility, e.g., for testing or procedure. Note: Patients transferred into a Medicare-certified hospice inpatient unit contiguous with the stay should not include hospice days in the inpatient length of stay. Since the cases counted are based on discharge date falling within the Reporting Time Period, include any portion of a stay occurring prior to the start of the Reporting Time Period. Do not count any portion of any stay with a discharge date after the Reporting Time Period, even if a portion of that stay occurred during the Reporting Time Period. Example: Reporting Time Period = 12 months ending 12/31/2012. Case #1 admitted 12/28/2011 discharged 1/02/2012 counts as a case with 5 days stayed, including 4 days in 2011. Case #2 admitted 12/29/2012 discharged 1/03/2013 does not count as a case; no days should be accumulated for this case for this Reporting Time Period. The geometric mean length of stay is NOT the simple arithmetic mean of lengths of stay. (See About the Geometric Mean later.) To compute geometric mean length of stay (GMLOS), use the link on the ‘Survey Download Materials’ page of the online survey, Computing Geometric Mean Length of Stay: Excel Tool, and follow the instructions for Method 1 here. Alternative Methods 2 and 3 are also described below, but not supported. Method 1 – Using Excel Tool: Computing Geometric Mean Length of Stay: Access the tool from the link on the home page of the online survey. Click on the tool to open it, or right-click to download a copy of the tool to your workstation and open that copy. Enter the length of stay, as a whole number (no decimals entered), for each case in the column for the respective procedure or condition, one row for each discharge. As indicated above, a ZERO(0)-DAY LENGTH OF STAY IS INVALID as an observation for any case. GMLOS is computed as data are entered. Once all the cases for a given procedure/condition are entered, the final answer is displayed at the top of that column. Enter that value in the survey. As data are entered, and once data entry is complete, save the spreadsheet to a local workstation or network drive/folder for your records, re-use, or corrections if needed. The data and spreadsheet cannot be saved at the online survey site. Tips for using tool: Don’t delete, insert or reformat any data rows. There is room for up to 10,000 cases, far more than needed; empty cells are not used in the calculation and can be left as is. Data can be keyed in one case at a time, or cut and pasted from other spreadsheets. Lengths of stay in the source data must be whole, positive, non-zero number only. To paste data from another source, copy it from the source and use Edit->Paste Special-> Values so that formatting in the tool is unchanged. Otherwise, any fractional or decimal data entries might not display in the tool and will be difficult to locate when the tool indicates these errors in the data entry. Automatic recalculation is turned on and should be left on. Otherwise, the GMLOS displayed might not be calculated for all data entered. Page 83 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey If the GEOMEAN results indicate an error, see the error message just below and correct the error. Remember to enter whole numbers only, not decimals or fractions, and no value less than 1 for a case. Cells above the data entry area are locked and the sheet is protected so that users cannot alter that area of the spreadsheet. We recommend not turning spreadsheet protection off. Contact the Help Desk, if questions, at [email protected] Method 2 – Statistical software packages: Statistical software packages like SAS and SPSS provide a geometric mean (GEOMEAN) procedure. Make sure that each observation of length of stay for a case is a whole, positive, nonzero number when computing the geometric mean for the discharges included. Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32 The Help Desk cannot provide support for inquiries about how to use statistical software tools or packages to compute this statistic. Method 3 – Using logs to compute geometric mean (not recommended) The length of stay for each case must be a whole, positive, non-zero number for each discharge’s length of stay (observation). For each observation, take the logarithm of the length of stay (base 10 or natural log). Maintain at least four(4) decimal-place precision. Sum the log values for each observations and divide the total by the number of observations (discharges), still maintaining at least four(4) decimal place-precision throughout. Take the anti-log or log-inverse of the result, i.e., raise base 10 or base e (natural) to the result power, continuing to maintain at least four(4) decimal-place precision in the result that is used as the power. Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32 The Help Desk cannot provide support for inquiries about how to apply this method. Enter the Results in the Online Survey Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32 and report the result in the online survey at Q3 (AMI), Q3 (HF), Q3 (Pneum). About the Geometric Mean th Technically, the geometric mean is the N -root of the product of the length of stay for each discharge, i.e., (x1*x2*x3*x4*…xN) ^ (1/N). Whereas an arithmetic mean or simple average adds each observation then divides by the number of observations, the geometric mean multiplies each observation then takes the th N -root of that product. In part, because length of stay is truncated only on the left, at 1 day, a frequency distribution of lengths of stay is skewed to the right, i.e., a “long tail” to the right, and not normally distributed in statistical terms. Although simple average length of stay (ALOS) will tend to be normally distributed, any hospital’s ALOS can be highly influenced by a few exceptionally long-stay cases, or outliers, especially when total case volume (observations) are fewer. The logarithm of length of stay is more normally distributed and less susceptible to these influences. Rather than remove outliers or arbitrarily truncating them at some high-end limit, using a geometric mean length of stay reduces this effect. The severity-adjustment models developed by The Leapfrog Group use a geometric mean length of stay, which resulted in stronger statistical models for standardizing length-ofstay comparisons from hospital to hospital. Page 84 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey AMI Case Counts by Risk Factor Q4a-f = For those cases included in overall Case Count, Q2 as specified above, the number of cases which had the specified Risk Factor present for that case, respectively. Q# Risk Factor See Risk Factor Definition Tables 4a RF17 CABG RF17 4b RF33 Congestive heart failure RF33 4c RF085 Pneumonia RF085 4d RF070 Cardio-respiratory failure and shock RF070 4e RF050 Age >=65 None 4f RF32 Stroke or transient ischemic attack RF32 If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that 0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the number of cases with that respective risk factor. AMI Risk Factor Definitions RF17 -- CABG Any procedure . . . ICD-9-CM Procedure Codes 36.10 Bypass anasthamosis for heart revascularization to 36.19 36.2 Heart revascularization by arterial implant or . . . CPT-4 Procedure Codes 33510 Coronary artery bypass graft to 33523 33533 Coronary artery bypass graft to 33536 RF33 -- Congestive heart failure Any ICD-9-CM Diagnosis Codes 428.x Heart failure 402.01 Hypertensive heart disease, malignant, with heart failure failure 402.11 Hypertensive heart disease, benign, with heart failure failure 402.91 Hypertensive heart disease, unspecified, with heart failure 404.01 Hypertensive heart and renal disease, malignant, with congestive heart failure 404.03 Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure 404.11 Hypertensive heart and renal disease, benign, with congestive heart failure 404.13 Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure 404.91 Hypertensive heart and renal disease, unspecified, with congestive heart failure 404.93 Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal failure Page 85 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey RF085 –Pneumonia Corresponds to Hierarchical Condition Categories 111-113 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF070 –Cardio-respiratory failure and shock Corresponds to Hierarchical Condition Categoriy 79 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF050 –Age > 65 Age greater than or equal to 65 RF32 -- Stroke or transient ischemic attack Any ICD-9-CM Diagnosis Codes 430.x Subarachnoid hemorrhage 431.x Intracerebral hemorrhage 432.x Intracranial hem nec/nos 433.x1 Cerebral infarction 434.x1 Cerebral infarction 435.x Transient cerebral ischemia 436.x Acute, but ill-defined, cerebrovascular disease Page 86 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Length of Stay Measures Specifications – Heart Failure: Survey p. 70-71 Because of the clinical specificity needed, specifications DIFFER from those used to count eligible cases for CMS’ readmission measure for this same condition. Hospitals should utilize their all-payer administrative databases in responding to LOS questions. Heart Failure Case Count Q2 = Total number of patients (including those that expired) at this hospital location with a principal diagnosis of heart failure. Inclusion criteria: • Discharge date within Reporting Time Period • Inpatient discharges include deaths during the hospital stay • A principal diagnosis code in the following table: ICD-9-CM diagnosis codes 402.01 Malignant hypertensive heart disease with congestive heart failure (CHF) 402.11 Benign hypertensive heart disease with CHF 402.91 Hypertensive heart disease with CHF 404.01 Malignant hypertensive heart and renal disease with CHF 404.03 Malignant hypertensive heart and renal disease with CHF & renal failure (RF) 404.11 Benign hypertensive heart and renal disease with CHF 404.13 Benign hypertensive heart and renal disease with CHF & RF 404.91 Unspecified hypertensive heart and renal disease with CHF 404.93 Hypertension and non‐specified heart and renal disease with CHF & RF 428.0 Congestive heart failure, unspecified 428.1 Left heart failure 428.20 Systolic heart failure, unspecified 428.21 Systolic heart failure, acute 428.22 Systolic heart failure, chronic 428.23 Systolic heart failure, acute or chronic 428.30 Diastolic heart failure, unspecified 428.31 Diastolic heart failure, acute 428.32 Diastolic heart failure, chronic 428.33 Diastolic heart failure, acute or chronic 428.40 Combined systolic and diastolic heart failure, unspecified 428.41 Combined systolic and diastolic heart failure, acute 428.42 Combined systolic and diastolic heart failure, chronic 428.43 Combined systolic and diastolic heart failure, acute or chronic 428.9 Heart failure, unspecified Exclusions: • Patient age < 18 • Patients not admitted to this hospital for an inpatient stay, e.g., ambulatory procedures Page 87 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Heart Failure Geometric Mean Length of Stay See Length of Stay – AMI section, page 83 Heart Failure Case Counts by Risk Factor Q4a-g = For those cases included in overall Case Count, Q2 as specified above, the number of cases which had the specified Risk Factor present for that case, respectively. Q# Risk Factor See Risk Factor Definition Tables 4a RF083 Renal Failure RF083 4b RF070 Cardio-respiratory failure and shock RF070 4c RF119 Septicemia/shock RF119 4d RF122 Urinary Tract Infection RF122 4e RF085 Pneumonia RF085 4f RF108 Disorders of fluid/electrolyte/acid-base RF108 4g RF120 Pleural effusion/pneumothorax RF120 If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that 0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the number of cases with that respective risk factor. Heart Failure Risk Factor Definitions RF083 –Renal Failure Corresponds to Hierarchical Condition Category 131 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF070 –Cardio-respiratory failure and shock Corresponds to Hierarchical Condition Category 79 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF119 –Septicemia/shock Corresponds to Hierarchical Condition Category 2 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF122 –Urinary Tract Infection Corresponds to Hierarchical Condition Category 135 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF085 –Pneumonia Corresponds to Hierarchical Condition Categories 111-113 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx Page 88 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey RF108 –Disorders of fluid/electrolyte/acid-base Corresponds to Hierarchical Condition Categories 22 and 23 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF120 –Pleural effusion/pneumothorax Corresponds to Hierarchical Condition Category 114 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx Page 89 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Length of Stay Measures Specifications – Pneumonia: Survey p. 72-73 Because of the clinical specificity needed, specifications DIFFER from those used to count volume of procedures elsewhere in the survey and process measure denominator counts should not be used for that purpose. Hospitals should utilize their all-payer administrative databases in responding to LOS questions. Pneumonia Case Count Q2 = Number of inpatients (including deaths) discharged with an ICD-9-CM principal diagnosis of pneumonia. Inclusion criteria: • Discharge date within Reporting Time Period • Inpatient discharges include deaths during the hospital stay • A principal diagnosis code in the following table: ICD-9-CM Diagnosis Codes 480.0 Pneumonia due to adenovirus 480.1 Pneumonia due to respiratory syncytial virus 480.2 Pneumonia due to parainfluenza virus 480.3 Pneumonia due to SARS‐associated coronavirus 480.8 Viral pneumonia: pneumonia due to other virus not elsewhere classified 480.9 Viral pneumonia unspecified 481 Pneumococcal pneumonia [streptococcus pneumoniae pneumonia] 482.0 Pneumonia due to klebsiella pneumoniae 482.1 Pneumonia due to pseudomonas 482.2 Pneumonia due to hemophilus influenzae (h. influenzae) 482.30 Pneumonia due to streptococcus unspecified 482.31 Pneumonia due to streptococcus group a 482.32 Pneumonia due to streptococcus group b 482.39 Pneumonia due to other streptococcus 482.40 Pneumonia due to staphylococcus unspecified 482.41 Pneumonia due to staphylococcus aureus 482.42 Methicillin resistant pneumonia due to Staphylococcus aureus 482.49 Other staphylococcus pneumonia 482.81 Pneumonia due to anaerobes 482.82 Pneumonia due to escherichia coli [e.coli] 482.83 Pneumonia due to other gram‐negative bacteria 482.84 Pneumonia due to legionnaires' disease 482.89 Pneumonia due to other specified bacteria 482.9 Bacterial pneumonia unspecified 483.0 Pneumonia due to mycoplasma pneumoniae 483.1 Pneumonia due to chlamydia 483.8 Pneumonia due to other specified organism 485 Bronchopneumonia organism unspecified 486 Pneumonia organism unspecified 487.0 Influenza with pneumonia Page 90 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey 488.11 Influenza due to identified novel H1N1 influenza virus with pneumonia Exclusions: • Patient age < 18 • Patients not admitted to this hospital for an inpatient stay, e.g., ambulatory procedures Pneumonia Geometric Mean Length of Stay See Length of Stay – AMI section, page 83 Pneumonia Case Counts by Risk Factor Q4a-g = For those cases included in overall Case Count, Q2 as specified above, the number of cases which had the specified Risk Factor present for that case, respectively. Q# Risk Factor See Risk Factor Definition Tables 4a RF45 Respiratory failure RF45 4b RF33 Congestive heart failure RF33 4c RF087 Protein-calorie malnutrition RF087 4d RF112 History of infection RF112 4e RF43 Pleural effusion RF43 4f RF050 Age >=65 None 4g RF44 Septicemia RF44 If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that 0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the number of cases with that respective risk factor. Pneumonia Risk Factor Definitions RF45 – Respiratory failure Any diagnosis ICD-9-CM Diagnosis Codes 518.81 Acute respiratory failure 518.84 Acute and chronic respiratory failure RF33 – Congestive heart failure Any diagnosis ICD-9-CM Diagnosis Codes 428.x Heart failure 402.01 Hypertensive heart disease, malignant, with heart failure failure 402.11 Hypertensive heart disease, benign, with heart failure failure 402.91 Hypertensive heart disease, unspecified, with heart failure 404.01 Hypertensive heart and renal disease, malignant, with congestive heart failure 404.03 Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure 404.11 Hypertensive heart and renal disease, benign, with congestive heart failure 404.13 Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure 404.91 Hypertensive heart and renal disease, unspecified, with congestive heart failure 404.93 Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal failure Page 91 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey RF087 –Protein-calorie malnutrition Corresponds to Hierarchical Condition Category 21 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF112 –History of infection Corresponds to Hierarchical Condition Categories 1 and 3-6 utilized by Medicare to assess risk. A list of corresponding ICD-9-CM diagnosis codes can be found at https://leapfroghospitalsurvey.org/web/wp-content/uploads/hccriskfactors.xlsx RF43 – Pleural effusion Any diagnosis ICD-9-CM Diagnosis Codes 511.9 Unspecified pleural effusion RF050 –Age > 65 Age greater than or equal to 65 RF44 – Septicemia Any diagnosis ICD-9-CM Diagnosis Codes 038.0 Septicemia 038.10 Staphylococcal septicemia, unspecified 038.11 Staphylococcus aureus septicemia 038.19 Other staphylococcal septicemia 038.2 Pneumococcal septicemia 038.3 Septicemia due to anaerobes 038.40 Septicemia due to gram-negative organism, unspecified 038.41 Septicemia due to hemophilus influenzae (h. influenzae) 038.42 Septicemia due to escherichia coli (e. coli) 038.43 Septicemia due to pseudomonas 038.44 Septicemia due to serratia 038.49 Other septicemia due to gram-negative organisms 038.8 Other specified septicemias 038.9 Unspecified septicemia Page 92 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Length of Stay Scoring (Applies to AMI, Heart Failure, and Pneumonia) Length of stay is measured by the severity-adjusted average length of stay for AMI, Heart Failure, and Pneumonia cases. All inpatient discharges with the clinical condition meeting the inclusion/exclusion criteria are included. To calculate the severity-adjusted average length of stay for each clinical condition, the methods below are used. Expected log Length of Stay: The severity-adjustment models are linear regressions that estimate an expected loge length of stay (references throughout to “log” are the natural log, ln, or log base e) , based on NHDS national data for 2007-2010. The formula for the expected log length of stay for each model is of the form: E[loge(LOS)] = α + Σi βi rfi , where α is the model intercept, th βi is the parameter estimate (effect) for the i- risk factor, i.e., the coefficient estimating the incremental impact on loge(LOS) of the risk factor when present; and rfi is the proportion of total cases (Q2) with risk factor present (Q4). Tables included in the LOS Scoring document (https://leapfroghospitalsurvey.org/web/wpcontent/uploads/LOS_Scoring.pdf) indicate the parameters α and βi and reference how rfi is computed from survey responses. Note that the expected value being computed -- call it E -- is an expected loge(LOS), consistent with the statistical model, not the geometric mean LOS. Hospital Expected Length of Stay: Each hospital’s expected log length of stay from the previous step is converted to an expected (geometric mean) length of stay, ExpLOS = expe( E) , where E is the expected loge(LOS) from the prior step, and th expe is the loge-inverse, i.e., e to the Et[loge(LOS)] power Hospital Severity Index: For each procedure/condition, the hospital’s ExpLOS is an indication of the hospital’s severity or case complexity, compared to the all-hospital average ExpLOS. The hospital’s severity index (SI) for its cases is then computed as: SI = ExpLOS / ExpLOSt where ExpLOS is hospital’s expected (geometric mean) LOS from the prior step, and ExpLOSt is the average of all ExpLOS across all hospitals included in the development of the scoring algorithm. Procedure/ Condition AMI Heart Failure Pneumonia Page 93 Version 6.1 ExpLOSt 3.7886 3.9157 4.2974 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Hospital Standardized Length of Stay: Each hospital’s actual (geometric mean) length of stay is severity-adjusted to a standardized all-group severity to compute the hospital’s standardized length of stay: StdLOS = ActLOS / SI where ActLOS is the hospital’s actual (geometric mean) length of stay as reported, and SI is from the prior step. This standardizes all hospital's ALOS to a common and directly comparable severity index of 1.000. Details about these calculations can be found on each hospital’s “Details” page. A link to the “Details” page is available on the survey dashboard after July 25, 2014. (To log in to the survey and access the survey dashboard, visit: https://survey.leapfroghospitalsurvey.org/login//). More information about LOS scoring is available at https://leapfroghospitalsurvey.org/web/wpcontent/uploads/LOS_Scoring.pdf. Length of Stay Scoring Algorithm Leapfrog calculates a summary score based on the number of reported cases and average, risk-adjusted length of stay for each condition, where at least 25 cases were reported. Below is a description of the methodology. Dealing with Outliers For each measure, there are potential outliers with particularly short or long average LOS that, if utilized in determining performance cut points, would skew the distribution. Outliers, for purposes of scoring, are rd defined as LOS values that are more than 1.5 times the inter-quartile range greater than the 3 quartile th th th [LOS >= 75 percentile + 1.5*(75 percentile – 25 percentile)] and values that are more than 1.5 times st th th th the inter-quartile range greater than the 1 quartile [LOS<= 25 percentile + 1.5* (75 percentile – 25 percentile)]. These outliers are removed from the determination of the transformation to performance categories. Determining Performance Categories After removing outliers, the rates for each of the three conditions (AMI, heart failure, pneumonia) are rescaled separately to a fractional scale as follows: The highest non‐outlier LOS within a condition is mapped to the numerical value of 0.5. The lowest non-outlier LOS within a condition is mapped to the numerical value of 4.5. All other LOS values are linearly rescaled using the above two points as anchors (0.5 and 4.5). Hospitals with a LOS identified as one of the high outliers are assigned the value of 0.5. Each re-scaled LOS value (now a numerical value of 0.5 to 4.5) is weighted in proportion to the number of discharges for patients hospitalized for AMI, heart failure, or pneumonia at that hospital. (i.e. conditions with fewer discharges than others are weighted less) That weighted mean is rounded to whole numbers to produce scores of 1, 2, 3, and 4, where 1 is equal to Willing to Report, 2 is equal to Some Progress, 3 is equal to Substantial Progress, and 4 is equal to Fully Meets the Standard. A fractional value of 4.5 is assigned to the value of 4. Declined to respond means the hospital did not respond to this section of the survey, or has not submitted one. Does Not Apply means the hospital does not participate in the CMS Hospital Inpatient Reporting Program. Unable to Calculate Score means the hospital reported fewer than 25 cases for each applicable condition. Page 94 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Note: LOS anchor points for 2014 are based on the distribution of results from surveys submitted as of June 30, 2013. These LOS anchor points will remain in place for the entire survey reporting cycle, unless it is determined that there are compelling reasons to make revisions. However, at this time, there are no plans or commitments to change the anchor points. Details about LOS anchor points can be found on each hospital’s “Details” page. A link to the “Details” page is available on the survey dashboard after July 25, 2014. (To log in to the survey and access the survey dashboard, visit: https://survey.leapfroghospitalsurvey.org/login//). Page 95 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Readmissions Measures – AMI, HF, and PN 30-day risk standardized readmission rates are collected and calculated by CMS. To report on the number of cases and 30-day risk standardized readmission rate for each condition, access your hospital’s results at www.HospitalCompare.hhs.gov. Once on your hospital’s results page at www.HospitalCompare.hhs.gov, select the tab titled “Readmissions, Complications, and Deaths” from the navigation tabs at the top of the page. At the top of the “Readmissions, Complications, and Deaths” page, under the heading “30-day Outcome Readmissions and Deaths,” select the icon titled “View Graphs” pictured below: For each condition applicable to your hospital, locate the # of cases and the readmission rate. Report these values in Q5-6 (AMI), Q5-6 (heart failure), and Q5-6 (pneumonia). Refer to screenshot below: Page 96 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 Resource Use for Common Acute Conditions 2014 Leapfrog Hospital Survey Readmission Measures Scoring Algorithm Leapfrog calculates a summary score based on the number of reported cases and readmission rate for each condition, where at least 25 cases were reported. Below is a description of the methodology. Dealing with Outliers For each measure, there are potential outliers with particularly high or low readmission rates that, if utilized in determining performance cut points, would skew the distribution. Outliers, for purposes of scoring, are defined as readmission rates that are more than 1.5 times the inter-quartile range greater rd th th th than the 3 quartile [rate >= 75 percentile + 1.5*(75 percentile – 25 percentile)] and values that are st th more than 1.5 times the inter-quartile range greater than the 1 quartile [rate <= 25 percentile + 1.5* th th (75 percentile – 25 percentile)]. These outliers are removed from the determination of the transformation to performance categories. Determining Performance Categories After removing outliers, the rates for each of the three conditions (AMI, heart failure, pneumonia) are rescaled separately to a fractional scale as follows: The highest non‐outlier rate within a condition is mapped to the numerical value of 0.5. The lowest non-outlier readmission rate within a condition is mapped to the numerical value of 4.5. All other readmission rates are linearly rescaled using the above two points as anchors (0.5 and 4.5). Hospitals with readmission rates that are high outliers are assigned the value of 0.5. Each re-scaled readmission rate (now a numerical value of 0.5 to 4.5) is weighted in proportion to the number of discharges for patients hospitalized for AMI, heart failure, or pneumonia at that hospital. (i.e. conditions with fewer discharges than others are weighted less) That weighted mean is rounded to whole numbers to produce scores of 1, 2, 3, and 4, where 1 is equal to Willing to Report, 2 is equal to Some Progress, 3 is equal to Substantial Progress, and 4 is equal to Fully Meets the Standard. A fractional value of 4.5 is assigned to the value of 4. Declined to respond means the hospital did not respond to this section of the survey, or has not submitted one. Does Not Apply means the hospital does not participate in the CMS Hospital Inpatient Reporting Program. Unable to Calculate Score means the hospital reported fewer than 25 cases for each applicable condition. Note: Readmission anchor points for 2014 are based on the distribution of results from surveys submitted as of June 30, 2013. These readmission anchor points will remain in place for the entire survey reporting cycle, unless it is determined that there are compelling reasons to make revisions. However, at this time, there are no plans or commitments to change the anchor points. Details about LOS anchor points can be found on each hospital’s “Details” page. A link to the “Details” page is available on the survey dashboard after July 25, 2014. (To log in to the survey and access the survey dashboard, visit: https://survey.leapfroghospitalsurvey.org/login//). Page 97 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014 2014 Leapfrog Hospital Survey Reference Book Leapfrog Hospital Survey Reference Documentation Complete On behalf of The Leapfrog Group and its members, we appreciate your hospital’s continued commitment to transparency and participation in the Leapfrog Hospital Survey. View your Leapfrog’s Hospital Survey Results at www.leapfroggroup.org/cp. Page 98 Version 6.1 First Release: April 1, 2014 Updated Release: May 21, 2014
© Copyright 2024