The Leapfrog Hospital Survey Reference Book Supporting Documentation for the

Transcription

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
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.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.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
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
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
IPS FREQUENTLY ASKED QUESTIONS (FAQS) ........................................................................................ 46
IPS SCORING ALGORITHM ....................................................................................................................... 49
SECTION 6: 2014 LEAPFROG SAFE PRACTICES SCORE (SPS) ................................................... 51
SPS FREQUENTLY ASKED QUESTIONS (FAQS) ....................................................................................... 52
SPS SCORING ALGORITHM ...................................................................................................................... 57
SECTION 7: MANAGING SERIOUS ERRORS ................................................................................. 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
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
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
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
Basic Hospital Information
THIS PAGE WAS LEFT INTENTIONALLY LEFT BLANK
Page 5
Version 6.1
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
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
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
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
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
Computerized Physician Order Entry
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.
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/.
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
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
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
orders entered
through CPOE
System
CPOE not
implemented in at
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
CPOE Scoring Algorithm for Pediatric Hospitals
Implementation
Status
75% or greater of all
orders entered
through CPOE
System
medication orders
entered through
CPOE System
medication orders
entered through
CPOE System
CPOE implemented at
but <25% of all
orders entered
through CPOE
System
CPOE not
implemented in at
CPOE Score
Fully Meets
Standards
Substantial
Progress
Some Progress
Willing to
Report
Willing to
Report
The hospital did not respond to this section of the survey, or did not complete the survey.
Page 13
Version 6.1
Evidence-Based Hospital Referral
Section 3: 2014 Evidence-Based Hospital Referral (EBHR) Standards
Note: This section is not applicable to Pediatric hospitals.
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.
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
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
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
AAA
Volume & Mortality
December 31, 2013
June 30, 2014
December 31, 2013
June 30, 2014
December 31, 2013
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
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
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
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
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
Number of patients discharged with ICD-9-CM PROCEDURE CODES: 35.05 or 35.06 in any procedure
field.
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
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
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
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,
Q.1: All patients undergoing procedure
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.
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
Q.2: Patients with an unruptured AAA procedure
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.
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
Page 22
Version 6.1
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,
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
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
Q.2: Select patients in Qu estion #1 with a diagnosis of duodenal, biliary, or
pancreatic cancer
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
Pancreatectomy Section Complete
Page 24
Version 6.1
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.
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.
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
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
Esophagectomy Scoring Algorithm
Quality Score
Survival Predictor: Details on p.19
Esophagectomy Section Complete
Page 26
Version 6.1
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,
The count can include inborn as well as transfer cases.
(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
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
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

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
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*
VON outcome measure)
Fully meets standards
(4 filled bars)
Hospital’s outcomes are
Death or Morbidity (from
VON)*
Substantial progress
(3 filled bars)
Substantial progress
(3 filled bars)
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*
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
** 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.
If the lower and upper bounds include 1, then the center is performing as expected.
High-risk Deliveries Section Complete
Page 32
Version 6.1
Maternity Care
Section 4: 2014 Maternity Care
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.
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
Maternity Care
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
Maternity Care
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
Sampling Cases
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.
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
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
642.22 Other pre-existing hypertension complicating pregnancy, childbirth & puerperium, delivered
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
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
642.92 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered
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
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
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
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
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
655.41 Suspected damage to fetus from other disease in the mother, delivered w/ or w/o mention of
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
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
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
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
Maternity Care
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
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
Sampling
Hospitals opting to identify a sufficient sample of mothers for this measure, in lieu of full case
reporting, should follow these instructions:
2. Evaluate this case against the inclusion criteria; retain the case for the sample if the delivery was
>=37 weeks gestation.
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).
Page 39
Version 6.1
Maternity Care
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).
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)
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
Maternity Care
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:
2. Evaluate this case against the inclusion criteria; retain the case for the sample if it meets the
inclusion criteria
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.
 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
Maternity Care
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.
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
Maternity Care
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
Maternity Care
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
Maternity Care
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.

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.
Maternity Care Section Complete
Page 45
Version 6.1
ICU Physician Staffing
Section 5: 2014 ICU Physician Staffing (IPS) Leap
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.
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
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
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
“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
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.
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
Page 50
Version 6.1
Safe Practices Score
Section 6: 2014 Leapfrog Safe Practices Score (SPS)
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.
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
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
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
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





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
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
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
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
Managing Serious Errors
Section 7: Managing Serious Errors
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.
Since initial 2014 edition dated 4/1/2014
Page 59
Version 6.1
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
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
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
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
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
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
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
ICU Type
Mean NHSN CLABSI Rates
2
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
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
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 :
 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
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
patients following cardiac and thoracic surgery.
Page 69
Version 6.1
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.
patients with significant/major burns.
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
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
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
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
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
Reporting Time Period: 12 months ending:
 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
Reporting Time Period: 12 months ending:
 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
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
Safety-Focused Scheduling
Section 8: Safety-Focused Scheduling
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.
Page 75
Version 6.1
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
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.
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
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
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):
Some Progress (2 filled bars):
Willing to Report (1 filled bar):
The hospital can document less than 25% of surgical subspecialties met their access targets 80% of the
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
Resource Use for Common Acute
Conditions
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.
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.”
Page 81
Version 6.1
Conditions
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:
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
Conditions
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
Conditions


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
Conditions
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
Conditions
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
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
Conditions
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
Conditions
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
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
Heart Failure Risk Factor Definitions
RF083 –Renal Failure
Corresponds to Hierarchical Condition Category 131 utilized by Medicare to assess risk. A list of
RF070 –Cardio-respiratory failure and shock
RF119 –Septicemia/shock
RF122 –Urinary Tract Infection
RF085 –Pneumonia
Corresponds to Hierarchical Condition Categories 111-113 utilized by Medicare to assess risk. A
Page 88
Version 6.1
Conditions
RF108 –Disorders of fluid/electrolyte/acid-base
Corresponds to Hierarchical Condition Categories 22 and 23 utilized by Medicare to assess risk. A
RF120 –Pleural effusion/pneumothorax
Page 89
Version 6.1
Conditions
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:
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
Conditions
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
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
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
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
Conditions
RF087 –Protein-calorie malnutrition
RF112 –History of infection
Corresponds to Hierarchical Condition Categories 1 and 3-6 utilized by Medicare to assess risk. A
RF43 – Pleural effusion
511.9
Unspecified pleural effusion
RF050 –Age > 65
Age greater than or equal to 65
RF44 – Septicemia
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
Conditions
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
Conditions
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.
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
Conditions
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
Conditions
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
Conditions
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.
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
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

The Leapfrog Hospital Survey Reference Book Supporting Documentation for the

Transcription

Similar documents

A Halloween Poem

The perfectly playful 5” tablet.

Number of surgery/ procedure done : 1,86,090 Amount spent

EPK - Wolf Wein

germ-killing soap is “super bug” kryptonite Big moves to simplify

Reliable health information on ibxpress.com poster

LEAPFROG PRESENTS

Early Reading Skills

An Epic Achievement! CaroMont Health Earns a Grade `A` for Safety

Scoring Methodology - Hospital Safety Score