Leapfrog Hospital Survey by 9nbFubn

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									                          The Leapfrog Hospital Survey
                    What's New in the 2012 Survey (Version 5.4)

Welcome to the 2012 Leapfrog Hospital Survey.



PLEASE READ!!!
VERY IMPORTANT ‘HOUSEKEEPING’ NOTES ABOUT THE 2012 SURVEY:

1. The Leapfrog Group has made an update to the online survey collection tool for the 2012 survey.
Hospitals should continue to use the following URL for submitting their survey:
www.leapfroghospitalsurvey.org

A Quick Start Guide providing users with guidance on how to use the new online survey collection tool
can be found on the ‘survey dashboard’ once a user has logged into the collection tool with their 16-digit
security code.

2. All 16-digit security codes from the 2011 survey are still valid. Use just the 16-digit security code to
access your survey. If you no longer have a valid 16-digit security code, see the home page of the online
survey for more information about getting a security code.



The content changes to the prior year’s survey (2011 v5.3) are as follows:

1. In section 2, Computerized Physician Order Entry (CPOE), an updated version of the inpatient
   pediatric CPOE Evaluation Tool has been introduced. The CPOE Evaluation Tool developers have
   worked with a group of free-standing pediatric hospitals to update the drug-drug interaction orders in
   the pediatric test and to ensure that these orders represent common, serious prescribing errors.

2. In section 4, focusing on three common acute conditions (CACs), the following changes have been
   made:
    Removed from the AMI subsection (Section 4A), the following three process measures that have
       been put “in reserve” status by the National Quality Forum:
            o “Aspirin at Arrival” (AMI-1)
            o “Aspirin Prescribed at Discharge” (AMI-2)
            o “Beta-blocker Prescribed at Discharge” (AMI-5)
       A hospital’s quality of care for AMI patients will be assessed with the two remaining current
       process measures – “ACEI or ARB for LVSD” (AMI-3) and “Primary PCI Received Within 90
       Minutes of Hospital Arrival” (AMI-8a).
    To remain consistent with CMS’s retirement timeline of a large number of core measures,
       hospitals will report their core measure data for the 12 months ending December 31, 2011,
       regardless of when they submit a survey during the survey cycle.
    To the Normal Deliveries subsection (Section 4C), a measure of a hospital’s incidence of
       episiotomy in vaginal births (NQF-endorsed measure #0470) has been added. This measure will
       be the fourth measure in Leapfrog’s Normal Deliveries composite. The target for this new
       measure will be 12% and hospitals will need to be at or below this target to earn credit on this
       measure.
    If a hospital has a small number of cases during the reporting time period (less than 30 cases for
       AMI and Pneumonia; less than 10 live births for Normal Deliveries), instead of showing the

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        hospital as “Does Not Apply” for that particular condition on the public website, they will now be
        shown as ‘Unable to Calculate Score”.

3. In section 5, ICU Physician Staffing (IPS) Leap, the following changes have been made:
    All hospitals, regardless of their classification as urban or rural, will be scored as “Substantial
       Progress” (3 bars) if they meet all of the following:
             24 hour/7 day a week teleintensivist coverage;
             The teleintensivists must manage or co-manage all patients in all adult or pediatric
                general medical and/or surgical ICUs or neuro ICUs;
             Daily care planning for these ICU patients must be provided by an on-site intensivist,
                hospitalist, anesthesiologist, or physician trained in emergency medicine.
            Note: The standards for hospitals to fully meet the IPS Leap have not changed.
    To reflect the introduction of technologies that have replaced and/or supplement traditional
       pagers (e.g., cell phones), references in the survey to ‘pager’ have been replaced with the more
       generic ‘notification device’. For both purposes of intensivists returning ICU calls/pages and the
       on-site ICU ‘effector’ reaching the patient, hospitals are still expected to track notification device
                                                        .
       response time based on a quantified analysis.

4. In section 6, NQF Safe Practices, hospitals will be asked to report on a reduced number of practices
   in the 2012 Survey, based on national expert panel advice. The changes were based on whether 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. Hospitals will now report on eight practices. In addition, some of the individual
   items within the eight practices that remain in the survey have been updated to improve their clarity.
   The continued inclusion of the NQF Safe Practices in the Leapfrog Hospital Survey reflects The
   Leapfrog Group’s strong belief that the NQF Safe Practices play a very important role in ensuring the
   highest level of safety in hospitals.

5. In section 7, Managing Serious Errors, the following changes have been made:
    Given CMS’s recent efforts to publicly report meaningful data on hospital-acquired stage III and
       IV pressure ulcers and hospital-acquired injuries and trauma, the measures for these two
       hospital-acquired conditions have been removed from the 2012 survey.
    The list of ICUs for which hospitals are asked to report their rates of central line associated
       bloodstream infections (CLABSI) has been expanded to include: Pediatric Cardiothoracic, Burn,
       Trauma, and Level II/III and Level III NICUs.
    Hospitals that score in the bottom performance category (1 bar) based on their standardized
       infection ratio (SIR) for central line associated bloodstream (CLABSI) infections will no longer
       receive 1 bar ‘extra credit’ for their participation in their state’s ON THE CUSP; STOP BSI
       program. Hospitals that score in the bottom performance category (1 bar) based on their
       standardized infection ratio (SIR) can still earn 1 bar ‘extra’ credit’ by utilizing personnel trained in
       human factors engineering in conducting root-cause analyses of adverse events (i.e., CLABSIs).

6. In, Section 8, Smooth Patient Scheduling, Leapfrog has improved definitions and overall clarity
   throughout this section, as hospitals have struggled to understand the full scope of introducing
   scientific methods to smooth patient flow in their hospital. Leapfrog will be holding a series of training
   calls with hospitals early in the 2012 survey cycle to re-educate hospitals on this important topic.

7. Only the hospital’s organizational and contact information from the 2011 survey is retained in the
   online survey. Review answers in the first section of the survey and update as needed, paying
   particular attention to hospital name and contact person. Hospitals are required to review, update,
   affirm and submit their survey responses by June 30, 2012. After that date, Leapfrog will no longer
   report results based on 2011 surveys submitted prior to March 28, 2012.




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8. 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:
(http://leapfroghospitalsurvey.org/wp-content/uploads/2012/03/2012SurveyResponseReviewProcess.pdf.)

In addition to the desk reviews, in 2010, Leapfrog began requesting randomly selected hospitals 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.

9. Hospitals that submit a Leapfrog Hospital Survey by the June 30, 2012 first 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 2012
   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 some hospital markets, 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, 2012 and an updated survey between November 1, 2012 and December 31,
    2012. For questions or more information, please contact info@leapfroggroup.org.

10. 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 2012
    Leapfrog Hospital Survey, the e-mail will go to the survey contact provided in the last survey
    submitted in the 2011 survey cycle.

11. 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 employee of the hospital to whom the hospital CEO has delegated responsibility,

Your hospital should also order a copy of the full report of the National Quality Forum’s Safe Practices
for Better Healthcare 2010 Update, if you don't already have one. It is needed to complete section 6 of
the survey. See the ordering links on the ‘Download Survey Materials’ page of the online survey for an
electronic version of the report.




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                                The Leapfrog Hospital Survey
Background and Overview

A 1999 report by the Institute of Medicine (IOM) found that up to 98,000 Americans die every year from
preventable medical errors made in hospitals. The report recommended that large healthcare purchasers
provide more market reinforcement for quality and safety. The Leapfrog Group (Leapfrog), a growing
consortium of Fortune 500 companies and other large private and public healthcare purchasers founded
by The Business Roundtable, launched a national effort in November 2000 to reward hospitals for
advances in patient safety and quality and to educate employees, retirees, and families about the
importance of hospitals’ efforts in this area. Leapfrog purchasers provide health benefits to millions of
Americans and spend billions on healthcare annually.

Leapfrog initially identified three quality and safety practices (leaps) as the focus for hospital recognition
and reward. They are Computer Physician Order Entry (CPOE), ICU Physician Staffing (IPS), and
Evidence-Based Hospital Referral (EBHR). Our research indicates that implementing these leaps in non-
rural hospitals could save more than 57,000 lives and could prevent as many as 900,000 serious
medication errors each year.

In April 2010, the National Quality Forum (NQF) updated and released the Safe Practices for Better
Healthcare 2010 Update, identifying 34 practices that, if adopted, would have major positive impact on
the safety of patients in healthcare settings. These 34 practices reference the original CPOE and IPS
leaps. The Safe Practices leap now contains eight of the remaining National Quality Forum Safe
Practices. This leap is applicable to both urban and rural acute-care hospitals, as is the EBHR leap for
hospitals which offer any of those high-risk services on an elective basis. Leapfrog continues to focus on
non-rural hospitals for implementation of the CPOE and IPS leaps.

The four leaps are outlined in this hospital survey, which asks hospitals to self-report their status relative
to those leaps.

In 2007, Leapfrog began providing additional recognition to hospitals that have implemented a Never
Events policy consistent with Leapfrog’s Serious Reportable Events “Never Events” Policy Statement.

In 2008, Leapfrog began asking hospitals to report their performance on a series of quality-of-care
process measures, resource utilization measures, and other safety performance measures, including
survival predictors for esophagectomy and pancreatectomy. These measures either augment the EBHR
leap or demonstrate the manifestation of key safety practices. In 2009, survival predictors were added for
CABG, PCI, AAA, and AVR, when a hospital’s risk-adjusted mortality rate is not available.

How Leapfrog Uses the Survey Results

Leapfrog purchasers will use the survey responses to (1) educate and inform enrollees about patient
safety and the importance of comparing provider performance on Leapfrog’s quality and safety leaps and
(2) recognize and reward providers that have implemented the leaps. This means that purchasers will
share the survey responses with their employees and use the survey results in their contracting
discussions with health plans and providers. The Leapfrog Group will share the responses from all
hospitals with the public on its website. The Web display of hospitals’ results is made available to aid
consumers in their decisions about where to receive care. External organizations who wish to use the
data, for other purposes such as consumer education tools, market analysis, or contracting decisions,
must license the data from The Leapfrog Group for a fee. The revenue from data licenses is used to
support the ongoing administration of the Leapfrog survey and Leapfrog’s data dissemination efforts. For
those hospitals that choose not to respond to a request to complete the survey, the publicly reported
survey results will read: “Declined to respond.”

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Accessing the Online Survey

Leapfrog’s efforts have a special focus on acute-care facilities in designated regions around the country.
If your hospital is located in one of Leapfrog's current “Regional Roll-Out” areas, your hospital CEO/chief
administrative officer should have received an introductory letter inviting your hospital’s participation in the
survey and containing a security code for completing the survey online.

 Leapfrog Group’s current Roll-Out regions

        Alabama                             Kansas City, MO                      Raleigh/Durham/Chapel Hill, NC
        Atlanta, GA                         Maine                                Savannah, GA
        Arizona                             Massachusetts                        Seattle, WA
        California                          Memphis/West TN                      South Carolina
        Central Florida                     Metro NYC                            South Florida
        Cincinnati, OH                      Michigan                             Southeast OH
        Colorado                            Minnesota                            Southern IN
        Columbus, OH                        New Hampshire                        Southern NV
        Dallas-Fort Worth, TX               New Jersey                           St. Louis, MO
        DC/Maryland                         New York State                       Toledo, OH
        East/Mid Tennessee                   (excluding NYC)                      Virginia
        Greater WA (state)                  Northeast OH                         Western NC
        Illinois                            Northern NV                          Wichita, KS
        Iowa                                Northern/Central IN                  Wisconsin
        Lehigh Valley, PA                   Philadelphia, PA                     Wyoming

Go to the ‘Get a Security Code’ page of the online survey for more information about the geographic
areas covered by these regions, regional contacts, and getting a security code needed to complete the
online survey.

The Leapfrog Group also invites all hospitals nationwide to complete the survey and share their progress
and plans with their communities. If your organization is not located in one of the Regional Roll-Out areas,
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.

Background information about The Leapfrog Group and details about Leapfrog’s four quality leaps is also
available on the home page of the online survey site.

                        Online survey: https://www.leapfroghospitalsurvey.org


If you have any questions, please use the Help Desk link on the home page of the survey site indicated
above.




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                               The Leapfrog Hospital Survey
Survey Overview

The Leapfrog Hospital Survey is divided into nine sections. The first section asks you to provide general
information about your hospital. Sections two, three, five, and six are meant to determine whether or not
your hospital has fully implemented or plans to implement fully The Leapfrog Group’s recommended
quality and safety practices (leaps) including: Computer Physician Order Entry, Evidence-Based Hospital
Referral, ICU Physician Staffing, and eight of the remaining National Quality Forum Safe Practices.
Sections four and seven are meant to demonstrate a hospital’s adoption of key safety practices. Sections
eight and nine are meant to reflect the patient’s experience of care in your hospital.

Each of these sections has the same format:
1. General discussion about The Leapfrog Group safety leap(s) for that area. [in the hardcopy only]
   Where appropriate, there are references that provide more detailed information about each leap and
   other supporting information that you may need to complete the survey questions.
2. Survey questions that indicate your organization’s status vis-à-vis implementing each leap.
3. Affirmation of accuracy by your hospital’s CEO/ chief administrative officer or by an individual that has
   been designated as a delegate by the hospital CEO. These statements affirm the accuracy of the
   description of your hospital’s current practices or plans.

The Leapfrog Group is committed to presenting information that is as current as possible. Leapfrog and
its participating members will use your responses to describe to the public the progress that your hospital
is making toward implementing the Leapfrog quality and safety leaps. You can visit this survey site at any
time to review your responses or update them as needed. We update the public display of survey results
monthly, June through March, and results from your survey (re)submissions will appear on the site in the
first week of the following month. We invite you to update the information in this survey within 60 days of
any change in status. We reserve the right either to omit or have disclaimers accompany information that
is not current.

If you have additional questions about this survey or The Leapfrog Group, please visit
http://www.leapfroggroup.org.


Completing the Survey

The home page of the online survey is at https://www.leapfroghospitalsurvey.org.

Completing this survey will require a number of steps:

    1. Read through the entire survey to ensure that you understand the information required.

    2. Review background information about The Leapfrog Group’s quality and safety leaps. There is a
       fact sheet and a bibliography of the pertinent medical literature for each of the leaps on the home
       page of the online survey.

    3. Download the Leapfrog Hospital Survey Reference Book and other supporting documentation
       from the home page of the online survey. These documents contain key information that
       hospitals will need for responding to most of the survey questions. Note that the reference
       material, including all measure specifications, is contained in one document for ease of use.

    4. For the NQF Safe Practices (section 6), review the NQF’s Safe Practices for Better Healthcare
       2010 Update and have a copy of the full report accessible for cross-reference as you complete

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        that section. You can order a copy of the full report using the ‘Download Survey Materials
        page of the online survey.

    5. This survey requires information that you might not have readily available. We recommend that
       you print a hard copy of this survey, available from the home page of the online survey site,
       review it, and then assign the survey completion to others in your organization as appropriate. It
       is important that all parties with assigned responsibility for a section also review the online version
       to access or print other references found there. This might include someone from your quality
       management area who regularly compiles data about your hospital, as well as representatives
       from your information technology group or medical staff. Hospital survey testers suggested it
       might take anywhere from four to six days to gather these data depending on the number of
       people involved in collecting the information and the ease of access to statistical or audit data
       needed for some questions.

    6. When printed, endnotes referenced throughout the survey can be located at the end of the
       survey.

    7. As the survey information is collected, it should be marked on a hardcopy of the survey. This will
       speed the online completion and avoid the survey "timing out" after 12 hours of idle time ( a
       security precaution). Once all information has been collected, the CEO/chief administrative officer
       or his/her designated respondent(s) can typically complete the survey online in less than 90
       minutes from the hardcopy record.

    8. Submit your responses to the survey questions online. Hardcopy or faxed submissions are not
       accepted. Use your hospital’s security code to gain access to the survey.

    9. Since each section of questions may be separately delegated within your hospital, there are
       distinct “sign-offs” identified for each survey section. In each case, the information submitted
       should be affirmed by your organization’s CEO/chief administrative officer or his/her authorized
       delegate.

    10. Completing parts of the survey in different online sessions:
        The online survey tool (https://www.leapfroghospitalsurvey.org) allows users to enter individual
        answers, save those answers, and come back in at another time to finish a survey section. At the
        bottom of each section submission page are three navigation buttons. The three navigation
        buttons and a brief description of each one are as follows:

         Button                               Description
         Clear Subsection                     Clears all data from the current page
                                              (section/subsection).

         Save Responses and Logout            Saves entered data in all sections and logs the
                                              user out of the survey.

         Submit Sections, Save Others         Submits survey sections which have been affirmed;
                                              saves all other entered data.


        If survey responses are updated, remember to re-affirm the section in which updates were made
        and re-submit the survey.
        A Quick Start Guide that provides users with guidance on how to use the new online survey
        collection tool can be found on the ‘survey dashboard’ once a user has logged into the collection
        tool with their 16-digit security code.

    11. Separate sections can be completed online at different times, by different users, in different (non-
        concurrent) online sessions. Once all necessary sections are completed, the entire survey must

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        then be submitted to release the results to Leapfrog for its monthly update of public results. Make
        sure to submit your hospital’s survey results after completing or updating the survey.

        Accessing the CPOE Evaluation Tool is an exception to the above statements. Hospitals must
        first indicate they have a CPOE system implemented in at least one inpatient unit before they are
        able to access the CPOE Evaluation Tool (answer “Yes” to CPOE question #1). Any updates
        made to survey responses after initial submission will require the re-affirmation of survey sections
        in which responses were changed and a re-submission of the survey.

Note the word “hospital” used throughout this survey refers to an individual hospital. If your hospital is part
of a multi-hospital healthcare system, you will need to complete the survey for each individual hospital
within the system. (See FAQ #8 in Section 1 of the Leapfrog Hospital Survey Reference Book.)

Additional Questions

If you have any questions, please use the Help Desk link at the bottom of the home page of the survey
site at https://www.leapfroghospitalsurvey.org. Most questions submitted to the Help Desk will receive a
response within one business day.




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                                  Section 1: Basic Hospital Information

Organization Information

If your hospital is part of a larger healthcare system, you should respond to this survey for your individual
hospital only. Your hospital has been identified based on its separate designation as a Medicare-certified
hospital. (If your hospital was not included in the roster derived from the Medicare Provider of Service
directory, you have been assigned a special identification number through the form located on this site for
the purposes of completing this survey only.)

Your responses should reflect the status and information pertaining only to this hospital, as identified. If
you are responding on behalf of a multi-hospital system, separate survey responses are required for each
hospital based on their separate Medicare certification (or the special identifier assigned to your hospital
through the form located on this site).

1)    Hospital name
      (make any necessary corrections online)
2)    Street address
3)    City
            1
4)    State
5)    ZIP code
6)    Main phone number
                                                2
7)    Hospital’s Medicare Provider Number (MPN)
8)    Hospital Web site address
      (So consumers can learn more about your hospital’s
      efforts in the area of patient safety and quality
                                                        3
      improvement.) Tips for entering Web addresses
                         4
9)    Number of licensed medical, surgical, and obstetric
      beds.
                          5
10)   Number of staffed medical, surgical, and obstetric beds.
                                               6
11)   Number of total acute-care admissions to your hospital
      for most recent 12 months available.
                                  7
12)   Number of licensed ICU beds.
                               8
13)   Number of staffed ICU beds.
14)   Number of admissions to adult and pediatric general
                                 9
      medical/surgical ICU(s) for most recent 12 months
      available.
15)   Is this hospital part of a healthcare system or Integrated                     Yes
      Delivery Network (IDN)?                                                        No
16)   If so, please enter the name of the healthcare system or
      IDN.
                                                  10
17)   Hospital's federal tax identification number (TIN)




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Contact Information

1)   Name of Chief Executive Officer of your hospital
2)   Name of Chairman of Board of your hospital
3)   Name of contact person for this survey
4)   Contact’s title
5)   Contact's phone number
6)   Contact's e-mail address

If this hospital is part of a healthcare system or Integrated Delivery Network (IDN), you may optionally
indicate a contact person at the system level to be included in communications about your hospital’s
survey.
7) Name of system contact for this survey
8) System contact’s e-mail address

Leapfrog may need to contact your hospital’s community relations department (e.g., if your hospital is
chosen as a Leapfrog Top Hospital). You may optionally indicate a community relations contact for such
correspondence.
9) Name of community relations contact at your hospital
10) Community relations contact’s phone number
11) Community relations contact’s e-mail address




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                Section 2: 2012 Computerized Physician Order Entry (CPOE) Leap
         (Results are shown on Leapfrog’s consumer site as “Prevent Medication Errors”)


Each hospital fulfilling this Leap:
   1. Assures that prescribers* enter at least 75% of inpatient medication orders via a computer system
       that includes decision support software to reduce prescribing errors; and,
   2. Demonstrates, via a test**, that its inpatient CPOE system can alert physicians to at least 50% of
       common serious prescribing errors in a majority of medication checking categories, including the
       drug:drug and drug:allergy checking categories.

* “Prescribers” used throughout this section refers to all clinicians authorized by the hospital to order
pharmaceuticals for patients.

** For the 2012 survey, scored results on the CPOE Evaluation Tool will be used to assess if a hospital’s
CPOE system is alerting physicians to at least 50% of common serious prescribing errors in a majority of
medication checking categories, including the drug:drug and drug:allergy checking categories. A hospital
may access the CPOE Evaluation Tool only after indicating that your hospital has a functioning
CPOE system in at least one inpatient unit of the hospital (answered ‘yes’ to Q1 below). Then, use
the link on the survey home page to access the CPOE Evaluation Tool. Follow the detailed instructions
there about how to conduct a test. Once you have completed a test appropriate to your hospital, the score
of the completed test will be used automatically to determine whether your hospital meets criterion #2
above and what level of credit your hospital has earned in the overall scoring of this Leap.

Additional Information about the Leap is available on the home page of the online survey.

1) Does your hospital have a functioning CPOE system in at least one inpatient                    Yes
   unit of the hospital?                                                                          No


If yes, continue with questions 2 and 3; otherwise, skip to Affirmation of Accuracy
2) What percent of your hospital’s total inpatient medication orders (including
     orders made in units which do NOT have a functioning CPOE) do prescribers
     enter via a CPOE system that:                                                              _____%
      includes decision support software to reduce prescribing errors; and,
      is linked to pharmacy, laboratory, and admitting-discharge-transfer (ADT)
                  11

         information in your hospital


If you answered Yes to question 1, indicating that your hospital has a functioning CPOE system in at
least one inpatient unit, you will be able to evaluate your CPOE system using the Leapfrog CPOE
Evaluation Tool, accessible from the home page of the online survey site.
3) What was your hospital’s score when it tested its CPOE                   No answer required
     system using the Leapfrog CPOE Evaluation Tool?                Determined automatically based on
     Test must be completed on or after January 1, 2012.          separately completing a test using the
                                                                     Leapfrog CPOE Evaluation Tool




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Affirmation of Accuracy

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Computerized Physician Order Entry
(CPOE) Leap at our hospital, and I hereby certify that these statements are accurate and reflect the
current, normal operating circumstances at our hospital. I am authorized to make this certification on
behalf of our hospital. The hospital and I understand that The Leapfrog Group and its participants are
relying on the accuracy of this information and will make this information and/or analyses of it public, and
The Leapfrog Group and its participants reserve the right to omit or disclaim information that is not
current.

Affirmed by _____________________, the hospital’s ___________________________,
                 (name)                                           (title)
on _______________________.
            (date)




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                      Section 3: 2012 Evidence-Based Hospital Referral (EBHR) Leap

Each hospital fulfilling one or more of the high-risk surgical Leaps:

1. Participates in and scores better than the group average for participating hospitals in its ratio of
                                                                                    a
   observed-to-expected mortality in a national performance measurement system , in a regional
                                       b                                       c
   performance measurement system , or in a robust statewide public report , and either i) achieves one
   or more of the favorable volume characteristics listed below or ii) earns one quartile “extra credit” by
   achieving a high level of adherence to nationally endorsed process measures of quality. (See the
   Process Measure Specifications in Section 3 of the Leapfrog Hospital Survey Reference Book, link
   available on the ‘Download Survey Materials’ page of the online survey).


                  Treatments
                                                                                                                 d
          (See specifications below)                                Favorable Volume Characteristics
Coronary artery bypass graft (CABG)                           450 or more patients/year for the hospital
Percutaneous coronary intervention (PCI)                      400 or more total patients/year for the hospital
Aortic valve replacement (AVR)                                120 or more patients/year for the hospital


         or

2. Does not participate in a robust performance measurement system, and places in the best quartile for
   the predicted mortality composite measure for the procedure, as compared to a national sample of
   hospitals.

         or

3. For coronary bypass graft surgery (CABG), percutaneous coronary intervention (PCI), and abdominal
   aortic aneurysm repair (AAA), does not participate in a robust performance measurement system,
   and places in the next best quartile nationally for the predicted mortality composite measure but earns
   one quartile “extra credit” by achieving a high level of adherence to nationally endorsed process
   measures of quality. (See the Process Measure Specifications in Section 3 of the Leapfrog Hospital
   Survey Reference Book, available on the home page of the online survey).

    and, for coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention
    (PCI):

4. The hospital is in the lowest (best) two quartiles for resource utilization, as measured by adjusted
   ALOS.




a
  Society of Thoracic Surgeons (STS) and/or American College of Cardiology’s NCDR CathPCI Registry (ACC-NCDR).
b
  Northern New England Cardiovascular Disease Study Group (NNECDSG) and/or Blue Cross Blue Shield of Michigan
Cardiovascular Consortium (BMC2).
c
  Thus far, The Leapfrog Group has endorsed statewide performance assessment systems for CABG mortality in CA, MA, NJ, NY,
and PA, and for PCI in MA and NY.
d
  Annual total volume for hospital is calculated for most recent 12 months available or as annual average over most recent 24
months available, for a period ending within the last year.

April 2, 2012                                                                                                        Page 13
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    Each hospital fulfilling the High-Risk Deliveries Leap:

    1. Achieves favorable hospital volume characteristics for high-risk deliveries by admitting 50 or more
       very-low birth-weight newborns/year to its NICU.

         and

    2. Achieves 80% or higher adherence to nationally endorsed process measures of quality. (See the
       Process Measure Specifications in Section 3 of the Leapfrog Hospital Survey Reference Book,
       link available on the ’Download Survey Materials’ page of the online survey).

For hospitals that do not perform these procedures or treat these high-risk deliveries, or refer/transfer all
safely and legally transferable patients for such high-risk procedures or conditions, the leap does not
apply for that procedure or condition. If you answer ‘No’ to any of the procedures listed in questions 1-7
below, the notation ‘Does Not Apply’ will be displayed for that procedure on the public Web site.

See links and additional information about these Leaps on the home page of the online survey to:
    Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference Book for ICD-9
        coding specifications to identify and count the procedures or conditions identified above,
        and
    Process Measure Specifications in Section 3 of the Leapfrog Hospital Survey Reference
        Book for specification of the procedure-specific process measures of quality.




April 2, 2012                                                                                         Page 14
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EBHR: High-Risk Surgical Procedures Provided


Does your hospital perform these procedures on an elective basis?

If your hospital does not perform the procedure or ONLY does so when a patient is too unstable
for safe transfer, answer ‘No’.

1) Coronary artery bypass graft                                                            Yes
                                                                                           No
2) Percutaneous coronary intervention                                                      Yes
                                                                                           No
3) Aortic valve replacement                                                                Yes
                                                                                           No
4) Abdominal aortic aneurysm repair                                                        Yes
                                                                                           No
5) Pancreatic resection                                                                    Yes
                                                                                           No
6) Esophagectomy                                                                           Yes
                                                                                           No
7) Bariatric surgery                                                                       Yes
                                                                                           No


On the home page of the online survey, see link to the Volume Standards in Section 3 of the Leapfrog
Hospital Survey Reference Book for ICD-9 coding specifications and other criteria to identify and count
patients with these procedures.




April 2, 2012                                                                                    Page 15
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3A: Coronary Artery Bypass Graft (CABG)
(Results are shown on Leapfrog’s consumer site as “Heart Bypass Surgery”)
If you answered Yes to #1 on page 15, complete these questions pertaining to this high-risk surgery.


Coronary Artery Bypass Graft (CABG) – Volume
Specifications: See CABG Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #1-3 for the 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with a CABG
   procedure at this hospital location.                                                     _______
   Annual number of patients for the volume Reporting Time Period

2) Total number of patients (including those that expired) with an isolated CABG
   procedure (i.e. CABG without concomitant valve replacement/repair or major               _______
   organ transplant) at this hospital.
   Annual number of patients for the volume Reporting Time Period
3) How many patients included in question 2 died in the hospital following this
                                  12
   procedure? (More information )                                                           _______




Coronary Artery Bypass Graft (CABG) – National Performance Measurement

Indicate your hospital’s participation in and results from the following national performance measurement
system.

Reporting Time Period: Base your responses on the latest 12-month report received from the Society
of Thoracic Surgeons (STS).

4) Has your hospital participated in the STS performance reporting system                  Yes
   for coronary artery bypass graft surgery and submitted data for all such                No
   procedures in the most recent 12-month period for which performance
                                                    13
   reports have been released? More Information                                     Participating but no
   If Yes, continue with questions #5-7.                                           reports yet available
   If “Prefer not to share results”, complete question #5 and skip to
   question #8.                                                                    Reports available but
   Otherwise, skip to question #8.                                                  prefer not to share
                                                                                          results
5) What is the most recent 12-month reporting period for which STS
   performance results are available? 12 months ending:                                __________
                                                                                        MMYYYY
                                                                                        e.g. 122005
6) From the report for that time period, what was the observed mortality
       14
   rate as a percentage for coronary artery bypass graft surgery?                       _______%
   Enter as percent with two decimal-place precision.                                    (e.g. 3.14)




April 2, 2012                                                                                          Page 16
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2012 Leapfrog Hospital Survey

                                                                 15
7) From the same report, what was the expected mortality rate         as a
   percentage for coronary artery bypass graft surgery?                               _______%
   Enter as percent with two decimal-place precision.                                  (e.g. 3.14)




Coronary Artery Bypass Graft (CABG) – Publicly Reported Outcomes and
Regional Registries
Hospitals in California, Maine, Massachusetts, New Hampshire, New Jersey, New York,
Pennsylvania, and Vermont ONLY. If you did not answer question #4 as “Yes”, please complete
questions #8-12.

All other hospitals skip questions #8-12.

Reporting Time Period:
        Hospitals in CA, MA, NJ, NY, and PA: Base your responses on the most recently reported
           public data following instructions in the CABG Outcomes Specifications in Section 3 of the
           Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey Materials’
           page of the online survey).
        Hospitals in ME, NH, and VT: Base your responses on the latest 12-month report received
           from your regional registry [Northern New England Cardiovascular Disease Study Group
           (NNECDSG)],

8) Are CABG mortality outcomes for your hospital included in your state-                  Yes
   sponsored public outcomes report or in your regional registry                          No
                                                               16
   (NNECDSG) report for the most recently reported period ? If no, skip to
   Question 13.
.
9) What is the most recent 12-month reporting period for which your
   hospital’s results are included in publicly released state performance            __________
   reports or your regional registry report? 12 months ending:                        MMYYYY
                                                                                       e.g. 122005
10) If CABG mortality outcome results for your hospital are included with another hospital and/or
    reported under a different hospital name from that indicated in the Organization Information
    section of this survey, indicate the reported name of the hospital:

11) From the report for that time period, what was the observed mortality
        17
    rate as a percentage for coronary artery bypass graft surgery?                    _______%
    Enter as percent with two decimal-place precision.                                 (e.g. 3.14)


                                                                 18
12) From the same report, what was the expected mortality rate        as a
    percentage for coronary artery bypass graft surgery?                              _______%
    Enter as percent with two decimal-place precision.                                 (e.g. 3.14)




April 2, 2012                                                                                        Page 17
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Coronary Artery Bypass Graft (CABG) – Process Measures of Quality
Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of
quality specific to this procedure, if measured.

You need only measure and report four of the seven indicators. You may measure and report on more
than four, in which case survey results will be scored based on the four with the highest adherence rate.

Specifications: Responses can and should be based on the same data reported to Joint Commission
for National Hospital Quality Measures, to CMS for Hospital Quality Measures, or to STS as reported
and accepted by those organizations. If data are not submitted to these other organizations, hospitals
can measure and report results as described here and in the CABG Process Measure Specifications
in Section 3 of the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey
Materials’ page of the online survey).

Reporting Time Period: Answer questions #13-19 for the most recent 12-month period available,
ending within the last 12 months.

Instructions
For each of the seven guidelines, indicate in column:
    (a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample
                  19
        of them) for coronary artery bypass graft surgery for the Reporting Time Period and measured
        adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.
        If no, skip (b) and (c) for this procedure.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        procedure i.e., number of cases audited and meeting the criteria for inclusion in the
        denominator of the measure.
    (c) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process
        guideline for this procedure (numerator).

                                                          (a)                (b)               ( c)
                  Guideline                         Measured?             # Cases            # Cases
                                                        if No,           Measured            Adhere
                                                   skip (b) and (c)    (denominator)       (numerator)
13)     Anti-platelet medication prescribed at           Yes
        discharge (CABG-1)                                No               ______             ______
14)     IMA grafting for isolated primary                Yes
        CABG (CABG-2)                                     No               ______             ______
15)     Beta-blocker within 24 hours prior to            Yes
        surgery (CABG-3)                                  No               ______             ______
16)     Beta-blockers prescribed at discharge            Yes
        (CABG-4)                                          No               ______             ______
17)     Lipid-lowering therapy at discharge              Yes
        (CABG-5)                                          No               ______             ______
18)     Antibiotic prophylaxis within 1 hour             Yes
        pre-op (SCIP-1b)                                  No               ______             ______
19)     Discontinue antibiotic prophylaxis <48           Yes
        hours post-op (SCIP-3b)                           No               ______             ______




April 2, 2012                                                                                     Page 18
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Coronary Artery Bypass Graft (CABG) – Resource Utilization Measures

Specifications: See CABG Resource Utilization Measures Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the
online survey), including additional exclusion criteria particular to questions #20-23.

Reporting Time Period: Answer questions #20-23 for the 12 months ending :
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.

20) Total number of patients (including those that expired) with an isolated CABG
    procedure (i.e. CABG without concomitant valve replacement/repair or major             _______
    organ transplant) at this hospital for the Reporting Time Period.

21) Number of patients reported in question 20 which were followed by any
    readmission(s) to this same hospital location, regardless of condition/cause of        _______
    readmission, within 14 days following discharge.

22) Geometric mean length of stay for patients reported in question 20.
    See ‘Download Survey Materials’ link on home page for calculation                      _______
    worksheet. Report value to two decimal place precision                                (e.g., 7.65)

23) Number of patients reported in question 20 which had the selected risk factor present, respectively:
    (enter 0 if no patients had that risk factor present)
                                                                                  Number of Patients
     Risk Factor Description, brief – see detailed specifications                in Question #20 with
                                                                                  Risk Factor Present
a) RF01               Age >=55
                                                                                        _______

b)   RF02           Is Male
                                                                                        _______

c)   RF08           Chronic Renal Disease
     CAUTION        (definition differs from RF34)                                      _______

d)   RF09           Chronic liver disease
                                                                                        _______

e)   RF11           COPD
     CAUTION        (definition differs from RF36)                                      _______

f)   RF12           Cardiomyopathy
                                                                                        _______

g)   RF19           AMI
                                                                                        _______

h)   RF33           Congestive heart failure
                                                                                        _______



April 2, 2012                                                                                      Page 19
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3B: Percutaneous Coronary Interventions (PCI)
(Results are shown on Leapfrog’s consumer site as “Heart Angioplasty”)
If you answered Yes to #2 on page 15, complete these questions pertaining to this high-risk surgery.



Percutaneous Coronary Interventions (PCI) – Volume
Specifications: See PCI Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #1-3 for the 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (inpatient and outpatient; including those that
   expired) with a PCI procedure at this hospital location.                               _______
   Annual number of patients for the volume Reporting Time Period

2) Total number of inpatients (including those that expired) with a PCI
   procedure at this hospital location                                                    _______
   Annual number of patients for the volume Reporting Time Period

3) How many patients included in question 2 died in the hospital following this
                               12
   procedure? (More information )                                                         _______




Percutaneous Coronary Intervention (PCI) – National Performance Measurement

Indicate your hospital’s participation in and results from the following national performance measurement
system.

Reporting Time Period: Base your responses on the latest 12-month report received from the
American College of Cardiology (ACC) NCDR CathPCI Registry.

4) Has your hospital participated in the American College of Cardiology                   Yes
   (ACC) NCDR CathPCI Registry and submitted data for all such                            No
   procedures in the most recent 12-month period for which performance
                                                    13
   reports have been released? More Information                                    Participating but no
   If Yes, continue with questions #5-7.                                          reports yet available
   If “Prefer not to share results”, complete question #5; skip to question #8.
   Otherwise, skip to question #8.
                                                                                  Reports available but
                                                                                   prefer not to share
                                                                                         results

5) What is the most recent 12-month reporting period for which NCDR
   CathPCI Registry performance results are available? 12 months ending:              __________
                                                                                       MMYYYY
                                                                                       e.g. 122005




April 2, 2012                                                                                        Page 20
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2012 Leapfrog Hospital Survey


                                                                              14
6) From the report for that time period, what was the actual mortality rate
   as a percentage for percutaneous coronary interventions?                              _______%
   Enter as percent with two decimal-place precision.                                     (e.g. 3.14)

                                                                 15
7) From the same report, what was the expected mortality rate         as a
   percentage for percutaneous coronary interventions?                                   _______%
   Enter as percent with two decimal-place precision.                                     (e.g. 4.23)




Percutaneous Coronary Interventions (PCI) – Publicly Reported Outcomes and
Regional Registries

Hospitals in Maine, Massachusetts, Michigan, New Hampshire, New York, and Vermont ONLY. If
you did not answer question #4 as “Yes”, please complete questions #8-12.

All other hospitals should skip questions #8-12.

Reporting Time Period:
        Hospitals in MA and NY: Base your responses on the most recently reported public data
           following instructions in the CABG Outcomes Specifications in Section 3 of the Leapfrog
           Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the
           online survey).
        Hospitals in ME, MI, NH, and VT: Base your responses on the latest 12-month report
           received from your regional registry [either the Northern New England Cardiovascular
           Disease Study Group (NNECDSG) or the Blue Cross Blue Shield of Michigan
           Cardiovascular Consortium (BMC2)],


8) Are PCI mortality outcomes for your hospital included in your state-                     Yes
   sponsored public outcomes report or your regional registry (NNECDSG                      No
                                                           16
   or BMC2) report for the most recently reported period ? If no, skip to
   Question 13.
.
9) What is the most recent 12-month reporting period for which your
   hospital’s results are included in publicly released state performance              __________
   reports or your regional registry report? 12 months ending:                          MMYYYY
                                                                                         e.g. 122005
10) If PCI mortality outcome results for your hospital are included with another hospital under a different
    hospital name from that indicated in the Organization Information section of this survey, indicate
    the publicly-reported name of the hospital:

11) From the report for that time period, what was the observed mortality
        17
    rate as a percentage for percutaneous coronary interventions?                        _______%
    Enter as percent with two decimal-place precision.                                    (e.g. 3.14)
                                                               18
12) From the same report, what was the expected mortality rate as a
    percentage for percutaneous coronary interventions?                                  _______%
    Enter as percent with two decimal-place precision.                                    (e.g. 4.23




April 2, 2012                                                                                           Page 21
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Percutaneous Coronary Intervention (PCI) – Process Measure of Quality
Indicate your hospital’s adherence to the nationally endorsed procedure-specific process measure of
quality regarding timing of Primary PCI for AMI patients, if measured.

Specifications: Responses can and should be based on the same data reported to Joint Commission
for National Hospital Quality Measures or to CMS for Hospital Quality Measures as reported and
accepted by those organizations. If data are not submitted to these other organizations, hospitals can
measure and report results as described in the PCI Process Measure Specifications in Section 3 of
the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of
the online survey).

Reporting Time Period: Answer question #13 for the most recent 12-month period available, ending
within the last 12 months.

Instructions
For the guideline, indicate in column:
    (a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample
                  19
        of them) for AMI/percutaneous coronary interventions for the Reporting Time Period, and
        measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for this
        procedure.
        If no, skip (b) and (c) for this procedure.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        procedure i.e., number of cases audited and meeting the criteria for inclusion in this measure.
    (c) For the cases in (b), the median time from arrival to primary percutaneous coronary intervention
        (PCI).

                                                          (a)                (b)              ( c)
                  Guideline                         Measured?             # Cases         Median Time
                                                        if No,           Measured            (min)
                                                   skip (b)and (c)
                                                                                         Report value to one
                                                                                           decimal point
                                                                                            precision20
13)     Median time to Primary PCI (PCI-1)              Yes
                                                        No                ______             ______
                                                                                             (e.g. 72.3)




April 2, 2012                                                                                      Page 22
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Percutaneous Coronary Intervention (PCI) – Resource Utilization Measures

Specifications: See PCI Resource Utilization Measures Specifications in Section 3 of the Leapfrog
Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online
survey), including additional exclusion criteria particular to questions #14 – 17.

Reporting Time Period: Answer questions #14 – 17 for the 12 months ending :
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.

14) Total number of inpatients (including those that expired) with a PCI
    procedure at this hospital location during the Reporting Time Period.                  _______


15) Number of patients reported in question 14 which were followed by any
    readmission(s) to this same hospital location, regardless of condition/cause of        _______
    readmission, within 14 days following discharge.

16) Geometric mean length of stay for patients reported in question 14.
    See ‘Download Survey Materials’ link on home page for calculation                      _______
    worksheet.                                                                            (e.g., 7.65)
    Report value to two decimal place precision

17) Number of patients reported in question 14 which had the selected risk factor present, respectively:
    (enter 0 if no discharges had that risk factor present)
                                                                                  Number of Patients
     Risk Factor Description, brief – see detailed specifications                in Question #14 with
                                                                                  Risk Factor Present
a) RF06               Cancer
                                                                                        _______

b)   RF08           Chronic renal disease
     CAUTION        (definition differs from RF34)                                      _______

c)   RF09           Chronic liver disease
                                                                                        _______

d)   RF11           COPD
     CAUTION        (definition differs from RF36)                                      _______

e)   RF17           CABG
                                                                                        _______

f)   RF19           AMI
                                                                                        _______

g)   RF33           Congestive heart failure
                                                                                        _______




April 2, 2012                                                                                      Page 23
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3C: Aortic Valve Replacement
(Results are shown on Leapfrog’s consumer site as “Aortic Valve Replacement”)
If you answered Yes to #3 on page 15, complete these questions pertaining to this high-risk surgery.



Aortic Valve Replacement (AVR) – Volume
Specifications: See AVR Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24- month time
period ending:
     December 31, 2011, for surveys submitted prior to November 1, 2012;
     June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with an AVR procedure
   at this hospital location.                                                               _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
2) How many patients included in question 1 died in the hospital following this
                                  12
   procedure? (More information )                                                           _______
   (annual average if 24 months of data)



Aortic Valve Replacement – National Performance Measurement
Indicate your hospital’s participation in and results from the following national performance measurement
system.

Reporting Time Period: Base your responses on the latest 12-month report received from the Society
of Thoracic Surgeons (STS).

3) Has your hospital participated in the Society of Thoracic Surgeons (STS)                Yes
   performance reporting system for aortic valve replacement surgery and                   No
   submitted data for all such procedures in the most recent 12-month
   period for which performance reports have been released? More                    Participating but no
               13
   Information                                                                     reports yet available
   If Yes, continue with questions #4-6.
   If “Prefer not to share results”, complete question #4 and skip questions     Reports available but
   #5 and #6.                                                                     prefer not to share
   Otherwise, skip questions #4-6.                                                      results

4) What is the most recent 12-month reporting period for which STS
   performance results are available? 12 months ending:                               __________
                                                                                       MMYYYY
                                                                                        e.g. 122005
5) From the report for that time period, what was the observed mortality
       14
   rate as a percentage for aortic valve replacement surgery?                           _______%
   Enter as percent with two decimal-place precision.                                    (e.g. 3.14)

6) From the same report, what was the risk-adjusted expected mortality
       15
   rate as a percentage for aortic valve replacement surgery?                           _______%
   Enter as percent with two decimal-place precision.                                    (e.g. 4.23)




April 2, 2012                                                                                          Page 24
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2012 Leapfrog Hospital Survey



Aortic Valve Replacement (AVR) – Regional Registries
Hospitals in Maine, New Hampshire, and Vermont ONLY. If you did not answer question #3 as
“Yes”, please complete questions #7-11.

All other hospitals skip questions #7-11.

Reporting Time Period: Base your responses on the latest 12-month report received from your
regional registry [Northern New England Cardiovascular Disease Study Group (NNECDSG)],

7) Are AVR mortality outcomes for your hospital included in the regional                  Yes
                                                                         16
     registry (NNECDSG) report for the most recently reported period ?                    No
   If no, skip questions #8-11.
.
8) What is the most recent 12-month reporting period for which your
     hospital’s results are included in your regional registry report? 12 months      __________
     ending:                                                                           MMYYYY
                                                                                       e.g. 122005
9) If AVR mortality outcome results for your hospital are included with another hospital and/or reported
   under a different hospital name from that indicated in the Organization Information section of this
   survey, indicate the reported name of the hospital:

10) From the report for that time period, what was the observed mortality
        17
    rate as a percentage for aortic valve replacement surgery?                         _______%
    Enter as percent with two decimal-place precision.                                  (e.g. 3.14)


                                                                  178
11) From the same report, what was the expected mortality rate          as a
    percentage for aortic valve replacement surgery?                                   _______%
    Enter as percent with two decimal-place precision.                                  (e.g. 3.14)




April 2, 2012                                                                                         Page 25
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3D: Abdominal Aortic Aneurysm (AAA) Repair
(Results are shown on Leapfrog’s consumer site as “Abdominal Aortic Aneurysm Repair”)
If you answered Yes to #4 on page 15, complete these questions pertaining to this high-risk surgery.



Abdominal Aortic Aneurysm (AAA) Repair – Volume
Specifications: See AAA Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24- month time
period ending:
     December 31, 2011, for surveys submitted prior to November 1, 2012;
     June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with an AAA Repair
   procedure at this hospital location.                                                   _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
2) Total number of patients (including those that expired) with an unruptured
   AAA Repair procedure at this hospital location                                         _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
3) How many patients included in question 2 died in the hospital following this
                                  12
   procedure? (More information )                                                         _______
   (annual average if 24 months of data)




April 2, 2012                                                                                    Page 26
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Abdominal Aortic Aneurysm (AAA) Repair – Process Measures of Quality
Indicate your hospital’s adherence to the procedure-specific process measure of quality for this
procedure, if measured.

Specifications: See AAA Process Measure Specifications in Section 3 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer question #4 for the most recent 12- or 24-month period available,
ending within the last 12 months.

Instructions
For the guideline, indicate in column:
    (a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample
                  19
        of them) for abdominal aortic aneurysm repairs for the Reporting Time Period, and measured
        adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.
        If no, skip (b) and (c) for this procedure.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        procedure, i.e., number of cases audited and meeting the criteria for inclusion in the
        denominator of the measure.
    (c) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process
        guideline for this procedure (numerator).

                                                          (a)                (b)                ( c)
                  Guideline                         Measured?             # Cases             # Cases
                                                        if No,           Measured             Adhere
                                                   skip (b) and (c)    (denominator)        (numerator)
4)      Perioperative beta blocker for AAA               Yes
        patients on beta blockers prior to                No               ______             ______
        arrival
        (AAA-1)




April 2, 2012                                                                                      Page 27
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3E: Pancreatic Resections
(Results are shown on Leapfrog’s consumer site as “Pancreatic Resection”)
If you answered Yes to #5 on page 15, complete these questions pertaining to this high-risk surgery.



Pancreatic Resections – Volume
Specifications: See Pancreatectomy Volume Standards in Section 3 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).


Reporting Time Period: Answer questions #1-2 for the 12-month or, optionally, the 24- month time
period ending:
     December 31, 2011, for surveys submitted prior to November 1, 2012;
     June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with a Pancreatic
   Resection procedure at this hospital location.                                         _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
2) Total number of patients (including those that expired) in question 1 with a
   diagnosis of duodenal, biliary, or pancreatic cancer
   (annual average if 24 months of data)                                                  _______

3) How many patients included in question 2 died in the hospital following this
                                12
   procedure? (More information )                                                         _______
   (annual average if 24 months of data)




April 2, 2012                                                                                    Page 28
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3F: Esophagectomy
(Results are shown on Leapfrog’s consumer site as “Esophageal Resection”)
If you answered Yes to #6 on page 15, complete these questions pertaining to this high-risk surgery.



Esophagectomy – Volume
Specifications: See Esophagectomy Volume Standards in Section 3 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #1-2 for the 12-month or, optionally, the 24- month time
period ending:
     December 31, 2011, for surveys submitted prior to November 1, 2012;
     June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with an
   Esophagectomy procedure at this hospital location.                                     _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
2) Total number of patients (including those that expired) in question 1 with a
   diagnosis of esophageal cancer                                                         _______
   (annual average if 24 months of data)

3) How many patients included in question 2 died in the hospital following this
                                12
   procedure? (More information )                                                         _______
   (annual average if 24 months of data)




April 2, 2012                                                                                    Page 29
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3G: Bariatric Surgery
(Results are shown on Leapfrog’s consumer site as “Weight-loss Surgery”)
If you answered Yes to #7 on page 15, complete these questions pertaining to this high-risk surgery.



Bariatric Surgery – Volume
Specifications: See Bariatric Surgery Volume Standards in Section 3 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).


Reporting Time Period: Answer questions #1-2 for the 12-month or, optionally, the 24- month time
period ending:
     December 31, 2011, for surveys submitted prior to November 1, 2012;
     June 30, 2012, for surveys (re)submitted on or after November 1, 2012.

1) Total number of patients (including those that expired) with a Bariatric Surgery
   procedure at this hospital location.                                                   _______
   Annual number of patients for the volume Reporting Time Period
   (or annual average if 24 months of data)
2) How many patients (including those that expired) included in question 1 died
                                                              12
   in the hospital following this procedure? (More information )                          _______
   (annual average if 24 months of data)




Bariatric Surgery – National Performance Measurement Participation

Indicate your hospital’s participation in the following national performance measurement system.

3) Does your hospital currently participate in the American College of                    Yes
   Surgeons (ACS) NSQIP performance reporting system for bariatric                        No
   surgery, the ACS Bariatric Surgery database, or the Surgical Review
   Corporation’s Bariatric Outcome Longitudinal Database ( B.O.L.D.) and
   is your hospital submitting data for all such procedures?
   If No, skip question 4
4) If yes, what is the earliest month for which those data have been
   reported and have since been continuously reported?                                __________
                                                                                       MMYYYY
                                                                                       e.g. 042007




April 2, 2012                                                                                        Page 30
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3H: EBHR: High-Risk Deliveries
(Results are shown on Leapfrog’s consumer site as “High-Risk Delivery”)




High-Risk Deliveries
                                                               21
1) Does your hospital electively admit high-risk deliveries ?                           Yes
                                                                                        No

If “No”, skip remainder of this section; otherwise continue.




Neonatal Intensive Care Unit(s)
Reporting Time Period: Answer question #3, if applicable, for the 12 months ending :
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.
                                                                    22
2) Does your hospital operate a neonatal ICU, or is it co-located with a                Yes
   hospital that operates a NICU, that admits or accepts transfers of very-             No
                           23
   low birth weight babies ?
   If Yes, continue; otherwise skip to question #4.
   If the NICU is co-located in another hospital and your hospital
   immediately transfers all complicated newborns there, answer Questions
   2 and 3 based on information pertaining to the co-located hospital’s
   NICU.
3) For the Reporting Time Period, how many very-low birth-weight babies
   were admitted to your hospital’s neonatal intensive care unit(s)? (see link         _______
   on ‘Download Survey Materials’ page of online survey to High Risk
   Deliveries Volume Standards in Section 3 of the Leapfrog Hospital
   Survey Reference Book




April 2, 2012                                                                                    Page 31
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If question #1 is “No”, skip remainder of this section.


High-Risk Deliveries – Process Measures of Quality

Process Measures of Quality
Indicate your hospital’s adherence to the nationally endorsed condition-specific process measure of
quality regarding ante-natal steroids for certain high-risk deliveries, if measured.*
(see High Risk Deliveries Process Measure Specifications in Section 3 of the Leapfrog Hospital
Survey Reference Book; link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer questions #4 - 6 for the most recent 12-month period available, ending
within the last 12 months.

* Responses may be based on the same data reported to Vermont Oxford Network for this process measure where
those data are available. Data submitted from Vermont Oxford Network should be based on the most recent report.
If data are not submitted to VON,, hospitals can measure and report results as described in the Leapfrog
Hospital Survey Reference Book.

4) Has your hospital performed a medical record audit on all cases (or a                        Yes
                              19
   sufficient sample of them) for certain high-risk deliveries for the                          No
   Reporting Time Period, and measured adherence to the ante-natal
   steroids clinical process guideline for these high-risk deliveries.*
   If no, skip questions 5 and 6.
5) What is the number of cases measured against the guideline, either all
   cases or the sample size, for these deliveries i.e., number of cases                       _______
   audited and meeting the criteria for inclusion in the denominator of the
   measure.
6) What number of cases in question 5 adhere to the Leapfrog expert
   panel-endorsed clinical process guideline for this condition (numerator).                  _______




Affirmation of Accuracy

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Evidence-Based Hospital Referral
(EBHR) Leap at our hospital, and I hereby certify that these statements are accurate and reflect the
current, normal operating circumstances at our hospital. I am authorized to make this certification on
behalf of our hospital. The hospital and I understand that The Leapfrog Group and its participants are
relying on the accuracy of this information and will make this information and/or analyses of it public, and
The Leapfrog Group and its participants reserve the right to omit or disclaim information that is not
current.


Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)




April 2, 2012                                                                                           Page 32
v5.4
                          Section 4: 2012 Common Acute Conditions (CAC)

This section of the survey addresses three common acute conditions – Acute Myocardial Infarctions
(AMI), Pneumonia, and Normal Deliveries.

AMI and Pneumonia are measured by process of care and resource utilization measures that have been
endorsed by the National Quality Forum (NQF).

Normal deliveries are measured by outcome and process measures that have been endorsed by the
National Quality Forum (NQF).


Each hospital fully meeting the standards for AMI and/or Pneumonia:

1. Receives at least 80% of the possible quartile scoring points for the NQF-endorsed process-of-care
   quality measures for the condition as determined by national data.

2. Places in the two lowest (best) quartiles for resource utilization for the condition treated, as measured
   by Adjusted ALOS.

If your hospital treated fewer than 30 cases for AMI and/or Pneumonia during the specified 24-month
period, no further data need be reported for that respective condition and Leapfrog public results will
indicate “Unable to Calculate Score” for the condition.


Each hospital fully meeting the standards for Normal Deliveries:

1. Exceeds the specified goal for performance on the nationally-endorsed “Elective Deliveries Before 39
   Weeks Gestation” outcome measure and either the “Incidence of Episiotomy” outcome measure or
   both of the process measures.

If your hospital delivered fewer than 10 live births during the specified 12-month period, no further data
need be reported for this condition and Leapfrog public results will indicate “Unable to Calculate Score”
for the condition.


Note 1: Data must be reported for all three common acute conditions (AMI, Pneumonia, and
Normal Deliveries) for this section of the survey to be submitted.

Note 2: This section of the survey does not apply to free-standing pediatric hospitals.




April 2, 2012                                                                                       Page 33
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4A: Acute Myocardial Infarctions (AMI)
(Results are shown on Leapfrog’s consumer site as “Heart Attack”)




Acute Myocardial Infarction (AMI) – Volume
Specifications: See AMI Volume Standards in Section 4 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).


Reporting Time Period: Answer question #1 for the 12 months* ending :
    December 31, 2011 for all surveys

* If fewer than 30 cases during that period qualify for question 1, use 24 months ending at these dates.

1) Total number of inpatient discharges (including deaths) at this hospital
   location with a principal diagnosis of AMI                                              _______
   Number of patients for the Reporting Time Period


If question 1 is fewer than 30 cases, skip remaining questions for this condition.
Otherwise, complete questions # 2-7.


Acute Myocardial Infarctions (AMI) – Process Measures of Quality
Indicate your hospital’s adherence to nationally endorsed condition-specific process measures of quality
specific to this condition, if measured.

Specifications: Responses can and should be based on the same data reported to Joint Commission
for National Hospital Quality Measures or to CMS for Hospital Quality Measures, as reported and
accepted by those organizations. If data are not submitted to these other organizations, hospitals can
measure and report results as described here and in the AMI Process Measure Specifications in
Section 4 of the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey
Materials’ page of the online survey).

Reporting Time Period: Answer questions #2 and #3 for the most recent 12-month period available,
ending within the last 12 months. (If response to question #1 is for 24 months, report the most recent 24-
month period available, ending within the last 12 months, for these process measures.)

Instructions
For each of the two guidelines, indicate in column:
    (a) if your hospital has performed a medical record audit on all cases (or a sufficient sample of
               19
        them) for AMI patients for the Reporting Time Period and measured adherence to the clinical
        process guideline for this condition.
        If no, skip (b) and (c) for this condition.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        condition i.e., number of cases audited and meeting the criteria for inclusion in the denominator
        of the measure.
    (c) The number of cases in (b) that adhere to the clinical process guideline for this condition
        (numerator).




April 2, 2012                                                                                      Page 34
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2012 Leapfrog Hospital Survey


                                                         (a)                (b)              ( c)
                 Guidelines                        Measured?             # Cases           # Cases
                                                       if No,           Measured           Adhere
                                                  skip (b) and (c)    (denominator)      (numerator)
2)      ACEI or ARB for LVSD (AMI-3)                    Yes
                                                         No               ______           ______
3)      Primary PCI received within 90                  Yes
        minutes of hospital arrival(AMI- 8a)             No               ______           ______




Acute Myocardial Infarctions (AMI) – Resource Utilization Measures

Specifications: See AMI Resource Utilization Measures Specifications in Section 4 of the Leapfrog
Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online
survey), including additional exclusion criteria particular to questions #4 – 7.

Reporting Time Period: Answer questions #4-7 for the 12 or 24 months* ending :
    December 31, 2011 for all surveys

* Report for the same 12- or 24-month period, consistent with response to question #1

4) Total number of inpatient discharges (including deaths) at this hospital
   location with a principal diagnosis of AMI for the Reporting Time Period
   All remaining questions 5-7 pertain to these cases only                              _______

5) Number of discharges reported in question 4 which were followed by a
   readmission to this same hospital location, regardless of condition/cause of
   readmission, within 14 days following discharge.                                     _______

6) Geometric mean length of stay for discharges reported in question 4.
   See ‘Download Survey Materials’ link on home page for calculation                    _______
   worksheet. Report value to two decimal place precision                               (e.g., 7.65)




April 2, 2012                                                                                    Page 35
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7) Number of discharges reported in question 4 which had the selected risk factor present,
   respectively: (enter 0 if no discharges had that risk factor present)
                                                                              Number of Discharges
    Risk Factor Description, brief – see detailed specifications               in Question #4 with
                                                                               Risk Factor Present
a) RF01             Age >= 55
                                                                                      _______

b)   RF06          Cancer
                                                                                  _______

c)   RF08          Chronic renal disease
     CAUTION       (definition differs from RF34)                                 _______

d)   RF09          Chronic liver disease
                                                                                  _______

e)   RF16          PCI
                                                                                  _______

f)   RF17          CABG
                                                                                  _______

g)   RF32          Stroke or transient ischemic attack
                                                                                  _______

h)   RF33          Congestive heart failure
                                                                                  _______




April 2, 2012                                                                               Page 36
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4B: Pneumonia
(Results are shown on Leapfrog’s consumer site as “Pneumonia”)




Pneumonia – Volume
Specifications: See Pneumonia Volume Standards in Section 4 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer question #1 for the 12 months* ending:
    December 31, 2011 for all surveys

* If fewer than 30 cases during that period qualify for question 1, use 24 months ending at these dates.

1) Total number of inpatient discharges (including deaths) at this hospital
   location with Pneumonia                                                                  _______
   Number of patients for the Reporting Time Period


If question 1 is fewer than 30 cases, skip remaining questions for this condition
Otherwise, complete questions # 2-9.


Pneumonia – Process Measures of Quality
Indicate your hospital’s adherence to nationally endorsed condition-specific process measures of quality
specific to this condition, if measured.

Specifications: Responses can and should be based on the same data reported to Joint Commission
for National Hospital Quality Measures or to CMS for Hospital Quality Measures, as reported and
accepted by those organizations. If data are not submitted to these other organizations, hospitals can
measure and report results as described here and in the Pneumonia Process Measure Specifications
in Section 4 of the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey
Materials’ page of the online survey).


Reporting Time Period: Answer questions #2 - #5 for the most recent 12-month or 24- month period
available, ending within the last 12 months. (If response to question #1 is for 24 months, report the most
recent 24-month period available, ending within the last 12 months, for these process measures.)

Instructions
For each of the four guidelines, indicate in column:
    (a) if your hospital has performed a medical record audit on all cases (or a sufficient sample of
               19
        them) for pneumonia patients for the Reporting Time Period and measured adherence to the
        clinical process guideline for this condition.
        If no, skip columns (b) and (c) in the table below for this condition.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        condition i.e., number of cases audited and meeting the criteria for inclusion in the denominator
        of the measure.
    (c) The number of cases in (b) that adhere to the clinical process guideline for this condition
        (numerator).




April 2, 2012                                                                                      Page 37
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                                                             (a)               (b)            ( c)
                   Guideline                           Measured?            # Cases         # Cases
                                                           if No,          Measured         Adhere
                                                      skip (b) and (c)   (denominator)    (numerator)
2)      Pneumococcal vaccination (PN-2)                     Yes
                                                             No             ______          ______
3)      Blood culture performed within 24 hours             Yes
        prior to or 24 hours after hospital arrival          No             ______          ______
        for patients who were transferred or
        admitted to the ICU within 24 hours of
        hospital arrival
        (PN-3a)
4)      Initial antibiotic received within 6 hours         Yes
        of hospital arrival (PN-5c)                        No               ______          ______
5)      Influenza vaccination (PN-7)                       Yes
                                                           No               ______          ______




Pneumonia – Resource Utilization Measures
Specifications: See Pneumonia Resource Utilization Measures Specifications in Section 4 of the
Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the
online survey), including additional exclusion criteria particular to questions #6 – 9.

Reporting Time Period: Answer question #6 – 9 for the 12 or 24 months* ending :
    December 31, 2011 for all surveys

* Report for the same 12- or 24-month period, consistent with response to question #1

6) Total number of inpatient discharges (including deaths) at this hospital
   location with Pneumonia for the Reporting Time Period.
   All remaining questions 7 – 9 pertain to these cases only                             _______

7) Number of discharges reported in question 6 which were followed by a
   readmission to this same hospital location, regardless of condition/cause of          _______
   readmission, within 14 days following discharge.

8) Geometric mean length of stay for discharges reported in question 6.
   See ‘Download Survey Materials’ link on home page for calculation                     _______
   worksheet. Report value to two decimal place precision                                (e.g., 7.65)




April 2, 2012                                                                                     Page 38
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9) Number of discharges reported in question 6 which had the selected risk factor present,
   respectively: (enter 0 if no discharges had that risk factor present)
                                                                              Number of Discharges
    Risk Factor Description, brief – see detailed specifications               in Question #6 with
                                                                               Risk Factor Present
a) RF01             Age >= 55
                                                                                      _______

b)   RF31          Cirrhosis or chronic hepatitis
                                                                                  _______

c)   RF32          Stroke or transient ischemic attack
                                                                                  _______

d)   RF33          Congestive heart failure
                                                                                  _______

e)   RF34          Kidney disease
     CAUTION       (definition differs from RF08)                                 _______

f)   RF36          COPD
     CAUTION       (definition differs from RF11)                                 _______

g)   RF43          Pleural effusion
                                                                                  _______

h)   RF44          Septicemia
                                                                                  _______

i)   RF45          Respiratory failure
                                                                                  _______




April 2, 2012                                                                               Page 39
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4C: Normal Deliveries
(Results are shown on Leapfrog’s consumer site as “Normal Deliveries”)




Normal Deliveries – Volume
Specifications: See Normal Deliveries Volume Standards in Section 4 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).

Reporting Time Period: Answer all questions #1 – 7 for the 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.

1) Total number of live births at this hospital location for the Reporting Time Period
                                                                                           ______

If fewer than 10 cases, skip remaining questions for this condition.
Otherwise, continue to question #2.




Normal Deliveries – Outcome Measures
Indicate your hospital’s performance on two nationally-endorsed outcome measures of quality specific to
this condition, if measured.

Specifications:
    For questions 2 and 3, responses can and should be based on the same data reported to The
        Joint Commission, as reported and accepted by that organization (recognizing that the reporting
        time period may be different that what is stated below). If data are not submitted to The Joint
        Commission, hospitals should measure and report results as described in the Normal
        Deliveries Outcome Measure Specifications in Section 4 of the Leapfrog Hospital Survey
        Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
        Answer questions 2 and 3 based on all cases (or a sufficient sample* of them) for the Reporting
        Time Period per the specifications.

Reporting Time Period: Answer questions #2 – 3 for the 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.

Instructions
Answer questions #2 and #3 based on all cases (or a sufficient sample of them*) for the Reporting Time
Period.

*Sufficient Sample: Instructions for identifying a sufficient sample to answer questions #2 and #3 are
found in the Normal Deliveries Outcome Measure Specifications in Section 4 of the Leapfrog
Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online
survey).




April 2, 2012                                                                                    Page 40
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Elective Delivery Prior To 39 Completed Weeks of Gestation
2) Total number of mothers (or sufficient sample of them) that delivered newborns
    with >=37 weeks of gestation completed and <39 weeks of gestation completed                ______
    during the reporting period, with Excluded Populations removed (see the
    Normal Deliveries Outcome Measure Specifications in Section 4 of the
    Leapfrog Hospital Survey Reference Book for the exact measure
    specifications).

    Response should reflect at least a 100-case sample size, unless the total number of
    mothers that delivered newborns after applying both the inclusion and exclusion criteria
    is less than 100. In this situation, report the number of remaining mothers. See the
    Normal Deliveries Outcome Measure Specifications in Section 4 of the Leapfrog
    Hospital Survey Reference Book for instructions on identifying the sample.

3) Total number of mothers indicated in question 2 which had their newborn
   delivered electively (not spontaneously).                                                   ______



Specifications:
    For questions 4 and 5, hospitals should measure and report results as described in the Normal
        Deliveries Outcome Measure Specifications in Section 4 of the Leapfrog Hospital Survey
        Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
        Answer questions 4 and 5 based on all cases for the Reporting Time Period per the
        specifications.

Reporting Time Period: Answer questions #4 – 5 for the 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.

Instructions
Answer questions 4 and 5 based on all cases during the Reporting Time Period.

Incidence of Episiotomy in Vaginal Deliveries
4) Total number of vaginal deliveries during the reporting period with
    Excluded Populations removed.                                                              ______


5) Total number of mothers indicated in question 4 that had an episiotomy
   procedure performed..                                                                       ______




April 2, 2012                                                                                      Page 41
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Normal Deliveries – Process Measures of Quality
Indicate your hospital’s adherence to the following two process measures of quality specific to this
condition, if measured.

Specifications: Hospitals should measure and report results as described in the Normal Deliveries
Process Measure Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book (link
found on the ‘Download Survey Materials’ page of the online survey)

Reporting Time Period: Answer questions #6 – 7 for 12 months ending:
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.


Instructions
For each of the process measures below, indicate in column:
    (a) if your hospital has performed a medical record audit on all cases (or a sufficient sample of
                19
        them) for the Reporting Time Period and measured adherence to the clinical process
        guidelines below.
        If no, skip columns (b) and (c) in the table below for that guideline.
    (b) the number of cases measured against the guideline, either all cases or the sample size, for this
        condition i.e., number of cases audited and meeting the criteria for inclusion in the denominator
        of the measure.
    (c) The number of cases in (b) that adhere to the clinical process guideline for this condition
        (numerator).

                                                                (a)               (b)             ( c)
Guideline                                                 Measured?            # Cases          # Cases
                                                              if No,          Measured          Adhere
                                                         skip (b) and (c)   (denominator)     (numerator)
6)      Newborn Bilirubin Screening Prior to                   Yes
        Discharge                                               No             ______           ______
7)      Appropriate DVT Prophylaxis in Women                   Yes
        Undergoing Cesarean Delivery                            No             ______           ______
        If fewer than 10 cases for denominator (b),
        numerator (c) need not be reported.



Affirmation of Accuracy

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Common Acute Conditions (CAC) leap
at our hospital, and I hereby certify that these statements are accurate and reflect the current, normal
operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital. The hospital and I understand that The Leapfrog Group and its participants are relying on the
accuracy of this information and will make this information and/or analyses of it public, and The Leapfrog
Group and its participants reserve the right to omit or disclaim information that is not current.

Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)


April 2, 2012                                                                                      Page 42
v5.4
                           Section 5: 2012 ICU Physician Staffing (IPS) Leap
               (Results shown on Leapfrog’s consumer site as “Appropriate ICU Staffing”)

A hospital fulfilling this leap assures that all patients in its adult or pediatric general medical and/or
                                                                   24
surgical ICUs and neuro ICUs are managed or co-managed by physicians certified in critical care
          25
medicine who:
 Are ordinarily present in the ICU (on-site, or via telemedicine that meets Leapfrog specifications)
                                        26

    during daytime hours a minimum of 8 hours per day, 7 days per week, and during this time provide
                               26
    clinical care exclusively in the ICU; and
 At other times . . . ;
                                                                                                           27
    – Return more than 95% of ICU calls/pages within 5 minutes, based on a quantified analysis of
         notification device response time;* and
    – Can rely on a physician, physician assistant, nurse practitioner, or a FCCS-certified nurse
                    28
         “effector” who is in the hospital and able to reach ICU patients within 5 minutes in more than
         95% of cases, based on a quantified hospital analysis of notification device response time.*

* This may exclude low-urgency calls/pages, if the notification device system can designate low-urgency calls/pages or if the
hospital has an alternative scientific method for documenting high-urgency calls/pages that are not returned within 5 minutes.

If you have no licensed or staffed adult or pediatric general medical and/or surgical ICU beds or neuro
ICUs, this section does not apply to your hospital. Simply answer “No” to the first question to finish the
section. Your hospital’s results will be displayed as ‘Does Not Apply’ on the public website.

Notes:
1. When nationally reported robust meaures of ICU performance become available, favorable
   performance will replace or supplement the physician staffing Leap.

2. Some intensivist “presence” may be accomplished via teleintensivists per Leapfrog’s specifications
                        29
   (More Information ). However, at this time hospitals cannot fully meet the Leap through the sole use
   of teleintensivists.

3. On an interim basis, other categories of physicians may be considered by Leapfrog to be “certified in
                                             25
   Critical Care Medicine” (More Information ).


1) Does your hospital operate any adult or pediatric general medical and/or                                        Yes
                              30
   surgical ICUs or neuro ICUs ?                                                                                   No

If ‘Yes’, continue; otherwise, skip remaining questions:
2) Are all patients in these ICUs managed or co-                        Yes, all are certified in critical care
     managed by one or more physicians who are                          Yes, based on expanded definition of certified
     certified in critical care medicine?                               No
                           31
     (More Information )




April 2, 2012                                                                                                             Page 43
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3) Is one or more of these physicians ordinarily present in each of these                   Yes
   ICUs during daytime hours for at least 8 hours per day, 7 days per                       No
   week, and do they provide clinical care exclusively in one ICU during
                                    26
   these hours? (More Information )
4) When these physicians are not present in these ICUs on-site or via                       Yes
   telemedicine, do they return more than 95% of calls/pages from these units               No
                                                      27
   within five minutes, based on a quantified analysis of notification device
   response time?
   (This percentage may exclude low-urgency calls/pages, if the notification
   device system can designate low-urgency calls/pages or if the hospital has
   an alternative scientific method for documenting high-urgency calls/pages
   that are not returned within 5 minutes.)

5) When these physicians are not present on-site in the ICU or not able to                  Yes
   reach an ICU patient within 5 minutes, can they rely on a physician,                     No
                                                                              28
   physician assistant, nurse practitioner, or FCCS-certified nurse “effector
   who is in the hospital and able to reach these ICU patients within five
                                                                            27
   minutes in more than 95% of the cases, based on a quantified analysis of
   notification device response time?
   (This percentage may exclude low-urgency calls/pages, if the notification
   device system can designate low-urgency calls/pages or if the hospital has
   an alternative scientific method for documenting high-urgency calls/pages
   that are not returned within 5 minutes.)



If you answered "No" to any of questions #2-5 in this section, please answer the following questions for
adult and pediatric, general medical and/or surgical ICUs and neuro ICUs.

6) Are all patients in these ICUs managed or co-managed by one or more                      Yes
   physicians certified in critical care medicine who are:                                  No
    ordinarily present on-site in these units;
    for at least 8 hours per day, 4 days per week, and
    providing clinical care exclusively in one ICU during these hours?
                       26
   (More Information )

7) Are all patients in these ICUs managed or co-managed by one or more                      Yes
   physicians certified in critical care medicine who are:                                  No
    present via telemedicine for 24 hours per day, 7 days per week
    meet modified Leapfrog ICU requirements for intensivist presence in
                                                    32
       the ICU via telemedicine (More Information )
    supported in the establishment and revision of daily care planning for
       each ICU patient by an on-site intensivist, hospitalist, anesthesiologist,
       or physician trained in emergency medicine

8) Are all patients in these ICUs managed or co-managed by one or more                      Yes
   physicians certified in critical care medicine who are:                                  No
    on-site at least 4 days per week to establish or revise daily care plans
       for each ICU patient?

9) If not all patients are managed or co-managed by physicians certified in                 Yes
   critical care medicine, are some patients managed by these physicians?                   No



April 2, 2012                                                                                     Page 44
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10) Does your hospital have a board-approved budget that is adequate to                      Yes
    meet this commitment?                                                                    No

11) Does a clinical pharmacist make daily rounds on patients in these ICUs?                  Yes
                                                                                             No
12) Does a physician certified in critical care medicine lead daily multi-                   Yes
    disciplinary rounds on-site on all patients in these ICUs?                               No

13) When certified physicians are on-site in these ICUs, do they have                        Yes
    responsibility for all ICU admission and discharge decisions?                            No



Affirmation of Accuracy:

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the ICU Physician Staffing (IPS) leap at our
hospital, and I hereby certify that these statements are accurate and reflect the current, normal operating
circumstances at our hospital. I am authorized to make this certification on behalf of our hospital. The
hospital and I understand that The Leapfrog Group and its participants are relying on the accuracy of this
information and will make this informaion and/or analyses of it public, and The Leapfrog Group and its
participants reserve the right to omit or disclaim information that is not current.


Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)




April 2, 2012                                                                                      Page 45
v5.4
                         Section 6: 2012 Leapfrog Safe Practices Score (SPS)
                (Results shown on Leapfrog’s consumer site as “Steps to Avoid Harm”)

In May 2003, the National Quality Forum (NQF) published Safe Practices for Better Healthcare: A
Consensus Report, which lists 30 practices that, if adopted, would have major positive impact on the
safety of patients in healthcare settings. In 2009, NQF modified these Safe Practices and added six new
practices.

This section focuses on eight of the 34 practices in the Safe Practices for Better Healthcare: A
Consensus Report 2010 update.

Before completing this section of the survey, please review some important background information on
the design of this section and how users can most easily complete it. To complete this section, you
should have a full copy of the NQF Safe Practices for Better Healthcare 2010 Update. See link on
‘Download Survey Materials’ page of online survey to purchase a copy from NQF if you do not
already have one.

Other references available on the ‘Download Survey Materials’ page of the online survey include:
    National Quality Forum Safe Practices for Better Healthcare 2010 Update: Full Report (ordering
        information)
    Safe Practices Frequently Asked Questions found in Section 6 of the Survey Reference Book
        link found on the ‘Download Survey Materials’ page of the online survey

For each of the eight NQF-endorsed Safe Practices listed on the next page, please review and check
items, as appropriate. Safe Practice #23 may not apply to your hospital and you can indicate so at the
beginning of that practice. As you complete each practice in the online survey, you can use the navigation
buttons at the bottom of each practice to save and clear responses. Once you have completed
reviewing each Practice, click the “Review of this Practice Complete” checkbox at the top of the
Practice. This will mark the Practice with a green dot in the left-hand navigation. After you have
finished responding to all eight Safe Practices, you will be able to affirm this section.




April 2, 2012                                                                                      Page 46
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                                                                        Results Shown On Leapfrog’s                              Weighting
NQF Safe Practice                                                       Consumer Site As:                                          (pts)

    1    Leadership Structures and Systems                              Establish leadership structure and                               120
                                                                        systems

    2    Culture Measurement for Performance                            Invest in performance improvement                                20


    3    Teamwork Training and Skill Building                           Teamwork training and skill building to                          40
                                                                        promote patient safety

    4    Identification and Mitigation of Risks and                     Identify and mitigate risks and hazards                          120
         Hazards

    9    Nursing Workforce                                              Nursing staff meets patient's needs                              100


    17   Medication Reconciliation                                      Patient medication list is updated and                           35
                                                                        reviewed with new orders

    19   Hand Hygiene                                                   Comply with CDC hand-washing                                     30
                                                                        guidelines

    23   Prevention of Ventilator Associated                            Provide proper interventions for all                             20
                       a
         Complications                                                  patients on ventilators

                                                GRAND TOTAL                                                                              485
a
  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.


Affirmation of Accuracy

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Leapfrog Safe Practices Score (SPS) at
our hospital, and I hereby certify that these statements are accurate and reflect the current, normal
operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital. The hospital and I understand that The Leapfrog Group and its participants are relying on the
accuracy of this information and will make this informaion and/or analyses of it public, and The Leapfrog
Group and its participants reserve the right to omit or disclaim information that is not current.

Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)



At end of each Safe Practice . . .
Make sure to click “Review of this Practice Complete” checkbox at the top of each Practice even if
no items are checked, to mark the Safe Practice as “Data Entry Complete” (green circle). This checkbox
for all Safe Practices must be checked to submit this section of the survey.




April 2, 2012                                                                                                                 Page 47
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                           Practice #1 – Leadership Structures and Systems
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

Check all boxes that apply.
1.1  In regard to raising the awareness of key stakeholders to our organization’s efforts to
     improve patient safety, the following actions related to identification and mitigation of risk
     and hazards have been taken:

                    a   Board (governance) minutes for the past 12 months reflect regular communication
                         regarding risks, hazards, culture measurement, and progress towards resolution of safety
                         and quality problems. (p.75)
                    b   patients and family of patients are formal participants in safety and quality committees that
 AWARENESS




                         meet on a regularly scheduled basis. (p.75)
                    c   steps have been taken to report to the community in the last 12 months of ongoing efforts
                         to improve safety and quality in the organization and the results of these efforts. (p.75)
                    d   all staff and independent practitioners were made aware in the past 12 months of ongoing
                         efforts to reduce risks and hazards and to improve patient safety and quality in the
                         organization. (p.75)

1.2               In regard to holding the Board, senior management, mid-level management, physician
                  leadership, and frontline caregivers directly accountable for results related to mitigating
                  unsafe practices, the organization has done the following:

                    a   an integrated, patient safety program has been in place for at least the past 12 months
                         providing oversight and alignment of safe practice activities. (p.76)
                    b   A patient safety officer (PSO) has been appointed and communicates regularly with the
                         Board (governance) and senior administrative leadership; the PSO is the primary point of
 ACCOUNTABILITY




                         contact of the integrated, patient safety program. (p.76)
                    c   performance has been documented in performance reviews and/or compensation
                         incentives for all levels of hospital management and hospital-employed caregivers noted
                         above. (p.76)
                    d   the interdisciplinary patient safety team communicated regularly with management
                         regarding root cause analyses, progress in meeting safety goals, and providing team
                         training to caregivers. Actions taken to mitigate system and process failures have been
                         documented in meeting minutes. (pp.76-77)
                    e   the facility reported adverse events to external mandatory or voluntary programs. (p.77)

1.3               In regard to implementation of the patient safety program, the Board (governance) and
                  senior administrative leaders have provided resources to cover the implementation during
                  the last 12 months, and:

                    a   patient safety program budgets were sufficiently resourced to support the program,
 ABILITY




                         staffing, and technology investment. (p.77)
                    b   documentation of these budgets is available for review by external organizations. (p.77)




April 2, 2012                                                                                                 Page 48
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1.4       Structures and systems for assuring that leadership is taking direct and specific actions
          have been in place for the past 12 months, as evidenced by:

            a   CEO and senior administrative leaders are personally engaged in reinforcing patient safety
                 improvements, e.g., “walk-arounds”, holding patient safety meetings, reporting to the Board
                 (governance). Calendars reflect allocated time. (p.78)
            b
 ACTION




                 CEO has actively engaged unit, service-line, departmental and mid-level management
                 leaders in patient safety improvement actions. (p.79)
            c   CEO has established a structure for input into the patient safety program by independent
                 medical practitioners and medical leadership. Input documented in meeting minutes or
                 materials. (p.79)




April 2, 2012                                                                                       Page 49
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                  Practice #2 –Culture Measurement, Feedback, and Intervention
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

Check all boxes that apply.
2.1  In regard to Culture Measurement, our organization has done the following within the last 24
     months:

                    a    conducted a safety and quality survey using a nationally recognized tool with consideration
                          of validity, consistency and reliability, with a sample that accounts for 50% of the
 AWARENESS




                          aggregated care delivered to patients within the facility, and covers the high patient safety
                          risk units or departments.(p.88)
                          If this item ‘a’ is not checked, no other items in this Practice #2 may be checked.

                    b    portrayed the results of the culture survey in a report, which reflects both hospital-wide and
                          individual unit level results. (p.88)
2.2               In regard to accountability for improvements in the measurement of the culture of safety,
                  our organization has done the following within the last 24 months:

                    a    involved senior administrative leadership in the identification and selection of sampled
 ACCOUNTABILITY




                          units; and, in the selection of an appropriate tool for measuring the culture of safety. (p.88)
                    b    Shared the results of the culture measurement survey with the Board (governance) and
                          senior administrative leadership in a formal report and discussion. (p.88)




2.3               In regard to the culture of safety measurement, the organization has done the following (or
                  has had the following in place) within the last 12 months:

                    a    conducted staff education program(s) on methods to improve the culture of safety, or
                          conducted team training development programs, based on survey results. Training was
 ABILITY




                          documented in personnel or other administrative records. (p.89)
                    b    included the costs of annual culture measurement/follow-up activities in the patient safety
                          program budget. (p.88)

2.4               In regard to culture measurement, feedback, and interventions, our organization has done
                  the following or has had the following in place within the last 12 months:

                    a    developed or implemented explicit, hospital-wide organizational policies and procedures for
                          regular culture measurement (p.88)
                          OR
                          implemented strategies for improving culture based on survey results. (p.88)
 ACTION




                    b    disseminated the results of the survey widely across the institution, with follow-up meetings
                          held by senior administrative leadership with the sampled units. (p.88)
                    c    identified performance improvement interventions based on the survey results, which were
                          shared with senior administrative leadership and subsequently measured and monitored.
                          (p.88)




April 2, 2012                                                                                                    Page 50
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                          Practice #3 –Teamwork Training and Skill Building
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

Check all boxes that apply.
3.1  In regard to teamwork training and skill building, our organization has done the following
     within the last 12 months:

                    a   conducted a literature review of the teamwork training impact in healthcare or in other
                         settings. (p.101)
                         OR
                         conducted a review of available teamwork training programs in progressive organizations.
                         (p.99)
 AWARENESS




                    b   conducted an assessment of high patient safety risk areas by an Interdisciplinary Patient
                         Safety Team to determine specific processes in need of teamwork improvement. Those
                         processes were identified to senior administrative leadership. (p.97)
                    c   informed senior management, mid-level management and physician leadership about the
                         need for teamwork training, skill building, and identified internal resources and possible
                         resources from progressive organizations. (pp.97-98)
                    d   assessed the organizational need for rapid response systems and any associated training.
                         (p.97)

3.2               In regard to leadership being held accountable for the demonstration of teamwork skills in
                  the organization, our organization has done the following within the last 12 months:

                    a   determined, through a literature review or an assessment, a set of targeted units or service
                         lines for detailed teamwork training and effective teamwork skill building. These units/lines
 ACCOUNTABILITY




                         were identified by the CEO to the Board (governance), senior managers, and medical staff.
                         (p.97)
                                                            33
                    b   provided basic teamwork training to the Board (governance), senior managers, medical
                         staff, mid-level management, and frontline nurses on communication hand-offs and team
                         failures leading to patient harm. Training was documented in personnel records. (p.96)



3.3               In regard to effective teamwork training and skill building, our organization has done the
                  following within the last 12 months:

                    a   resourced patient safety program budgets in a sufficient manner to support the assessment
                         of need and team training activities.
 ABILITY




                    b   provided clinical staff and licensed independent practitioners in the hospital-targeted units
                         detailed teamwork training and skill building. Participation was documented. (p.96)

3.4               Effective team-centered interventions were either in place or were initiated in the past 12
                  months, as evidenced by:

                    a   notation in board minutes documenting that the performance improvement targets in
                         identified units were being addressed. (p.97)
 ACTION




                    b   evaluation or documentation of unit or service line results for teams that had received the
                         detailed team training intervention during the past 12 months. (pp.97-98)




April 2, 2012                                                                                                 Page 51
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                  Practice #4 –Identification and Mitigation of Risks and Hazards
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)


Check all boxes that apply.
4.1  Within the last 12 months our organization has done the following:

                    a   assessed risks and hazards to patients by reviewing retrospective sources, such as:
                              serious and sentinel event reporting;
                              root cause analyses for adverse events;
                              independent comparative mortality and morbidity information with the hospital’s
                                performance;
                              patient safety indicators;
                              trigger tools;
                              hospital accreditation surveys;
                              risk management and filed litigation;
                              anonymous internal complaints, including complaints of abusive and disruptive
 AWARENESS




                                caregiver behavior; and
                              complaints filed with state/federal authorities;
                         and based on those findings, documented recommendations for improvement. (p.105)

                    b   assessed risks and hazards to patients using prospective identification tools: Failure
                         Modes and Effects Analysis (FMEA) and/or Probabilistic Risk Assessment, and has
                         documented recommendations for improvement. (p.106)
                    c   defined their risk mitigation efforts based on their own risk profile, and has documented
                         recommendations for improvement. (p.107)
                    d   integrated results from the three assessments, noted in (a), (b) and (c) above. Results
                         have been shared widely across the organization, from the Board (governance) to front-line
                         caregivers. (p.107) This item may not be checked unless all items 4.1a, b, c are checked.

4.2               Leadership is accountable for identification of risks, hazards and mitigation efforts in the
                  past year, as evidenced by:

                    a   approval of an action plan by the CEO and the Board (governance) for undertaking the
 ACCOUNTABILITY




                         assessments of risk, hazards and for the mitigation of risk for patients. (p.106)
                    b   incorporation of the identification and mitigation of risks into performance reviews.
                         OR
                         outlined financial incentives for leadership and the Patient Safety Officer for identifying and
                         mitigating risks to patients as identified in the approved action plan.


4.3               In regard to developing the ability to appropriately assess risk and hazards, the organization
                  has done the following or had in place during the last 12 months:

                    a   resourced patient safety program budgets sufficiently to support ongoing risk and hazard
                         assessments and programs for reduction of risk.
 ABILITY




                    b   provided managers at all levels with training on the tools for monitoring risk in their areas;
                         senior managers have received training in the integration of risk and hazard information
                         across the organization. Training was documented. (pp.107-108)




April 2, 2012                                                                                                   Page 52
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4.4       Structures and systems for assuring that direct and specific actions have taken place to
          mitigate risks for the past 12 months, include:

           a    provided risk identification training to the high risk patient safety units such as: emergency
                 department, labor and delivery, ICUs, and operating rooms. (p.106)
            b   established or already had in place a structure, developed by the CEO and senior
 ACTION




                 leadership, for gathering all information related to risks, hazards and mitigation efforts
                 within the organization with input from all levels of staff within the organization and from
                 patients and their families. (p.110)
            c   evidence of high-performance or actions taken for the following five patient safety risk
                 areas: falls, malnutrition, pneumatic tourniquets, aspiration, and workforce fatigue (p.108)




April 2, 2012                                                                                          Page 53
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                                        Practice #9 – Nursing Workforce
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)


                                                                                  ○ Yes
Is your hospital currently recognized as an American Nurses
                                       ®
Credentialing Center (ANCC) Magnet organization?
                                                    34                            ○ No


If Yes, your hospital will receive full credit for this Safe Practice and no boxes need to be checked. If No,
please check all of the boxes that apply.

9.1               In regard to ensuring adequate and competent nursing staff service and nursing leadership
                  at all levels, our organization has done the following or has had the following in place within
                  the last 12 months:

                    a     held at least one educational meeting for clinicians, senior management, mid-level
                           management, and line management specifically related to the areas of patient safety and
                           adequate nurse staffing effectiveness. (p.155)
                    b  performed a risk assessment and an evaluation of the frequency and severity of adverse
 AWARENESS




                           events that can be related to nurse staffing. (p.155)
                    c  submitted a report to the Board (governance) with recommendations for measurable
                           improvement targets. (p.155)
                    d  collected and analyzed data of actual unit-specific nurse staffing levels on a quarterly basis
                           to identify and address potential patient safety-related staffing issues. (p.155)
                    e  provided unit-specific reports of potential patient safety-related staffing issues to senior
                           administrative leadership and the Board (governance) at least quarterly. (p.155)
9.2               In regard to ensuring adequate and competent nursing staff service and nursing leadership
                  at all levels, our organization has done the following or has had the following in place within
                  the last 12 months:

                    a    held departmental/clinical leadership directly accountable for improvements in performance
                          through performance reviews or compensation. (p.155)
                    b    included senior nursing leadership as part of the hospital senior management team.
 ACCOUNTABILITY




                          (p.155)
                    c    reported performance metrics related to this area to the Board (governance). (p.155)
                    d    held the Board (governance) and senior administrative leadership accountable for reducing
                          patient safety risks related to nurse staffing decisions. (p.155)
                    e    held the Board (governance) and senior administrative leadership accountable for the
                          provision of financial resources for nursing services. (p.155)
                    f    reported to the Board (governance) the results of the measurable improvement targets.
                          (p.155)




April 2, 2012                                                                                                 Page 54
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9.3        In regard to ensuring adequate and competent nursing staff service and nursing leadership
           at all levels, our organization has done the following or has had the following in place within
           the last 12 months:

             a   conducted staff education on maintaining and improving competencies specific to assigned
                  job duties related to the safety of the patient, with attendance documented. (p.155)
             b   allocated dedicated and compensated staff time to reduce adverse events related to
                  staffing levels or competency issues.
 ABILITY




             c   documented actual expenses incurred during the past year tied to this safe practice.
             d   budgeted financial resources for balancing staffing levels and skill levels to improve
                  performance. (p.155)
             e   governance has approved a budget for reaching optimal nurse staffing. (p.155)

           In regard to ensuring adequate and competent nursing staff service and nursing leadership
9.4
           at all levels, our organization has done the following within the last 12 months or has had
           the following in place during the last 12 months and updates are made regularly:

             a   implemented policies and procedures, with input from nurses, to ensure that adequate
                  nursing staff-to-patient ratios are achieved. (p.154)
             b   developed policies and procedures for effective staffing targets that specify number,
                  competency and skill mix of nursing staff. (p.155)
             c   implemented a performance improvement project that minimizes the risk to patients from
                  less than optimal staffing levels. (p.155)
                  OR
 ACTION




                  monitored a previously implemented hospital-wide performance improvement program that
                  measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
                  (p.155)
             d   provided unit-specific reports of potential patient safety-related staffing issues to senior
                  administrative leadership and the Board (governance) at least quarterly. (p.155)
             e   provided reports at least annually to the public through the appropriate organizations on
                  your hospital’s current status in achieving nurse staffing goals. (p.155)




April 2, 2012                                                                                         Page 55
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                                 Practice #17 – Medication Reconciliation
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

Check all boxes that apply.
17.1 In regard to adverse drug events and the medication reconciliation process, our
     organization has done the following or has had the following in place within the last 12
     months:

                    a    completed a review of the literature and identified specific best practices for process
 AWARENESS




                          redesign. (pp.225-228)
                    b  performed a hospital-wide evaluation of the frequency and severity of adverse drug events
                          associated with medication reconciliation in our patient population.
                    c  submitted a report to the Board (governance) with recommendations for measurable
                          improvement targets. (p.224)
17.2              In regard to adverse drug events and the medication reconciliation process, our
                  organization has done the following or has had the following in place within the last 12
                  months:

                    a   held senior administrative leadership directly accountable for improvements in performance
 ACCOUNTABILITY




                         through performance reviews or compensation.
                    b   held the person responsible for patient safety directly accountable for improvements in
                         performance through performance reviews or compensation.
                    c   reported to the Board (governance) the results of the measurable improvement targets.
                         (p.224)

17.3              In regard to adverse drug events and the medication reconciliation process, our
                  organization has done the following or has had the following in place within the last 12
                  months:

                    a   conducted staff education and skill development programs, with attendance documented.
                         (p.221)
 ABILITY




                    b   conducted an education program for all newly hired clinicians on the importance of
                         medication reconciliation, with attendance documented. (p.219)
                    c   allocated compensated caregiver staff time and dedicated line item budget resources for
                         best practices development for the organization’s medication reconciliation system. (p.222)




April 2, 2012                                                                                               Page 56
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17.4      In regard to adverse drug events and the medication reconciliation process, our
          organization has done the following within the last 12 months or has had the following in
          place during the last 12 months and updates are made regularly:

           a    developed explicit, hospital-wide organizational policies and procedures regarding
                 medication reconciliation.
            b   implemented a hospital-wide performance improvement program that measures the impact
                 of this specific Safe Practice.
                 OR
                 monitored a previously implemented hospital-wide performance improvement program that
                 measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
            c   implemented standardized processes to obtain and document a complete list of each
 ACTION




                 patient’s current medications at the beginning of each episode of care. (p.219)
            d   implemented standardized processes to ensure that a complete list of the patient’s
                 medications is communicated to the next provider of service, including the documentation
                 of communication between providers. (p.220)
            e   implemented standardized processes to provide the patient, and family/caregiver as
                 needed, a current list and explanation of the patient’s reconciled medications upon the
                 patient leaving the organization’s care. (p.220)
            f   have reconciled medications for patients whose care setting, or level of care has changed,
                 or has had a change in health status. (p.220)




April 2, 2012                                                                                      Page 57
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                                         Practice #19 – Hand Hygiene
                   (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

Check all boxes that apply.
19.1 In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
     organization has done the following or has had the following in place within the last 12
     months:

                   a    undertaken a hospital-wide educational effort addressing the frequency and severity of
 AWARENESS




                         hospital-acquired infections within our patient population and the potential impact of
                         performance improvement practices related to improvements in hand hygiene. (p.250)
                    b   submitted a report to the Board (governance) with recommendations for measurable
                         improvement targets.

19.2              In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
                  organization has done the following or has had the following in place within the last 12
                  months:

                   a    held clinical leadership directly accountable for this patient safety area through
 ACCOUNTABILITY




                         performance reviews or compensation.
                    b   held senior administrative leadership directly accountable for this patient safety area
                         through performance reviews or compensation.
                    c   held the person responsible for patient safety directly accountable for improvements in
                         performance through performance reviews or compensation.
                    d   reported to the Board (governance) the results of the measurable improvement targets.

19.3              In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
                  organization has done the following or has had the following in place within the last 12
                  months:

                   a    conducted staff education/knowledge transfer and skill development programs, with
 ABILITY




                         attendance documented. (p.251)
                    b   documented expenditures on staff education related to this Safe Practice in the previous
                         year.
19.4              In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
                  organization has done the following within the last 12 months or has had the following in
                  place during the last 12 months and updates are made regularly:

                   a    implemented explicit organizational policies and procedures across the entire organization
                         to prevent hospital-acquired infections due to inadequate hand hygiene including CDC
                         guidelines with category IA, IB, or IC evidence. (p.250)
                    b   implemented a formal performance improvement program addressing hospital-acquired
 ACTION




                         infections focused on hand hygiene compliance, with regular performance measurement
                         and tracking improvement (pp.250-251)
                         OR
                         monitored a previously implemented hospital-wide performance improvement program that
                         measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
                         (pp.250-251)




April 2, 2012                                                                                               Page 58
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             Practice #23 – Prevention of Ventilator Associated Complications
                (page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)

                                                                              ○   Yes
Does your facility care for patients on ventilators?
                                                                              ○   No

If Yes, continue with the remainder of this Safe Practice. Otherwise, skip it; the Practice does not apply.

Check all boxes that apply.
23.1 In regard to complications associated with ventilator use, our organization has done the
     following or has had the following in place within the last 12 months:

                 a   conducted an evaluation of the frequency and severity of ventilator-associated
                      complications in our patient population and communicated findings to senior administrative
 AWARENESS




                      and clinical leadership. (p.280)

                 b   submitted a report to the Board (governance) with recommendations for measurable
                      improvement targets.

23.2           In regard to complications associated with ventilator use, our organization has done the
               following or has had the following in place within the last 12 months:

                 a   held senior administrative leadership and clinical leadership directly accountable for
 ACCOUNTABIL




                      improvements in performance through performance reviews or compensation.
                 b   held the person responsible for patient safety directly accountable for improvements in
     ITY




                      performance through performance reviews or compensation.
                 c   reported to the Board (governance) the results of the measurable improvement targets.

23.3           In regard to complications associated with ventilator use, our organization has done the
               following or has had the following in place within the last 12 months:

                 a   conducted a staff education/ knowledge transfer and skill development programs on best
                      practices and strategies to reduce complications with attendance documented.
 ABILITY




               The organization:
                 b  documented or can document expenses incurred during the past year tied to this Safe
                      Practice. (p.284)
                 c  allocated compensated caregiver staff time to work on this Safe Practice.




April 2, 2012                                                                                            Page 59
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2012 Leapfrog Hospital Survey


23.4      In regard to complications associated with ventilator use, our organization has done the
          following within the last 12 months or has had the following in place during the last 12
          months and updates are made regularly:

           a    documented evidence that all ventilated patients are included in an appropriate adult or
                 pediatric specific bundle or prevention plan that is clearly documented in the medical
                 record. (p.281)
            b   implemented explicit organizational policies for the disinfection, sterilization, and
                 maintenance of respiratory equipment that are aligned with evidenced based guidelines.
                 (p.280)
            c
 ACTION




                 documented evidence that all ventilated patients and/or their families have been educated
                 on prevention measures involved in the care of the ventilated patient. (p.280)
            d   implemented a formal performance improvement program with regular performance
                 measurement and tracking improvement addressing ventilator associated complication
                 prevention and compliance with prevention strategies. (p.283)
                 OR
                 monitored a previously implemented hospital-wide performance improvement program that
                 measures, and demonstrates full achievement of the impact of this specific Safe Practice.
                 (p.283)




April 2, 2012                                                                                     Page 60
v5.4
                                   Section 7: Managing Serious Errors

This section of the survey addresses the occurrence of serious errors in hospitals.

Hospitals are asked to implement the five principles of Leapfrog’s Never Events policy when a serious
error or “never event” occurs within their facility. More information on the five principles of the policy and a
complete list of included “never events” can be found at:
http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_survey_copy/never_events/

In addition to the management of serious errors, hospitals are asked to report their rates of a serious
condition that patients commonly acquire during their ICU stay – central line associated bloodstream
infections. These rates are measured as occurrences per 1,000 central-line days.


Each hospital fully meeting the standards for this section of the survey:

1. Has agreed to implement the five principles of Leapfrog’s Never Events policy if a never event occurs
   within their facility.

2. Has a rate of zero central line associated bloodstream infections for patients in the ICU, as measured
   by cases per 1000 central line days.

Hospitals should refer to CLABSI Specifications in Section 7 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey) for counting central line
bloodstream infections, central line days, and for appropriate inclusion and exclusion criteria.




April 2, 2012                                                                                          Page 61
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2012 Leapfrog Hospital Survey




The Leapfrog Group Serious Reportable Events “Never Events”
Policy Statement
(Results shown on Leapfrog’s consumer site as “Managing Serious Errors”)
                                                                                             35
The Leapfrog Group asks hospitals to agree to all of the following principles if a never event occurs
within their facility:
     We will apologize to the patient and/or family affected by the never event
                                        36

     We will report the event to at least one of the following external agencies within 10 days of
                                                                                    37

         becoming aware that the never event has occurred:
          Joint Commission, as part of its Sentinel Events policy
          State reporting program for medical errors
          Patient Safety Organization (as defined in The Patient Safety and Quality Improvement Act of
              2005))
     We agree to perform a root cause analysis , consistent with instructions from the chosen
                                                    38

         reporting agency
     We will waive all costs directly related to a serious reportable adverse event
     We will make a copy of this policy available to patients, patients’ family members, and payers
         upon request


Indicate below your hospital’s efforts in relation to the Leapfrog Group policy statement on “Never
Events.”
1) Has your hospital implemented a policy that adheres to all of the principles       Yes
    of the Leapfrog Group Policy Statement, above?                                    No




April 2, 2012                                                                                         Page 62
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2012 Leapfrog Hospital Survey




Hospital-Acquired Conditions
Specifications: See CLABSI Specifications in Section 7 of the Leapfrog Hospital Survey Reference Book
(link found on the online survey ‘Download Survey Materials’ page) or counting central line bloodstream
infections, central line days, and for appropriate inclusion and exclusion criteria.

Reporting Time Period: Answer question #2-20 for the 12 months ending :
    December 31, 2011, for surveys submitted prior to November 1, 2012;
    June 30, 2012 for surveys (re)submitted on or after November 1, 2012.


Central Line Associated Blood Stream Infections
(Results shown on Leapfrog’s consumer site as “Reduce ICU Infections”)

2) Does your hospital care for patients with central lines in an intensive care unit            Yes
        39
   (ICU) ? If no, skip questions 3 – 20; otherwise continue.                                    No
                                                                               40
3) Does your hospital utilize personnel trained in human factors engineering in                 Yes
   conducting root-cause analyses of adverse events (e.g., central line associated              No
   bloodstream infections)?

4) Has your hospital measured its incidence of Central Line Associated Blood                    Yes
   Stream Infections (CLABSI) for the Reporting Time Period and chosen to report                No
   this information to the survey?
   If no, score will show as ‘Declined to Respond’ and skip questions 5 –20 ;
   otherwise continue.

5) Is your hospital designated as a “major teaching hospital”?                                  Yes
                                         41
   (Definition of Major Teaching Hospital )                                                     No
   Continue with questions 6-20 regardless.

Instructions
For each of the fifteen ICUs listed below, indicate in column:
    (a) if your hospital operates this type of ICU
        If no, skip columns (b) and (c) in the table below for that ICU type.
    (b) Total central line days during the reporting period in the specified ICU (denominator); see CLABSI
        Specifications in Section 7 of the for Excluded Populations and details on calculating central line
        days
    (c) Total number of central line associated bloodstream infections during the reporting period in the
        specified ICU, per CDC’s criterion 1 or 2 (numerator); see CLABSI Specifications in Section 7 of
        the Leapfrog Hospital Survey Reference Book for Excluded Populations and details on CDC’s
        criteria

    Hospitals reporting central line associated bloodstream infection data to National Healthcare Safety
    Network (NHSN) can use those data in answering the questions below; see CLABSI Specifications in
    Section 7 of the Leapfrog Hospital Survey Reference Book for specific details.




April 2, 2012                                                                                    Page 63
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                                         (a)                                          (c)
                                                              (b)
                               Does your hospital                       # of Central Line Associated
            ICU Type                                     # of Central
                             operate this type of ICU?                     Bloodstream Infections
                                                          Line Days
                                if No, skip (b) & (c)                    (per CDC’s Criterion 1 or 2)
6)      Medical                          Yes
                                         No                ______                 ______

7)      Surgical                       Yes
                                       No                  ______                 ______

8)      Medical/Surgical               Yes
                                       No                  ______                 ______

9)      Pediatric Medical              Yes
                                       No                  ______                 ______

10)     Pediatric Surgical             Yes
                                       No                  ______                 ______

11)     Pediatric                      Yes
        Medical/Surgical               No                  ______                 ______

12)     Pediatric                      Yes
        Cardiothoracic                 No                  ______                 ______

13)     Coronary Care                  Yes
                                       No                  ______                 ______

14)     Surgical                       Yes
        Cardiothoracic                 No                  ______                 ______

15)     Neurology                      Yes
                                       No                  ______                 ______

16)     Neurosurgical                  Yes
                                       No                  ______                 ______

17)     Burn                           Yes
                                       No                  ______                 ______

18)     Trauma                         Yes
                                       No                  ______                 ______




April 2, 2012                                                                              Page 64
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2012 Leapfrog Hospital Survey


                                           (a)                                          (c)
                                                                (b)
                                 Does your hospital                       # of Central Line Associated
        ICU Type                                           # of Central
                               operate this type of ICU?                     Bloodstream Infections
                                                            Line Days
                                  if No, skip (b) & (c)                    (per CDC’s Criterion 1 or 2)
19)     Level II/III NICU                  Yes
                                           No


                         Birthweight Category

        i)               <= 750 g                            ______                 ______


        ii)              751 – 1, 000 g                      ______                 ______


        iii)             1,001 – 1,500 g                     ______                 ______


        iv)              1,501 – 2,500 g                     ______                 ______


        v)               > 2,500 g                           ______                 ______


                                            (a)                                         (c)
                                                                (b)
                                   Does your hospital                     # of Central Line Associated
        ICU Type                                           # of Central
                               operate this type of ICU?                     Bloodstream Infections
                                                            Line Days
                                 if No, skip (b) & (c)                     (per CDC’s Criterion 1 or 2)
20)     Level III NICU                      Yes
                                            No


                         Birthweight Category

        i)               <= 750 g                            ______                 ______


        ii)              751 – 1, 000 g                      ______                 ______


        iii)             1,001 – 1,500 g                     ______                 ______


        iv)              1,501 – 2,500 g                     ______                 ______


        v)               > 2,500 g                           ______                 ______




April 2, 2012                                                                                Page 65
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2012 Leapfrog Hospital Survey


Affirmation of Accuracy:

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Managing Serious Errors section at our
hospital, and I hereby certify that these statements are accurate and reflect the current, normal operating
circumstances at our hospital. I am authorized to make this certification on behalf of our hospital. The
hospital and I understand that The Leapfrog Group and its participants are relying on the accuracy of this
information and will make this informaion and/or analyses of it public, and The Leapfrog Group and its
participants reserve the right to omit or disclaim information that is not current.


Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)




April 2, 2012                                                                                      Page 66
v5.4
                                 Section 8: Smooth Patient Scheduling

This section of the survey asks hospitals about their use of operations management methods (e.g.
queuing theory, variability management) to smooth patient flow across all operating rooms that service
inpatients, eliminating unnatural fluctuations in patient scheduling and resulting in more optimal
scheduling of patient procedures. With the widespread use of these operations management methods,
the need for building additional capacities will either be postponed or eliminated.



VERY IMPORTANT NOTES – PLEASE READ PRIOR TO COMPLETING THE SURVEY QUESTIONS
IN THIS SECTION

(1) Hospitals will need to review the following three documents for more information on smoothing patient
scheduling prior to answering the survey questions in this section:
    Technical Implementation Guidelines:
       http://www.leapfroggroup.org/media/file/SmPtSkedTechnicalImplementationGuidelines.pdf
    Bibliography:
       http://www.leapfroggroup.org/media/file/SmoothPtSked_Bibliography.pdf
    Fact Sheet:
       http://www.leapfroggroup.org/media/file/FactSheet_SmoothPtSked.pdf

(2) A hospital that has applied ‘operations management methods’ to their operating rooms (ORs) that
service inpatients would be one that has done all, or most, of the following:
     Separated their inpatient and outpatient flows into dedicated operating rooms
     Implemented prospective ‘smoothing’ of their operating room schedule
     Balanced their elective surgical admissions across the days of the week
     Revised the schedules of their surgeons to balance operating room utilization across the days of
         the week and throughout the day
     Likely utilized the assistance of consulting services to implement these methods


Each hospital fully meeting the standards for Smooth Patient Scheduling:

    1. Has applied operations management methods to smooth patient flow across all of its operating
       rooms that service inpatients and can document at least a 5% improvement in utilization across
       all units by the end of the first year -OR- at least a 10% improvement in utilization across all units
       by the end of the second year – OR- at least a 15% improvement in utilization across all units –
       OR- an average utilization of 85% or greater across those units post-implementation.




April 2, 2012                                                                                       Page 67
v5.4
2012 Leapfrog Hospital Survey

IMPORTANT NOTE: The Smooth Patient Scheduling questions may be best completed by your
hospital’s administrative and clinical leadership. These questions address fundamental structural
changes in how hospitals schedule elective surgeries and the implementation of those changes
may fall outside of the scope of the typical hospital quality department.

Also, hospitals should answer these questions as they relate to their main (or busiest) operating
room location. For instance, offsite surgical units would be ignored in answering these
questions.

Smooth Patient Scheduling
(Results will be shown on Leapfrog’s consumer site as “Safety-Focused Scheduling”)

Questions #1-#3 are designed to see if this section of the survey applies to your hospital.
1) Does your hospital operate 25 or more staffed beds?                                         Yes
                                                                                               No
If ‘Yes’, please continue with question #2; If “No”, please affirm section
responses and skip to the next survey section.


2)    Does your hospital operate more than one operating room that services                     Yes
     inpatients (i.e., exclude any operating rooms that exclusively service                     No
     outpatients)?

If ‘Yes’, please continue with question #3; If “No”, please affirm section
responses and skip to the next survey section.

3) Did elective inpatient surgeries make up 10% or more of your hospital’s                      Yes
   total inpatient admissions during the latest 12-month period?                                No

If ‘Yes’, please continue with question #4.

 If ‘No’, your hospital is able to calculate the potential return on investment
 (ROI) it could achieve by applying operations management methods to
 improve patient flow using this calculator: http://www.ihoptimize.org/about-
 extranet.htm.
           If your hospital chooses to report on the remaining questions,
              progress toward meeting the standard will be assessed using the
              same criteria as other hospitals. Please continue with question #4.
           If your hospital chooses to not report on the remaining questions,
              your hospital will be scored as “Response Not Required”. Please
              affirm section responses and skip to the next survey section.



Important note: For question 4, include both surgical and non-surgical patients
when looking at scheduled and unscheduled admsissions.
4) To identify your hospital’s variablity in scheduled and unscheduled
   admissions, use one month of your hospital’s total admission data (not
   just surgical admisisons) from the last 12 calendar months and calculate                   _______
   your hospital’s ratio of absolute deviations using the Admission Variablity                  n.nn
               42
   Calculator and report the value here.




April 2, 2012                                                                                         Page 68
v5.4
2012 Leapfrog Hospital Survey

5) As of today, has your hospital applied operations management methods (                     Yes
   (AS DESCRIBED in the three documents listed at the beginning of this                       No
   section) to all operating rooms that service inpatients to smooth patient
   flow?

If ‘No’, please skip to question #11; if ’Yes’, please continue with question #6.

6) When did your hospital first apply operations management methods (AS
   DESCRIBED in three documents listed at the beginning of this
   section) to its operating rooms that service inpatients to smooth patient              _________
   flow?                                                                                   MMYYYY



The next four questions ask about the available and utilized ‘prime time’ hours of your hospital’s operating
rooms that service inpatients before and after the application of operations management methods to
smooth patient flow.

Reporting Periods:
    Pre-implementation: Hospitals should report data from the four consecutive weeks prior to the
       first wide-spread announcement that these methods were being introduced at your hospital.
    Post-completed implementation: Hospitals should report data from the four consecutive weeks
       after they have fully completed their revisions of surgical schedules (which may be a point after
       which future cases have already been scheduled).

Specifications: All hospitals should use the Smooth Patient Scheduling Specifications in Section 8 of
the Leapfrog Hospital Survey Reference BookSurvey Reference Book (link found on the online survey
‘Download Survey Materials’ page) for calculating both available and utilized ‘prime time’ hours of its
operating rooms that service inpatients.

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’.

7) What were your hospital’s total available ‘prime time’ hours in its
   operating rooms that service inpatients in the four weeks prior to (pre-
   implementation) applying operations management methods to smooth                        _______
   patient flow?

8) What were your hospital’s total utilized ‘prime time’ hours in its operating
   rooms that service inpatients in the four weeks prior to (pre-implementation)
   applying operations management methods to smooth patient flow?                          _______


9) What were your hospital’s total available ‘prime time’ hours in its
   operating rooms that service inpatients in the four weeks after (post-
   completed implementation) applying operations management methods to                     _______
   smooth patient flow?

10) What were your hospital’s total utilized ‘prime time’ hours in its operating
    rooms that service inpatients in the four weeks after (post-completed
    implementation) applying operations management methods to smooth                       _______
    patient flow?




April 2, 2012                                                                                       Page 69
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2012 Leapfrog Hospital Survey



If you answered ‘No’ to question 5, please complete the following optional questions for partial credit:

11) Does your hospital have a written plan for applying operations management                  Yes
    methods (e.g. queuing theory, variability management) to smooth patient                    No
    flow across its operating rooms that service inpatients within the next 12
    months?

12) Has your hospital board approved a dedicated budget for the application of                 Yes
    operations management methods (e.g. queuing theory, variability                            No
    management) to smooth patient flow in its operating rooms that service
    inpatients?

13) Has the chief of one surgical department of the hospital contacted and held                Yes
    discussions with a peer at another hospital that has already applied                       No
    operations management methods (e.g. queuing theory, variability
    management) to smooth patient flow and has increased utilization by at
    least 15%?




Affirmation of Accuracy:

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to Smooth Patient Scheduling at our hospital,
and I hereby certify that these statements are accurate and reflect the current, normal operating
circumstances at our hospital. I am authorized to make this certification on behalf of our hospital. The
hospital and I understand that The Leapfrog Group and its participants are relying on the accuracy of this
information and will make this informaion and/or analyses of it public, and The Leapfrog Group and its
participants reserve the right to omit or disclaim information that is not current.


Affirmed by _____________________, the hospital’s ___________________________,
                 (name)                                           (title)
on _______________________.




April 2, 2012                                                                                        Page 70
v5.4
                                 Section 9: Patient Experience of Care

This section of the survey addresses the patient experience of care in hospitals such as pain
management, medication education, and discharge instructions.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Bundle
Hospitals are asked to report their latest HCAHPS scores for three of ten composite measures as
reported by CMS on HospitalCompare – pain management, communication about medications, and
discharging patients home.


Each hospital fully meeting the standards for the HCAHPS Bundle:

1. Receives at least 91.7% of the possible scoring points on a bundle of three HCAHPS composite
   measures as determined by national data.


Note: This section does not apply to children’s hospitals and is optional for critical access hospitals and
other PPS exempt hospitals.




April 2, 2012                                                                                        Page 71
v5.4
2012 Leapfrog Hospital Survey



HCAHPS Bundle
(Results shown on Leapfrog’s consumer site as “Patient Experience”)

This section of the survey does not apply to Pediatric hospitals (skip questions #1-7).

Reporting Period: Answer questions #1 - #7 for the most recent period of data available as reported by
CMS on HospitalCompare.




1) Does your hospital receive payment from the Centers for Medicare &                      Yes
   Medicaid Services (CMS) through the Prospective Payment System (PPS)?                   No

    If yes, please continue to question #2.
    If no, your hospital can optionally answer questions #2-7. If your hospital
    chooses not to answer the remaining questions, they will be shown
    as’Response Not Required’ on the public website.

2) Has your hospital conducted and submitted HCAHPS surveys of recently                    Yes
   discharged patients to the Centers for Medicare & Medicaid Services (CMS)               No
   and chosen to report the mode and patient-mix adjusted results to this
   survey?

    If no, score will show as ‘Declined to Respond’ on the public website and
    skip remaining questions #3-7.

3) Did your hospital have 100 or more completed HCAHPS surveys during the                  Yes
   reporting period?                                                                       No

    If yes, please continue to question #5. If no, please continue to question #4.



CMS has noted that rates for hospitals with fewer than 100 completed HCAHPS surveys should be used
with caution, as the number of surveys may be too low to reliably assess hospital performance. Leapfrog
is providing hospitals with less than 100 completed surveys the opportunity to voluntarily report their
results.

4) Would your hospital like to voluntarily report their mode and patient-mix               Yes
   adjusted results?                                                                       No

    If yes, please continue to question #5. If no, your hospital will be shown as
    ’Response Not Required’ on the public website.




April 2, 2012                                                                                    Page 72
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2012 Leapfrog Hospital Survey


Instructions:
For each HCAHPS composite measure listed below, indicate your hospital’s mode and patient-mix
adjusted results on the measure as most recently reported by CMS on HospitalCompare.

                HCAHPS Composite Measure                          Results from CMS/HospitalCompare
                                                                    (www.hospitalcompare.hhs.gov)
5) Pain Management
Patients who reported their pain was “Always” well controlled.                   _______%
                                                                                 (e.g.82%)


6) Communication About Medications
Patients who reported that staff “Always” explained about                        _______%
medicines before giving it to them.                                              (e.g.82%)


7) Discharge Home
Patients at each hospital who reported that YES, they were                       _______%
given information about what to do during their recovery at                      (e.g.82%)
home.



Affirmation of Accuracy:

As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to Patient Experience of Care at our hospital,
and I hereby certify that these statements are accurate and reflect the current, normal operating
circumstances at our hospital. I am authorized to make this certification on behalf of our hospital. The
hospital and I understand that The Leapfrog Group and its participants are relying on the accuracy of this
information and will make this informaion and/or analyses of it public, and The Leapfrog Group and its
participants reserve the right to omit or disclaim information that is not current.


Affirmed by _____________________, the hospital’s ___________________________,
                  (name)                                          (title)
on _______________________.
            (date)




April 2, 2012                                                                                     Page 73
v5.4
                                 Endnotes and “More Information” Link



1
 State
Your hospital is assigned to a state based on the Medicare Provider Number assigned (or identifier
specially issued by the Leapfrog Survey Help Desk) to your hospital. If your hospital is incorrectly
assigned to a state, contact the Help Desk to resolve the discrepancy.

2
  Medicare Provider Number (MPN)
A Medicare Provider Number (MPN) is issued by the Centers for Medicare and Medicaid Services (CMS)
to financial reporting entities, which may be individual hospitals or a group of hospitals, for purposes of
reimbursement. While Leapfrog does ask each campus of a multi-hospital system to submit an individual
survey, hospitals within the system may be assigned the same Medicare Provider Number and therefore
should report the same MPN in this field. MPNs are six digits, with the first two digits represent the state
in which the hospital is located. Hospitals that do not receive Medicare reimbursement may not have a
Medicare Provider Number and should indicate 00-0000 in this field.

3
 Tips for entering Web addresses
 This address becomes the link attached to your hospital’s name in public release of survey results.
   Enter it exactly as you wish it to be and test it.
 Do not exit out of the survey to go to the Web page of interest while you are entering data into the
   survey or some of your survey entries may be lost.
 Instead, minimize (but don’t close) the survey window, and any other windows that are open, then
   open your internet browser in a separate window. Find the Web page whose address you wish to
   enter and Copy/Paste the entire address into the survey entry. Remove the http:// prefix from the
   address!
 If entering the Web page address manually, be careful to type it correctly, without embedded spaces.
   Forward (/) or backward (\) slashes may be used. Don’t forget the www. if that is part of the address.
 Make sure to use .org, rather than .com, if that’s the domain for your hospital’s Web site. Remember
   to remove the http:// prefix from the address!
 Test the address with the button in the survey form just below the entry.
 Although many hospitals elect to enter the address for the home page of their hospital Web site,
   consider pointing it to a page specific to patient safety, the Leapfrog safety practices, or other quality
   improvement activities about which you want to communicate to your community.

4
  Licensed Beds
Include short-term, acute-care medical, surgical, and obstetrical beds as licensed by your state. Exclude
beds licensed or used for long-term rehabilitation or psychiatric care, or sub-acute care, (e.g., skilled
nursing facility (SNF), hospice extended care, sub-acute eating disorder treatment, extended care facility,
or residential substance abuse treatment). If the number of licensed beds has changed in the last year,
indicate the most recent number for which it is licensed.

5
  Staffed Beds
Include licensed beds regularly in operation, whether currently occupied by a patient or not. If the number
has changed over the last year, indicate the average or other number most representative of your
operating bed capacity over the last year.



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6
  Total Acute-Care Admissions
Include acute-care medical, surgical and obstetrical admissions to your hospital. Exclude long-term,
rehabilitation, psychiatric, sub-acute care (e.g., skilled nursing facility (SNF), hospice extended care, sub-
acute eating disorder treatment, extended care facility, or residential substance abuse treatment)
admissions. Exclude normal newborn admissions to the nursery. Include transfers from other hospitals as
admissions to your hospital. Include any admissions directly to an ICU in your hospital, even if counted in
question 14.

7
  Licensed ICU Beds
If your state separately designates ICU beds in its licensure, indicate the number of such beds currently
licensed this way. If your state does not designate and license ICU beds, enter the number of staffed
beds from question 13.

Include adult and pediatric general medical and surgical ICU beds as well as beds in neurology/
neurosurgery ICUs, but exclude Coronary Care Unit (CCU) beds if they are separately licensed and
operated. Do not include Neonatal Intensive Care Units, separate Trauma or Burn units, or beds in
intermediate care or step-down units. (If the same licensed ICU beds are used for both coronary intensive
care and other medical-surgical conditions, include them.) If the number licensed has changed over the
last year, indicate the most recent number for which it is licensed.

8
  Staffed ICU Beds
Include ICU beds regularly in operation, whether currently occupied by a patient or not. If the number has
changed over the last year, indicate the average or other number most representative of your operating
ICU capacity over the last year.

Include adult and pediatric general medical and surgical ICU beds as well as beds in neurology/
neurosurgery ICUs, but exclude Coronary Care Unit (CCU) beds if they are separately licensed and
operated. Do not include Neonatal Intensive Care Units, separate Trauma or Burn units, or beds in
intermediate care or step-down units. (If the same licensed ICU beds are used for both coronary intensive
care as well as other medical-surgical conditions, include them.) If the number has changed over the last
year, indicate the average or other number most representative of your operating bed capacity in these
units over the last year.

9
  ICU Admissions
Include admissions to adult or pediatric general medical and surgical ICU beds as well as beds in
neurology/ neurosurgery ICUs, whether directly admitted to the unit or transferred to the unit from another
area of your hospital, e.g., post-operatively. Count the number of hospitalizations that include an ICU
stay, not the number of patient trips to the ICU.

Ignore admissions to units dedicated exclusively to patients with highly specialized conditions -- e.g.,
ignore admissions to any Coronary Care Unit (CCU) that is distinct and separate from other
adult/pediatric general medical/surgical ICUs. (If the same ICU is used for both coronary intensive care as
well as other general medical-surgical conditions, include admissions to these units in your responses.)
Other examples of highly specialized units to ignore when responding are neonatal intensive care units,
separate trauma, burn, cardiovascular, or cardio-thoracic units. “Dedicated exclusively” means that
general med-surg patients are not also cared for in these specialized units (except in rare overflow
situations). Also ignore admissions or transfers to intermediate care or step-down units for this question.




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10
  Federal Tax Identification Number (TIN)
Enter the TIN that your hospital uses for billing purposes.

The number is a nine-digit number with a hyphen between the second and third digits, e.g., 09-8765432
and must conform precisely to this format. Enter any leading 0 and the hyphen.

If your hospital has more than one TIN, use the one that would most typically be used for UB-92 claims
filed with commercial health insurance plans for inpatient hospital stays.

11
  CPOE Linked to Pharmacy, Laboratory, ADT Information
The ability of a CPOE system to catch the majority of common, serious prescribing errors depends on
proper identification of patients (ADT information), current and recent pharmacy orders and drug
dispensing history, and access and integration of key laboratory results for the patient. CPOE systems
that are not linked to those other systems or do not reflect that current information accurately about the
patient are not likely to catch serious prescribing errors.

12
  Post-Procedure Inpatient Deaths
Include in-hospital deaths for the patients included in the previous question, i.e., where the patient died
during the hospital stay that included that procedure. Count deaths following the specific surgery, whether
the death can be directly related to that procedure or not. Do not count deaths where the patient was
discharged alive following the surgery but died during a subsequent re-admission (unless the procedure
was repeated during that re-admission and the patient subsequently died during that stay).

For participants in STS, ACC, NNECDSG or ACS national performance measurement systems, this
definition differs from “Operative Mortality” as used in those reporting systems, which include both in-
hospital and 30-day post-operative mortality out-of-hospital. (See endnotes below.)

13
   Participation in STS or ACC Performance Measurement Systems
If your hospital currently participates and has begun submitting data for all such procedures but has not
yet received any reports, you should indicate “Participating but no reports yet available". Return to the
survey and update answers to the remaining questions when you receive your hospital’s first reported
results.

14
  Observed Mortality Rate from National Performance Measurement Systems (STS and ACC)
Operative mortality rate, including in-hospital and 30-day post-operative rate. Report this as a percentage,
with two decimal-place precision. If the mortality rate in the STS or ACC 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.

STS reports: For the latest year reported, enter your hospital’s “Operative Mortality” for CABG (report p.
CAB-28) or for AVR (report p. AV Replace-60) in CABG Q6 and AVR Q5, respectively. These are your
hospital’s actual operative mortality rates, standardized (risk-adjusted) to the STS all-hospital risk.
Operative mortality includes in-hospital and 30-day post-operative mortality out-of-hospital.

ACC reports: Enter your hospital’s (actual) observed mortality rate (OMR) as a percentage. Using data
from the My Hospital R4Q “Num” column in the current NCDR CathPCI Registry Institutional Outcomes
Reports, OMR must be calculated by dividing the number for “Observed Mortality (among eligible)
(LFHS)” by the number for “Eligible pts (LFHS)” to obtain the % rate for the most recent rolling four




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quarters where 12 consecutive months of data was submitted [i.e., Observed Mortality (among eligible)
(LFHS)/Eligible pts (LFHS)].


15
  Risk-Adjusted Expected Mortality Rate from National Performance Measurement Systems
(STS and ACC)
Operative mortality rate, including in-hospital and 30-day post-operative rate. This is the expected
mortality rate based on all-hospital average mortality, but risk-adjusted for the severity of 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.

STS reports: Enter the all-hospital STS “Operative Mortality” for CABG (report p. CAB-28) or AVR
operative mortality (report p. AV Replace-60) in CABG Q7 and AVR Q6, respectively. These are the
national expected operative mortality rates to which your hospital’s actual standardized rate in CABG Q6 /
AVR Q5 will be compared. Operative mortality includes in-hospital and 30-day post-operative mortality
out-of-hospital.

ACC reports: Enter your hospital’s expected mortality rate (EMR) as a percentage. Using data from the
My Hospital R4Q “Num” column in the current NCDR CathPCI Registry Institutional Outcomes Reports,
EMR must be calculated by dividing the number for “Expected Mortality (among eligible) (LFHS)” by the
number for “Eligible pts (LFHS)” to obtain the % rate for the most recent rolling four quarters where 12
consecutive months of data was submitted [i.e., Expected Mortality (among eligible) (LFHS)/Eligible pts
(LFHS)].

If the STS or ACC report includes only actual (observed) mortality rate and an O/E ratio, compute the
expected mortality rate as follows:
 Divide the actual (observed) percentage by the O/E ratio. Round the result to a percentage with two
     decimal-place precision. Example: Actual (observed) rate 2.6% divided by O/E ratio 1.24 = 2.10%.
     Enter 2.60 for actual rate, 2.10 for expected rate.
 If the actual (observed) rate is 0.00%, the O/E rate will be 0.0. Enter 0.00% for both actual and
     expected mortality rates.

16
   Mortality Results in Publicly Reporting States and Regional Registries
Hospitals located in a state with publicly reported outcomes should refer to the Outcome Specifications
in Section 3 of the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey
Materials’ page of the online survey) to determine how they should report based on those reports. If you
are aware of publicly-reported results in these states for a more recent period, please contact the
Leapfrog Help Desk. Hospitals that participate in a regional registry should report their results from the
most recent report provided by the registry.

17
  Observed Mortality Rates from Publicly Reported Outcomes and Regional Registries
Publicly Reported Outcomes: Follow the instructions in the Outcome Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book (link found on the home page of the online survey) to
determine the value to report for this question for your hospital.

NNECDSG reports: Please refer to the document titled “Leapfrog Hospital Survey Data” provided to you
as an addendum to your most recent NNECDSG Cardiac Surgery or PCI report.

BMC2 reports: Enter your hospital’s observed risk-adjusted mortality rate from the last page of the report.




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18
  Expected Mortality Rates from Publicly Reported Outcomes and Regional Registries
Publicly Reported Outcomes: Follow the instructions in the Outcome Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book (link found on the home page of the online survey) to
determine the value to report for this question for your hospital.

NNECDSG Reports: Please refer to the document titled “Leapfrog Hospital Survey Data” provided to you
as an addendum to your most recent NNECDSG Cardiac Surgery or PCI report.

BMC2 Reports: Enter your hospital’s predicted risk-adjusted mortality rate from the last page of the
report.

19
   All Cases or a Sufficient Sample
If you have fewer than 60 cases that meet the criteria for inclusion in the denominator of the process
measure, include ALL of these cases in measuring adherence to the process indicators. You should
report results for cases from at least a 12-month period (unless your hospital only recently started offering
these services, in which case for the time period that you have offered those services.) You need NOT
use more than 12 months of historical experience to increase the eligible cases beyond 60; just measure
and report based on ALL eligible cases that you have in that period.

If you have more than 60 cases that meet those criteria during the time period of the audit, you may
randomly sample 60 of them for the denominator of each indicator, and measure and report adherence
based on that sample. When sampling from a larger population of cases, this is the minimum number of
cases needed to make a statistically reliable statement of percentage adherence to the process guideline.

20
  One Decimal Point Precision
Report this value as a number, with one decimal-place precision. If the precision of the resulting value is
more than one decimal-place precision, round it to one, e.g., 60.05 rounds to 60.1; report 60.1.

21
  High-Risk Deliveries Electively Admitted
Includes deliveries with:
     expected birth weight <1500 grams; or
     gestational age at least 22 weeks but <32 weeks.

Not all women at risk for delivery of babies with these conditions are known beforehand to be at risk.
Therefore, deliveries in which these high-risk conditions were unknown prior to admission are not
considered electively admitted high-risk deliveries.

If your hospital admits deliveries where these conditions are known prior to admission, then your hospital
electively admits high-risk deliveries and you should answer Yes to Question 1; otherwise, answer ‘No’.

22
  Co-located with a Hospital Having a NICU
A hospital without a neonatal ICU but in immediate physical proximity to another hospital that has a
neonatal ICU, e.g., a children’s hospital next door to which your hospital immediately transfers all
complicated newborns, is considered as sharing a co-located NICU. "Immediate physical proximity”
means the two facilities must be physically connected, either by a tunnel, an enclosed bridge, or the
hospitals should abut each other so that the hallways readily connect. Based on available research
evidence, the pivotal factor is that the neonatal team be able to attend the high-risk deliveries whenever a




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neonatal resuscitation might be necessary. If the hospitals are not immediately adjacent to each other,
this isn't possible.

23
  Very-low birth weight babies
Complicated newborns are those infants with a birth weight <1500 grams

If your hospital has a neonatal ICU (or is co-located with a hospital that has a neonatal ICU) that admits
or accepts transfers of neonates with these conditions, you should answer Yes to Question 2.

24
   Managed or Co-Managed
The intensivist, when present (whether on-site or via telemedicine), is authorized to diagnose, treat, and
write orders for a patient in the ICU on his/her own authority. Mandatory consults or daily rounds by an
intensivist are not sufficient to meet the managed/co-managed requirement. However, an ICU need not
be close-staffed to meet this requirement.

25
  Certified in Critical Care Medicine
A physician who is “certified in Critical Care Medicine” is a board-certified physician who is additionally
certified in the subspecialty of Critical Care Medicine. Certification in Critical Care Medicine is awarded by
the American Boards of Internal Medicine, Surgery, Anesthesiology and Pediatrics.

Because sub-specialty certification is not offered in emergency medicine, emergency medicine physicians
will be considered “certified in Critical Care Medicine” if they are board-certified in emergency medicine
and have completed a critical care fellowship at an ACGME-accredited program.

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.)

        Physicians board-certified in Medicine, Anesthesiology, Pediatrics, or Surgery who have
         completed training programs required for certification in the subspecialty of Critical Care Medicine
         but are not yet certified in this subspecialty.

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.

Physicians who have let their board certification lapse are not considered to be “Certified in Critical Care
Medicine”.

“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.




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        *The UCNS currently has 2 tracks to be certified as a neurointensivist. All current
        neurointensivists (past trained and in practice) and current graduating fellows can immediately
        apply for certification via the "practice" track which requires documentation of training and clinical
        practice. The practice track pathway will close on the last day of the application cycle for the 2013
        NCC examination. See UCNS’s website for more information (www.ucns.org).

26
   Ordinarily and Exclusively Present in the ICU
“Ordinarily present in the ICU” refers to direct presence in the ICU (or presence via telemedicine) of an
intensivist during the 8-hour period. While it need not be the same intensivist for the entire 8-hour
duration, it is expected that the ICU(s) are primarily staffed by dedicated ICU intensivists who are
ordinarily and exclusively present in the ICU(s). "Presence" does not mean staffed part-time by multiple
physicians who are not ordinarily and exclusively dedicated to the ICU, nor does it mean the cumulative
time that one or more intensivists spend in the unit visiting, rounding, consulting, or responding to pages.
Note: To meet the Leapfrog ICU requirement for intensivist presence in the ICU via telemonitoring, a
hospital must affirm that its telemonitoring intensivist presence fulfills all 10 key features found in endnote
#29, including daily care planning by an on-site intensivist.

The standard allows for normally expected intensivist activities outside of the ICU related to their
responsibilities in the ICU (e.g. evaluating patients proposed for ICU admission), as long as intensivists
are ordinarily present in the ICU and return immediately when paged. An intensivist present in one ICU
immediately adjacent to another can be considered present in both units as long as s/he can respond to
demands in both units as if s/he would if both units were one larger unit. While tele-intensivists can be
used to meet the presence requirement, some on-site intensivist presence is still necessary to meet the
Leapfrog specifications.

Any intensivist, including a neurointensivist, ordinarily present in a neuro ICU meets this requirement for
that unit. However, presence of a neurointensivist in a general med-surg ICU (i.e., other than a dedicated
neuro ICU) cannot meet this requirement in those units.

“Exclusively” means that when the physician is in the ICU, s/he has no concurrent clinical
responsibilities to non-ICU patients.

27
  Quantified Analysis of Pager Response Times
Providers can monitor pager 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 pages made to intensivists when they are not present in the unit (whether on-
     site or via telemedicine);
  the number of urgent 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 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 pages per day.

28
  FCCS-Certified Nurse “Effector”
FCCS certificates are awarded to nurses and doctors upon their successful completion of a brief course
developed by the Society for Critical Care Medicine to improve/confirm critical care knowledge and skills.
For more information visit http://www.sccm.org/SCCM/FCCS+and+Training+Courses/.. At present, this is



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the only such course recommended by The Leapfrog Group’s expert advisory panel. Intensivists, and any
other physicians who are certified in critical care medicine (or eligible based on residency training or
fellowship) need not also be FCCS certified. Physician assistants and nurse practitioners also are not
required to be FCCS certified.

29
   Intensivist Presence via Telemedicine
To meet the Leapfrog ICU requirement for intensivist presence in the ICU via telemonitoring, a hospital
must affirm that its telemonitoring intensivist presence fulfills the following 10 key features based on a
modification of the approach reported in Critical Care Medicine (Rosenfeld, B. et al. “Intensive care unit
telemedicine: Alternate paradigm for providing continuous intensivist care,” Critical Care Medicine, Vol.
28, No. 1, pp. 3925-3931.) Note that, as with other Leapfrog specifications, these features must be met
under ordinary circumstances.

1. An intensivist who is physically present in the ICU (“on-site intensivist) performs a comprehensive
   review of each ICU patient each day and establishes and/or revises the care plan. The tele-intensivist
   has immediate access to information regarding the on-site intensivist’s care plan at the time
   monitoring responsibility is transferred to him or her by the on-site intensivist. When care is
   transferred back to the on-site intensivist, the tele-intensivist communicates (rounds) with the on-site
   intensivist to review the patient’s progress and set direction.

2. When an intensivist is not on-site in the ICU managing or co-managing all ICU patients, a tele-
   intensivist is monitoring and able to manage all ICU patients for the remaining 24 hours per day,
   7 days per week. “Monitoring” means the tele-intensivist has no other concurrent responsibilities, is
   immediately available to communicate with ICU staff, and is in the physical presence of the tele-ICU’s
   patient monitoring and communications equipment. "Manage" means authorized to diagnose, treat,
   and write orders for a patient in the ICU on his/her own authority.

3. A tele-intensivist has immediate access to key patient data, including:
   a) physiologic bedside monitor data (in real-time);
   b) laboratory orders and results;
   c) medications ordered and administered; and,
   d) notes, radiographs, ECGs, etc. on demand.

4. Data links between the ICU and the tele-intensivist are reliable (>98% up-time) and secure (HIPAA
   compliant).

5. Via A-V support, tele-intensivists are able to visualize patients with sufficient clarity to assess
   breathing pattern, and communicate with on-site personnel at the bedside in real time.

6. Written standards for remote care are established and include, at a minimum:
   a) tele-intensivists are certified by a national medical specialty board in critical care medicine;
   b) tele-intensivists are licensed to practice in the legal jurisdiction in which the ICU is located;
   c) tele-intensivists are credentialed in each hospital to which he/she provides remote care (can be
        special telemedicine credentialing);
   d) activities of the tele-intensivist are reviewed within the hospital’s quality assurance committee
        structure;
   e) there are explicit policies regarding roles and responsibilities of both the on-site intensivist and
        the tele-intensivist; and,
   f)   there is a process for educating staff regarding the function, roles, and responsibilities of the
        tele-intensivist.




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7. Tele-ICU care is proactive, with routine review of all patients at a frequency appropriate to their
   severity of illness.

8. A tele-intensivist’s patient workload ordinarily permits him or her to complete a comprehensive
   assessment of any patient within five minutes of the request for assistance being initiated by hospital
   staff.

9. There is an established written process to ensure effective communication between the on-site care
   team and the tele-intensivist.

10. The tele-intensivist documents patient care activities and this documentation is incorporated into the
    patient record.

30
  Adult or Pediatric, General Medical and/or Surgical ICUs or Neuro ICUs
The IPS Leap applies only to adult and pediatric general medical and/or surgical ICUs and neuro ICUs.
When responding to this section, ignore units dedicated exclusively to patients with other highly
specialized conditions. E.g., ignore any Coronary Care Unit (CCU) that is distinct and separate from other
adult/pediatric general medical/surgical ICUs. (If the same ICU is used for both coronary intensive care as
well as other general medical-surgical conditions, include this unit in your responses.) Other examples of
highly specialized units to ignore when responding are: neonatal intensive care units, separate trauma,
burn, cardiovascular, or cardio-thoracic. “Dedicated exclusively” means that general med-surg patients
are not also cared for in these specialized units (except in rare overflow situations). If they are, then the
IPS Leap applies to those units as well. Also ignore intermediate care or step-down units when
responding to this section.

31
  All Patients Managed or Co-managed by Intensivist
“Managed or co-managed” means that the intensivist, when present (on-site or via telemedicine), is
authorized to diagnose, treat, and write orders for a patient in the ICU in his/her own authority. Mandatory
consults or daily rounds by an intensivist are not sufficient to meet the managed/co-managed
requirement. However, to meet this requirement, an ICU need not be “closed”, i.e., the intensivist
becomes the attending of record during the patient’s ICU stay.

“All patients” means any patient in the ICU.

“Physician certified in critical care medicine” (intensivist) means a board-certified physician who is
additionally certified in the subspecialty of Critical Care Medicine. Certification in Critical Care Medicine is
awarded by the American Boards of Internal Medicine, Surgery, Anesthesiology and Pediatrics.

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 ACGME-accredited program.

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.)
      Physicians board-certified in Medicine, Anesthesiology, Pediatrics or Surgery who have
         completed training programs required for certification in the subspecialty of Critical Care Medicine
         but are not yet certified in this subspecialty.




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If you can answer Yes to question #2, but only if some or all of the physicians considered intensivists fall
under these two interim definitions, answer “Yes, based on expanded definition of certified”.

Note: 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. Physicians who have let their board certification lapse are not considered to be
“Certified in Critical Care Medicine”.


For neuro ICUs, the definition of a physician “certified in critical care medicine” would be extended to
include neurointensivists. Neurointensivists are defined as neurologists and neurological surgeons who
are board-certified in their primary specialty and who has completed a UCNS-certified fellowship training
program in neurocritical care, or a physician who is board certified in neurocritical care. This alternative
definition of “certified in critical care medicine” is only applicable to neuro ICUs.

32
   Modified Intensivist Presence via Telemedicine
To earn reduced credit on the Leapfrog ICU standard for intensivist presence in the ICU via
telemonitoring, a hospital must affirm that its telemonitoring intensivist presence fulfills the following nine
key features based on a modification of the approach reported in Critical Care Medicine (Rosenfeld, B. et
al. “Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care,” Critical
Care Medicine, Vol. 28, No. 1, pp. 3925-3931.) Note that, as with other Leapfrog specifications, these
features must be met under ordinary circumstances.

1. When an intensivist is not on-site in the ICU managing or co-managing all ICU patients, a tele-
   intensivist is monitoring and able to manage all ICU patients for the remaining 24 hours per day,
   7 days per week. “Monitoring” means the tele-intensivist has no other concurrent responsibilities, is
   immediately available to communicate with ICU staff, and is in the physical presence of the tele-ICU’s
   patient monitoring and communications equipment. "Manage" means authorized to diagnose, treat,
   and write orders for a patient in the ICU on his/her own authority.

2. A tele-intensivist has immediate access to key patient data, including:
   a) physiologic bedside monitor data (in real-time);
   b) laboratory orders and results;
   c) medications ordered and administered; and,
   d) notes, radiographs, ECGs, etc. on demand.

3. Data links between the ICU and the tele-intensivist are reliable (>98% up-time) and secure (HIPAA
   compliant).

4. Via A-V support, tele-intensivists are able to visualize patients with sufficient clarity to assess
   breathing pattern, and communicate with on-site personnel at the bedside in real time.

5. Written standards for remote care are established and include, at a minimum:
   a) tele-intensivists are certified by a national medical specialty board in critical care medicine;
   b) tele-intensivists are licensed to practice in the legal jurisdiction in which the ICU is located;
   c) tele-intensivists are credentialed in each hospital to which he/she provides remote care (can be
        special telemedicine credentialing);
   d) activities of the tele-intensivist are reviewed within the hospital’s quality assurance committee
        structure;
   e) there are explicit policies regarding roles and responsibilities of both the on-site intensivist and
        the tele-intensivist; and,




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     f)   there is a process for educating staff regarding the function, roles, and responsibilities of the
          tele-intensivist.

6. Tele-ICU care is proactive, with routine review of all patients at a frequency appropriate to their
   severity of illness.

7. A tele-intensivist’s patient workload ordinarily permits him or her to complete a comprehensive
   assessment of any patient within five minutes of the request for assistance being initiated by hospital
   staff.

8. There is an established written process to ensure effective communication between the on-site care
   team and the tele-intensivist.

9. The tele-intensivist documents patient care activities and this documentation is incorporated into the
   patient record.

33
   Teamwork Training
Teamwork training subject matter includes: sources of communication failures, hand-offs, and team
failures that lead to patient harm. Participation should be documented.

34
   American Nurses Credentialing Center (ANCC) Magnet ® Organizations
For a list of hospitals that are currently recognized as Magnet organizations, please see ANCC’s website
at: http://www.nursecredentialing.org/Magnet/FindaMagnetFacility.aspx

35
   Never Event
In 2011, the National Quality Forum released a list of 29 events that they termed “serious reportable
events”, extremely rare medical errors that should never happen to a patient. Often termed “never
events”, these include errors such as surgery performed on the wrong body part or on the wrong patient,
leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person. This is
an update of NQF’s original 2002 and 2006 reports. Please see NQF’s “Never Events list at
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573

36
  Apology to the Patient
While Leapfrog recognizes that on very rare occasions 'never events' can occur that are not the fault of
care systems or clinical care staff, given the high level of trust patients place in health care providers,
Leapfrog feels it is appropriate for caregivers to apologize when a patient within their care setting suffers
a serious event.

As the National Quality Forum identified in their 2002, 2006,and 2011 Serious Reportable Events Report,
given the serious nature of these events, it is reasonable for hospitals to initially assume that the adverse
event was due to the referenced course of care. And while further investigation and/or root cause
analysis of the unplanned event may be needed to confirm or refute the presumed relationship, delaying
an apology to the patient is not treating the patient with compassion and sympathy.

37
   Reporting Never Events to External Agencies
If your hospital is not a Joint Commission accredited hospital, is located in a state without a state-wide
reporting program for medical errors, AND there is no available Patient Safety Organization to which your
hospital can report medical errors, the hospital should report the event to the Board of Trustees. Full




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implementation of the Never Events policy still requires the hospital to conduct a root cause analysis of
the event.

38
   Root Cause Analysis
The state of Minnesota has developed an online RCA toolkit designed to be a resource for any hospital
that would like to establish or improve their RCA process. The toolkit can be found at:
http://www.health.state.mn.us/patientsafety/toolkit/index.html

39
  Operating an on-site ICU
Hospitals should answer “Yes” if they operate an on-site ICU. Hospitals that use teleintensivist services to
monitor their ICUs are still considered as operating an on-site ICU. Hospitals that use teleintensivist
services to monitor their ICUs may need to work with their teleintensivist service to obtain the required
data points to complete these measures.

40
  Trained in Human Factors Engineering
Personnel trained in human factors engineering include those persons with formal training in human
factors engineering, human factors, ergonomics, or human engineering. Their training includes a focus
on the interaction between the human and the system, including the work environment, tools, and
computer systems.

41
  Major Teaching Hospital
A hospital is identified as a major teaching hospital if it achieves a minimum ratio of one resident (i.e.
physician in training) per four staffed inpatient beds; or, the hospital has self-designated as a major
teaching hospital to the CDC NHSN.

42
   Admission Variability Calculator
The admission variability calculator can be accessed by hospitals at the following URL:
http://www.leapfroggroup.org/media/file/AdmissionVariabilityCalculator.xls




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