What’s New in 2014: The Leapfrog Hospital Survey. Town Hall Calls May 13, 2014 and May 28, 2014. 1. Town Hall Call Overview. Introduction Goals for 2014 survey Survey Submission Online survey and logistics Website resources Timeline What’s New for 2014
Town Hall CallsMay 13, 2014 and May 28, 2014
Steps in the process to revise the survey have included:
Goals for the survey—
Expand survey to more hospitals
Keep reporting burden as low as possible
Continue alignment with other performance measurement groups (such as CDC-NHSN; CMS; The Joint Commission)
Include cutting-edge measures that improve the safety, quality, and efficiency of care delivery
Maintain consistent measurement structure for LHRP and for improvement purposes
Update measures with guideline changes
Add new performance measurement entities
Maintain measures meaningful to purchasers and consumers
Bulk of survey remains identical to the 2013 survey, including the performance cut-points for several measures
Added two measures, but neither will be publicly reported in 2014: NTSV Cesarean Section and OR Access
Added some exploratory questions at the end of Section 6 regarding culture of safety surveys.
Removed AAA process measure
Updated measure specifications to maintain alignment with other measurement entities (CMS, The Joint Commission)
Survey home page at www.leapfroghospitalsurvey.org includes links to:
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NEW THIS YEAR!
Extended the amount of time hospitals have to complete steps 4 and 5 of the CPOE Evaluation Tool (i.e., enter the orders, record advice/information, enter final results, and submit results).
Hospitals have requested additional time to enter orders into their CPOE System. Previously, hospitals were allowed 2 hours to complete steps 4 and 5. Hospitals will now have 2.5 hours to complete steps 4 and 5, with a 30-minute time limit for step 5. Hospitals will continue to have 4 hours to complete steps 1-3. For more information on the CPOE Evaluation Tool, visit https://leapfroghospitalsurvey.org/cpoe-evaluation-tool/.
Previously, hospitals were allowed 2 hours to complete steps 4 and 5. Hospitals will now have 2.5 hours to complete steps 4 and 5, with a 30-minute time limit for step 5. Hospitals will continue to have 4 hours to complete steps 1-3. For more information on the CPOE Evaluation Tool, visit https://leapfroghospitalsurvey.org/cpoe-evaluation-tool/.
Removed AAA Process Measures (SCIP-Card 2) from Section 3B.
Over the past several years, the number of AAA’s repaired via endovascular procedures have significantly increased. These endovascular procedures are typically lower risk than traditional open repair, and the importance of beta blockers has not been well studied within this group of patients.
Hospitals will be simply scored on the predicted survival of patients undergoing this procedure at their hospital. The AAA scoring algorithm will mirror how hospitals have been scored on the Pancreatectomy and Esophogectomy subsections of the survey.
Replaced Leapfrog’s Antenatal Steroids Measure with The Joint Commissions PC-03
Antenatal Steroids Measure.
For several years, Leapfrog has given hospitals two options when reporting on the administration of antenatal steroids to women prior to delivery of very low birth-weight babies: (1) hospitals could report data submitted to the Vermont Oxford Network or (2) use Leapfrog’s measure specifications, which closely align with the Vermont Oxford Network. With changes to The Joint Commissions mandatory reporting requirements, Leapfrog has decided to replace the second option (Leapfrog’s own measure specifications) with the Joint Commission’s PC-03 Antenatal Steroids measure.
Hospitals will continue to have the option of reporting data submitted to the Vermont Oxford Network. The scoring algorithm for this section will remain unchanged. The target for all hospitals on the antenatal steroid measure will remain 80% or greater adherence.
Addition of NTSV Cesarean Section Measure.
The NTSV cesarean section delivery measure focuses attention on a population of women who are low-risk and delivering for the first time. Unlike other cesarean section delivery measures, the NTSV cesarean section delivery rate is associated with concrete quality improvement activities that can be performed to address the differences in cesarean delivery rates among hospitals. These quality improvement activities include reducing admissions in early labor and eliminating elective labor induction before 41 weeks in the first births.
All hospitals reporting at least 50 births annually will be asked to provide their NTSV cesarean section delivery data on the Maternity Care section. Leapfrog will collect hospital responses to the new NTSV cesarean section delivery measure and score hospitals accordingly. However, individual hospital rates will not be publicly reported on the Leapfrog’s Hospital Survey Results website until 2015. In 2014, hospitals will only be able to view their results for this measure on their password-protected “Details” page. In 2015, Leapfrog plans to publicly report individual hospital results on the NTSV cesarean section delivery rate measure on the Leapfrog Hospital Survey Results website.
Hospitals have the opportunity to earn partial credit on the IPS standard if the hospital has physicians certified in critical care medicine managing or co-managing ICU patients for at least 4 hours per day, 7 days per week. The physicians providing this care must be ordinarily present on-site in these units and provide clinical care exclusively in one ICU during these hours.
The 4 hours per day, 7 days per week coverage will be an alternative to the historical 8 hours per day, 4 days per week coverage that has offered hospitals the opportunity for partial credit.
Hospitals have greater flexibility in staffing structure to earn a score of “substantial progress” on the IPS standard. Please see page 48 of the survey reference book for detailed information on the IPS scoring algorithm.
At the end the Safe Practices section, hospitals are asked to provide information about the culture of safety instrument they are using
Since introducing the NQF Safe Practices to the Leapfrog Hospital Survey in 2004, Leapfrog has asked hospitals if they conduct a safety and quality survey of units using a nationally recognized tool. Given research that shows a link between performance on specific domains on culture of safety surveys and better patient outcomes, Leapfrog is interested in better understanding which tool hospitals are using to measure their culture of safety.
Information that will be used to inform future survey questions. Responses to these extra questions will not be scored or publicly reported.
Added a set of questions that focuses on a patient’s access to the operating room by urgency level (i.e., urgent, emergent, scheduled) by surgical service.
The goal of these new questions is to ensure that hospitals are achieving appropriate utilization rates without sacrificing patient access.
These results will not be publicly reported until 2015. In 2014, hospitals will only be able to view their results for this measure on their password-protected “Details” page. In 2015, Leapfrog plans to publicly report individual hospital results on the OR Access section on the Leapfrog Hospital Survey Results website.
In 2013, Leapfrog added a series of questions based on volume and readmission rates reported by CMS for three common acute conditions: AMI, Heart Failure, and Pneumonia. At that time, critical access hospitals were not able to access these questions in the online survey.
In 2014, critical access hospitals that voluntarily reported 30-day risk standardized readmission rates for AMI, Heart Failure, and/or Pneumonia to CMS will be able to complete these questions on the online Leapfrog Hospital Survey. Critical access hospitals that do not voluntarily report this information to CMS will continue to be scored as “Does Not Apply.”