What’s New in 2011:
The Leapfrog Hospital Survey
Survey Town Hall Calls
April & May 2011
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Town Hall Call Overview
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Introduction
– Survey Team
– Leapfrog and the Leapfrog Hospital Survey—why complete?
– Goals for 2011 survey
Survey Submission Logistics/Timeline/Website Resources
What’s New for 2011
– Computerized Physician Order Entry (CPOE)
– Evidence-based Hospital Referral (EBHR)
– Common Acute Conditions (CACs)
• Normal Deliveries
– ICU Physician Staffing (IPS)
– National Quality Forum (NQF) Safe Practices
• Magnet-designated hospitals
– Hospital Acquired Conditions (HACs)
• Central line associated blood stream infections (CLABSI)
• Hospital-acquired pressure ulcers & injuries
– Two new survey sections:
• Smooth Patient Scheduling (Section 8)
• Patient Experience of Care (Section 9)
Q&A
Schedule for Town Hall Calls
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Why Complete Leapfrog Survey?
Unique in the Milieu
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Measures represent employers/purchasers/consumers interests
Requires public accountability/transparency
Rewards high performance
Contains meaningful measures with high impact “not the low
hanging fruit measures” (e.g., CPOE, IPS, EBHR, HACs,
Deliveries)
Full range of measures—structural, process and outcome (but
focused on outcome—36 measures)
Regional and national in scope—all payer/all patient information
Standardized measures to assure “same fruit” is sampled
Harmonized with other major national performance measurement
programs—but shows more complete picture of care delivery
Significant hospital input on survey revisions
CPOE Evaluation Tool is a one-of-a-kind opportunity to check
meaningful use
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Survey Review Process
Steps in the process to revise the survey have included:
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(November, 2010) - Public review and comment period – hospitals
and other stakeholders were invited to share comments and feedback
on the proposed changes for the 2011 Leapfrog Hospital Survey.
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(January, 2011) - Pilot test of revised survey – 25 hospitals were
asked to test a draft of the 2011 Leapfrog Hospital Survey and provide
feedback to Leapfrog.
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Examples of feedback:
(i) Two questions in Safe Practice #9 (Nursing Workforce) were
duplicative; revised questions to remove duplication.
(ii) Original section 8 scoring did not account for hospitals that have
already achieved high utilization of current O.R. capacities; updated
scoring to give credit to hospitals that have achieved 85%+ utilization.
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Behind the Changes
Goals for the survey—
1. Expand coverage to more hospitals
2. Keep burden as low as possible
3. Continue alignment with other performance
measurement groups (such as CDC-NHSN; CMS;
The Joint Commission)
4. Include cutting-edge measures that improve the
quality and efficiency of care delivery
5. Maintain consistent measurement structure for
LHRP and for improvement purposes
6. Update measures with guideline changes
7. Add new performance measurement entities
8. Maintain measures meaningful to purchasers and
consumers
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How did we do?
• Bulk of survey remains identical to the 2010 survey
• Added two new sections, to a) measure the hospital’s
efficient use of existing capacities; and b) measure
the patient’s experience of care
• 2010 survey was 65 pages of questions — added 4
pages of questions for the two new survey sections
• Updated measure specifications to maintain
alignment with other measurement entities (CMS,
The Joint Commission)
• Shifted preference to national performance
measurement systems where possible (STS, ACC)
• Replaced existing measures with more meaningful
measures (new version of CPOE Evaluation Tool,
replace PCI process measures)
• “Raised bar” for some performance targets
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Survey Submission Logistics, Timeline,
Website Resources
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Survey Security and Integrity
• Core principle: hospital self-certification
• Executive authority and accountability
• Survey security and integrity are critical:
– 16-digit security code
• Authorization to access granted only to:
– CEO . . . can provide code directly to any delegate(s)
– CEO-authorized delegate . . . Help Desk can email security
codes. See survey home page link, “Get a Security Code”
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Survey Helpdesk Available
• Survey Helpdesk -- designed to respond within 1-2
business days (unless it requires an expert panel
member to respond)
• Link on survey homepage
https://www.leapfroghospitalsurvey.org/helpdesk
• Other tips:
– Survey must be completed before CPOE Evaluation Tool is
taken. Help Desk cannot respond in real time. Plan to
complete early.
– Don’t wait until late June. If you have a problem, you likely
will not make deadline.
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2011 Timeline
• April 1, 2011 – Launched 2011 Survey
• June 30, 2011 -- RRO-targeted hospitals report or be
listed on Leapfrog’s website as “Declined To
respond”
• July 24, 2011 -- Leapfrog website lists new results
• Top Hospitals List –
2011 recognition programs/ initiatives begin as
early as mid-September
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Website Resources
See online survey home page for links to:
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Leapfrog Hospital Survey Reference Book
– Measure specifications (volume, process, resource utilization)
– Frequently Asked Questions
– Scoring Algorithms
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Hardcopy survey including explanatory “end notes”
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Other links on home page
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“What’s New in 2011”
Survey deadlines
Updates: Notable changes to survey or specs since 4/1/11 release
Excel tool for computing Geometric Mean Length of Stay
Supplemental info re: Resource Utilization scoring and Survival Predictors
Ordering info for NQF’s Safe Practices for Better Healthcare: 2010 Update
Fact sheets on each Leap (including bibliography information)
White Papers on Severity-adjustment for LOS, and Survival Predictor
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Leapfrog Hospital Survey Reference Book
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Medical Coding for High-Risk Procedures and Conditions (EBHR)
Procedure codes, diagnosis codes and other specifications for counting high-risk
surgery volumes
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EBHR Publicly Reported Outcomes for CABG and PCI
For hospitals in CA, MA, NJ, NY and PA – publicly reported risk-adjusted mortality
rates for responding to survey questions about PCI (MA, NY only) and CABG (all five
states).
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EBHR Process Measures -- Specifications
Detailed specifications for Leapfrog’s procedure-specific process measures of quality
for CABG, PCI, AAA Repair, and high-risk deliveries.
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EBHR Resource Utilization Measures – Specifications
Detailed specifications for Leapfrog’s CABG and PCI including:
• Coding for counting eligible cases
• Coding and other criteria for identifying cases with risk factors
• Specifications for reporting geometric mean length of stay
• Criteria for identifying cases followed by readmission
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Leapfrog Hospital Survey Reference Book
– Volume Standard Coding: Medical Coding for Chronic Acute Conditions (CAC)
Procedure/diagnosis codes and other specifications for counting AMI and Pneumonia
volume
– CAC Process Measures – Specifications
Specifications for Leapfrog’s nationally-endorsed condition-specific process measures
of quality -- for AMI, Pneumonia, and Normal Deliveries.
– CAC Resource Utilization Measures – Specifications
Detailed specifications for Leapfrog’s Common Acute Conditions (AMI and Pneumonia)
including:
• Coding for counting eligible cases
• Coding and other criteria for identifying cases with risk factors
• Specifications for reporting geometric mean length of stay
• Criteria for identifying cases followed by readmission
– CAC Normal Deliveries Measures – Specifications
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Early Delivery outcome measure
• Process measures: Bilirubin screening, DVT prophylaxis for C-sections
– Hospital-Acquired Conditions (HAC) – Specifications
– Smooth Patient Scheduling Utilization Calculations
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What’s New for 2011
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Computerized Prescriber Order Entry (CPOE)
Leap
Change: Introduction of version 2.0 of the CPOE Evaluation Tool
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Includes both new simulated patients and problem orders
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Incorporates many comments hospitals have provided to
Leapfrog and Tool developers over the last two years
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All medications are now listed in their generic form
Added checkboxes on the observation sheet to accommodate
structured orders [order sets/order sentences]
Added new checkbox on the orders/observation sheet for dosing
calculators
The updated instructions provide guidance on what to do with
'per protocol' ordering for high-risk medications
The drug-drug alerts being tested are now those that are
categorized as most severe, as agreed upon by most major
vendors
Removed three order checking categories: Drug-food
interactions, Cost of Care, and Contraindication based on
radiology studies
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Computerized Prescriber Order Entry (CPOE)
Leap
Reasoning: First version of the Tool was developed early in
previous decade; hospitals have advanced in their use of
decision support tools
Impact: Leapfrog’s CPOE standard will remain the same in 2011
To fully meet the standard:
(1) At least 75% of inpatient medication orders are entered
through hospital’s CPOE system
AND
(2) Hospitals demonstrate effective implementation of their
CPOE system by achieving a score of “Fully Meets
Standards” or “Good Progress” on the CPOE Evaluation
Tool (requires score of >=50% on drug:drug and
drug:allergy order checking categories + score of >=50%
on two additional order checking categories)
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ICU Physician Staffing (IPS) Leap
Change: Remove the opportunity for hospitals to indicate a
commitment date for fully meeting Leapfrog’s standard for IPS
Reasoning: After 10 years of asking hospitals to implement the
IPS Leap and publicly reporting those results, reporting future
commitments is no longer appropriate.
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ICU Physician Staffing (IPS) Leap
Impact: Scoring algorithms for Substantial Progress (3 bars) and
Some Progress (2 bars) have been updated to reflect the
removal of the commitment; Requirements for fully meeting the
standard have not changed.
To fully meet the standard:
• Intensivists and neurointensivists manage or co-manage
patients in all adult and pediatric medical and/or surgical ICUs
and neuro ICUs; and
• Intensivists are ordinarily present in the ICU* during daytime
hours (min. of 8 hours a day, 7 days a week) and provide care
exclusively in the ICU; and
• Intensivists respond to urgent pages within 5 minutes, >=95% of
time; and
• On-site physician, PA, NP, or FCCS-certified nurse “effector”
can reach ICU patients with 5 minutes, >=95% of time.
*24 hr x 7 day/week tele-monitoring w/ care planning done by
on-site intensivist can be substituted for 8 x 7 on-site presence
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Evidence Based Hospital Referral (EBHR) Leap
Change #1: Leapfrog has shifted its preference for cardiac surgery
outcome reporting from state reports to national performance
measurement systems.
Reasoning: As Leapfrog is a national organization and its
purchaser members often have covered lives in many states,
when and where possible, we want to give a preference to
measures that are comparable nationally
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Evidence Based Hospital Referral (EBHR) Leap
Impact:
• For CABG, PCI, AVR:
– Hospitals that participate in STS or ACC NCDR
CathPCI will be asked to report their risk-adjusted
mortality from latest report
– If hospital doesn’t participate, they can report data
from an approved state report (CA, MA, NJ, NY,
PA) or regional registry (Northern New England;
BCBS of Michigan)
– Scoring algorithms have been tweaked to reflect
this change in preference
– For hospitals that don’t report a risk-adjusted
outcome, will continue to calculate a Survival
Predictor
• AAA, Esophagectomy, Pancreatectomy
– Survival Predictor remains primary quality metric
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Evidence Based Hospital Referral (EBHR) Leap
Change #2: Replaced the three current PCI process measures (%
patients with door-to-balloon within 90 minutes; aspirin at arrival;
aspirin at discharge) with median door-to-balloon time; median
time needs to be <=60 minutes to earn credit
Reasoning: The research shows that there is an almost linear
relationship between door-to-balloon time and mortality for AMI
patients
Note: 25% of hospitals that participate in NCDR CathPCI registry
have median time of 62 minutes or less.
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Evidence Based Hospital Referral (EBHR) Leap
Impact: Hospitals that report median time at/under 60 minutes will
be given 1 bar ‘extra credit’; in previous surveys, hospitals had
to be at 80%+ adherence for 2 of the 3 process measures to
earn ‘extra credit’
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Common Acute Conditions (CACs)
Change: For ‘Elective Deliveries Before 39 Weeks’ measure,
performance target updated from 12% to 5%
Reasoning:
• Over 25% of hospitals that reported to 2010 survey reported a
rate <=5%
• Aligns with The Joint Commission thinking on an appropriate
target
• Zero is not a realistic goal for measure in current form, as
measure exclusions don’t capture every reason a delivery would
be appropriate before 39 completed weeks
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Elective Deliveries Before 39 Wks
Distribution of Elective Delivery Rates Before 39 Completed Weeks
Reported to the Leapfrog Hospital Survey (Data as of 03/28/2011)
Number of Hospitals
250
30%
23%
200
150
13%
13%
100
10%
4%
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6%
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0-5%
5-12%
12-20%
20-28%
28-36%
36-44%
Elective Delivery Rate Before 39 Completed Weeks
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44+
Common Acute Conditions (CACs)
Impact: For hospitals to receive credit on ‘Elective Deliveries
Before 39 Weeks’ measure, need to be at or under 5%.
Important Notes:
– Hospitals can report the data they submit to The Joint Commission
for this measure (Perinatal Care measure #1)
– Leapfrog has updated survey measure specifications to maintain
alignment with TJC.
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NQF Safe Practices
Change/Impact: Streamlined the survey response pattern for Safe
Practice #9 (Nursing Workforce), so that hospitals that carry
ANCC Magnet status can receive full credit for the Safe Practice
simply by indicating their status at the beginning of the practice
Reasoning: The Safe Practice FAQs have indicated that a
hospital that carries the Magnet designation meets all of the
requirements for the Safe Practice, but hospitals still had to
check every box to reflect full credit; streamlining response
burden.
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Hospital-Acquired Conditions (HACs)
Change: Added two ICUs for central line associated bloodstream
infection (CLABSI) reporting
– Neurosurgical ICU
– Surgical Cardiothoracic ICU
Reasoning: Extend reporting coverage to ICUs that provide postsurgical care to high-risk patients
Impact: Hospital’s CLABSI rates will be incorporated into the
standardized infection ratio (SIR)
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Hospital-Acquired Conditions (HACs)
Change: Hospitals can earn 1 bar ‘extra credit’ if they utilize
personnel trained in human factors engineering in conducting
root-cause analyses of adverse events
Reasoning: Personnel trained in human factors engineering are
trained to study the interaction between the human and the
system, including the work environment, tools, and computer
systems; root-cause analyses conducted by such persons bring
a valuable perspective
Impact: Hospitals that are in lowest (worst) performance category
for CLABSI based on SIR are eligible for extra credit;
opportunity is an alternative to extra credit for participation in ON
THE CUSP: STOP BSI
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Section 8 : Smooth Patient Scheduling (NEW!)
Background/Problem:
– Hospitals experience patient overcrowding on specific days
and times throughout the week, contrasted with slower levels
of activity on other days/times; results in expensive
resources (e.g., inpatient beds, operating rooms, cardiac
catheterization labs) and staff facing excessive demand at
times and are significantly underutilized at other times
– This peak/valley cycle has consequences: EDs go on
diversion status, patients are boarded in the hall or in a nonappropriate unit, and the nursing staff is stressed as the
patient census fluctuates; these peaks are a stress on both
hospital systems and hospital staff, potentially compromising
quality of care
– With the expected growth in insured patients, demand for
hospital services will grow and patient flow problems such as
ED overcrowding and surgical delays/cancelations are likely
to grow as well
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Section 8 : Smooth Patient Scheduling (NEW!)
Possible Alternatives to Address Capacity Concerns:
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Option #1: Build more capacity, which is expensive (est.
$800,000-$2 million per O.R.), and doesn’t address the
peak/valley cycles
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Option #2: Eliminate the current inefficiencies in existing
ED, ICU, and surgical suite capacities
Forward-thinking hospitals have employed the same methods
that manufacturing and other service organizations have used
to understand, manage, and optimize the performance of their
systems to reduce current inefficiencies (e.g., Toyota
production model).
Section Focus: Hospitals are being asked to report their progress
in applying operations management methods (e.g., queuing
theory, variability management) to smooth patient flow across
all operating rooms that service inpatients, with a focus on
minimizing current inefficiencies and managing existing
resources to the fullest.
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Section 8 : Smooth Patient Scheduling (NEW!)
Fully meeting the standard: Hospitals will need to have applied
operations management methods to all of its operating rooms
that service inpatients and either:
(1) Document an average utilization of 85% or greater across
those units post-implementation; or
(2) Document a 15% improvement in the utilization of those
units (or initially, a 5% improvement by the end of year 1, or a
10% improvement by the end of year 2).
Hospitals can earn partial credit for taking steps toward full
implementation.
Important Note: Hospital results on this new section on the survey
will be scored in 2011, but not publicly reported. Hospitals can
view their scored results for this section on their ‘hospital detail
page’, with results posted on the same schedule as the public
results.
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Section 9 : Patient Experience of Care (NEW!)
Background: Leapfrog’s purchaser members have requested the
inclusion of patient experience of care measures in the
Leapfrog survey
Details: We are asking hospitals to report three composite scores
from their latest HCAHPS results (as displayed on CMS’s
HospitalCompare). The three composite scores include:
– Pain Management
– Communication about Medicines
– Discharge Information
These three composites were chosen as they all reflect variations
in performance
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Section 9 : Patient Experience of Care (NEW!)
Scoring: Hospital performance on each composite will be
compared to national thresholds and summarized into a single
score (see next slide for details).
Notes:
(1) Reporting of this HCAHPS bundle will be voluntary for PPSexempt hospitals and will be non-applicable to children’s
hospitals.
(2) Hospital results on this new section on the survey will be scored
in 2011, but not publicly reported. Hospitals can view their
scored results for this section on their ‘hospital detail page’, with
results posted on the same schedule as the public results.
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Section 9 : Patient Experience of Care Scoring
Quartile
Points Earned
1 pt
2 pts
3 pts
4 pts
Bottom
Quartile
Scores
3rd
Quartile
Scores
2nd
Quartile
Scores
Top
Quartile
Scores
Pain Management
0-65
66-68
69-71
72-100
Communication
About Medications
0-55
55-58
59-62
63-100
Discharge Home
0-77
78-81
82-84
85-100
HCAHPS
Composite
Measure
Note: Quartile thresholds are based on 2009 national HCAHPS data; sample: 3,446 hospitals
that reported 100+ completed surveys.
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Ensuring Data Integrity
• Leapfrog will continue to conduct reviews of hospital responses
– 2008 – 153 hospitals contacted for follow-up on submitted
responses
– 2009 – 343 hospitals contacted for follow-up on submitted
responses
– 2010 – 445 hospitals contacted for follow-up on submitted
responses
• Leapfrog continues to add high-visibility data licensees and
release high-profile press campaigns
• 2010 – Leapfrog had a random 1% of responding hospitals
submit documentation for specific responses to provide greater
assurance of data accuracy (e.g., hospitals asked to provide a
copy of their Never Events policy)
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Breakdown of 2011 Survey Measures
Measure
Type
Description Of Measure Type
No. in 2011 Leapfrog
Hospital Survey
Outcome
Show the outcome of the care being
delivered, e.g., CABG mortality, or, are a
close proxy for outcomes (e.g., surgical
volume)
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Process
Reflect whether the specific care process 20
was implemented, e.g., aspirin at arrival
for AMI
Structure
Measures whether certain attributes are
present, e.g., Intensivist staffing and
paging of ICU
Efficiency
Focus on resources used in care delivery 5
(LOS, readmissions); also are often a
composite of quality and resources used
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21 (mainly Safe
Practices)
Questions?
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Dates of Town Hall Calls
• Leapfrog Hospital Survey - General Overview
– Wednesday, April 27 at 2 pm ET/11 am PT
– Tuesday, May 3 at 1 pm ET/10 am PT ***
– Tuesday, May 10 at 12 noon ET/9 am PT
• Specialty Town Hall Call– Overview of Smooth Patient
Scheduling
– Thursday, May 5 at 2 pm ET/11 am PT ***
*** These two calls will be recorded for future playback (dialin information on www.leapfroggroup.org)
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